Mountain View Conv Hosp
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylmar, California.
- Location
- 13333 Fenton Avenue, Sylmar, California 91342
- CMS Provider Number
- 056333
- Inspections on file
- 106
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Mountain View Conv Hosp during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities accused a CNA of hitting her during ADL care and remained visibly upset, but the CNA did not report the allegation, another CNA only informed an LVN, and the LVN checked for injuries and then continued medication administration without notifying the Adm or removing the alleged perpetrator from the assignment. The Adm did not learn of the allegation until several hours later, after the ADON was informed by the nurse assigned to the resident and confirmed that the allegation had occurred earlier that morning. Facility leadership and the DSD acknowledged that all staff are mandated reporters and that facility policy requires immediate reporting of any abuse allegation to the Adm and to CDPH, the Ombudsman, and LLE within two hours, as well as removal of the accused staff from resident contact, but these steps were not followed in this case.
A resident with hemiplegia, DM, HTN, and high pressure-ulcer risk (Braden score 11) had a care plan and IDT recommendations that included use of a low air loss (LAL) mattress for wound and skin management. The LAL mattress order was later discontinued when the resident’s skin was noted as intact, but the MD and responsible party were not notified at the time of this change in treatment. A family member subsequently complained about the mattress removal and was told by a treatment nurse that no MD order or notification was needed, citing facility protocol. In interview, the DON acknowledged that an order was required to start and stop the LAL mattress, that this constituted a change in treatment requiring MD and representative notification, and that failure to notify violated the resident’s and representative’s right to be informed and make decisions.
A resident with essential HTN and cognitive impairment had physician orders for atenolol and losartan to be held if SBP was below 110 mmHg, but an LVN documented administering these medications on several occasions when SBP readings were below the ordered parameter. The MAR showed check marks indicating administration despite low BP values, and the LVN later stated he had held the medications but could not provide proof. Interviews with an RN and the DON confirmed that nursing staff were expected to follow the ordered BP parameters and the facility’s medication administration policy requiring verification of vital signs and adherence to prescriber orders.
A resident with multiple medical conditions, including a UTI, received two different antibiotics (cephalexin followed by ciprofloxacin) as ordered by a physician, with administration documented on the MAR. The existing care plan addressed a history of UTI only in general terms, instructing staff to administer medications as ordered and monitor for side effects, but it did not identify or individualize care for the specific antibiotics prescribed. The IP stated that antibiotic use should be care planned on the day therapy starts and revised with any change in antibiotic, and confirmed that no such antibiotic-specific care plan was developed. The DON referenced facility policy requiring person-centered care plans with measurable objectives, timeframes, and revisions as conditions change, and acknowledged the resident’s care plan should have been revised to reflect the antibiotic therapy.
A resident was admitted with multiple documented pressure ulcers and deep tissue injury, along with severe cognitive impairment and dependence on staff for ADLs. Admission assessments and subsequent IDT wound management notes identified several pressure ulcers on the shoulder, arm, hip, knee, and leg, and treatment orders for daily betadine and dressings were initiated. Despite this, the WCP was not notified of the wounds at admission or during the next two weekly visits, in accordance with a practice described by the TN of only notifying the WCP during weekly rounds. As a result, the WCP did not assess the resident’s wounds or perform needed surgical debridement until 12 days after admission, when multiple pressure ulcers were finally evaluated and one hip ulcer was surgically debrided. The DON acknowledged that delayed debridement could slow wound healing.
A resident with multiple medical conditions and severe cognitive impairment received cephalexin and then ciprofloxacin for a UTI, with care plans and physician orders requiring monitoring for side effects. Facility policy and the IP, RN, and DON all indicated that residents on antibiotics must be monitored every shift for signs and symptoms of infection and adverse reactions, with documentation in progress notes or skilled notes. Review of the MAR and clinical record showed that while the antibiotics were administered as ordered, nursing staff did not document required monitoring for adverse effects during several identified shifts, contrary to the facility’s antibiotic stewardship, infection surveillance, and medication administration policies.
A nurse left a resident's EHR open and unattended at a nurses' station, exposing confidential health information. The nurse admitted to not logging off the computer before leaving, and the DON confirmed this violated facility policy for protecting e-PHI. The resident involved had dementia and required significant assistance with daily care.
A resident with dementia and a history of falls was placed on a bed alarm following a fall, but informed consent from the responsible party was not obtained until nearly two weeks after the device was implemented. The DON confirmed that consent should have been secured at the time of the order, in accordance with facility policy.
A resident with a history of GI bleed and dementia had both NPO and clear liquid diet orders active at the same time, resulting in conflicting instructions in the medical record. Staff interviews and record reviews confirmed the orders were not updated accurately, leading to confusion about the resident's care and failure to maintain complete and accurate documentation as required by facility policy.
A resident with multiple diagnoses, including UTI and diabetes, underwent an intermittent catheterization procedure that was not documented in the medical record by the LVN who performed it. Both the LVN and DON acknowledged that the procedure and the resident's response should have been recorded, as required by facility policy and professional standards.
A resident with intact cognitive function reported that an x-ray technician entered her room at night without knocking, introduction, or explanation, causing distress. The complaint, voiced to a CNA, was not reported to licensed nurses or documented as a grievance, contrary to facility policy. Staff interviews and record reviews confirmed the failure to address and document the resident's concern.
The facility did not provide medical records within the required 48-hour timeframe for two residents after receiving written requests, resulting in significant delays. One resident's records were delayed due to attempts to collect additional documentation, while another resident's family did not receive records or an invoice within the policy window, contrary to facility policy.
A resident with end stage renal disease and dependent on dialysis was transferred from a dialysis center to a hospital and did not return, resulting in the facility not retrieving the Dialysis Communication binder. Staff interviews confirmed that the binder, essential for documenting and communicating care, was not recovered, leading to incomplete medical records in violation of facility policy.
A resident with multiple serious diagnoses experienced hematuria, a significant change in condition. Although lab tests were ordered and results indicated infection, there was no documentation that a COC note was created or that the physician and resident's representative were notified at the time of the change, as required by facility policy. Staff interviews confirmed the lack of timely notification and documentation.
A resident with a history of prostate cancer, chronic kidney disease, and acute respiratory failure experienced hematuria, but staff did not create or update a care plan to address this change in condition. Although physician orders for urinalysis and urine culture were obtained, no change in condition note or care plan interventions specific to hematuria were implemented until several days later, delaying appropriate monitoring and response.
A resident with severe cognitive impairment was found with a bruise and swelling on the face, which was not reported to the Survey State Agency as required by the facility's abuse prevention policy. The injury was noted by a CNA and reported to an LVN and RN, but despite the policy mandating immediate reporting to authorities, it was only reported to a doctor.
A facility failed to create a baseline care plan for a resident with epilepsy within 48 hours of admission. Despite the resident's severe cognitive impairment and history of seizures, the care plan lacked specific seizure precautions. Staff interviews confirmed the absence of a care plan for seizure precautions and fall risk, which should have been established upon admission. The facility's policy required a baseline care plan to address immediate health and safety needs, but this was not implemented for the resident.
The facility failed to provide a clean and comfortable environment for its residents. A resident's electric fan was found dusty, and three residents experienced room temperatures below the required range, leading to discomfort and complaints. Despite being informed, the maintenance department did not adequately address the issues, impacting the residents' quality of life.
The facility failed to implement comprehensive care plans for residents requiring supplemental oxygen, diabetes management, and the use of physical restraints. One resident frequently removed their nasal cannula, yet no care plan addressed this behavior. Another resident receiving diabetes treatment lacked a care plan for monitoring blood sugar levels. Additionally, a resident using grab bars/side rails had no care plan or physician's order, and a resident on amitriptyline for depression had no measurable goals for treatment monitoring.
A facility failed to provide adequate range of motion (ROM) and mobility services for three residents. One resident did not receive passive range of motion (PROM) exercises on the knees as ordered, and this was not reported to therapy staff. Another resident's ROM was not appropriately monitored, as the facility's system relied on visual assessments rather than objective measurements. A third resident had a discrepancy in RNA orders, with PROM exercises ordered less frequently than splint application, which should be preceded by PROM. The facility's policies for maintaining and improving mobility were not effectively implemented.
The facility failed to maintain a safe environment for residents, with fall mats improperly used, a non-functional bed pad alarm, frayed wires on a bed remote, an elevated bed, and an oxygen concentrator placed unsafely. These deficiencies increased the risk of injury, as confirmed by staff and the DON, and violated facility policies on fall risk management and hazardous equipment.
The facility failed to manage enteral feeding appropriately for three residents. A resident's feeding was administered without checking residuals, contrary to physician orders. Another resident's water flush bag lacked labeling for the delivery rate, risking improper hydration. Additionally, a third resident's feeding and water flush bags were not labeled with the administration rate, potentially affecting their nutritional intake. These deficiencies were confirmed by staff and the DON, highlighting lapses in following established protocols.
The facility failed to properly dispose of medications and maintain accurate records in one medication room. Medications were found in their original packaging without being rendered irretrievable, contrary to policy. Additionally, six records lacked verifying signatures of two licensed nurses, as required. The DON acknowledged these deficiencies could lead to medication diversion and accidental exposure.
The facility failed to monitor Trazodone side effects for a resident and did not limit PRN lorazepam orders to 14 days for another resident, as required by policy. The lack of documentation and adherence to protocols led to deficiencies in medication management, putting residents at risk for unnecessary medication use and potential adverse effects.
A facility failed to maintain a medication error rate below 5%, resulting in a 17.86% error rate due to incorrect medication administration to three residents. Errors included wrong doses and omissions of prescribed medications. Observations revealed that two LVNs did not follow the facility's medication administration guidelines, leading to these errors.
The facility failed to prepare puree foods to the required consistency for residents on a level 4 diet, as observed during a lunch trayline. Puree Boston baked beans did not hold their shape, and puree cabbage was weeping liquid, contrary to the facility's policies and IDDSI guidelines. This inconsistency in food texture posed potential risks for 11 residents on the puree diet.
The facility failed to maintain safe and sanitary food storage and preparation practices, with issues such as chipped and rusted kitchen equipment, unclean food preparation surfaces, and improper hand hygiene by staff. These deficiencies were acknowledged by the Dietary Supervisor and could lead to cross-contamination and foodborne illnesses.
A resident's POLST indicated full treatment and resuscitation, but an active physician's order for DNR/DNI was found, creating a discrepancy. The DON entered the DNR/DNI order without reviewing the POLST, leading to potential confusion and risk of delayed life-saving treatment. The facility's policies on resident rights and advance directives were not followed.
A resident in a long-term care facility was unable to complete passive range of motion (PROM) exercises for both knees, but the facility failed to notify the physician of this change in condition. Despite orders for PROM exercises to all extremities, the RNAs did not report the inability to perform these exercises on the knees, which was considered a change in condition. The facility's policy required physician notification for significant changes, which was not followed, potentially delaying necessary intervention.
A facility failed to develop a baseline care plan for a resident who was prescribed lorazepam for anxiety management. The resident, with chronic respiratory failure and ventilator dependence, was admitted without a care plan addressing the use of lorazepam, as confirmed by staff interviews. This omission could lead to delays or lack of care, contrary to the facility's policy requiring a care plan within 48 hours of admission.
A resident was not offered shaving equipment or assistance for grooming facial hair, despite being capable of self-care with setup assistance. Observations showed the resident had noticeable facial hair, and interviews with staff confirmed the resident should have been offered a razor daily. The facility's policy supports providing care to maintain residents' ability to perform ADLs, which was not followed in this case.
A facility failed to label an oxygen humidifier with the date it was last changed for a resident with a tracheostomy, as required by policy. This oversight was confirmed by a respiratory therapist and a registered nurse, who stated that humidifiers should be changed twice a week and labeled. The absence of a date placed the resident at risk for infection.
A facility failed to assess a resident for the use of bed rails, obtain informed consent, and develop a care plan, despite the resident being observed with grab bars in use. The resident, with a history of falls and encephalopathy, was found to have grab bars applied without a physician's order or updated assessment, contrary to the facility's policy on bed safety.
The facility failed to maintain appropriate food temperatures for breakfast in Station 3, affecting 34 residents, including one with a regular diet. Observations showed food temperatures below acceptable levels, with fried eggs at 114°F and oatmeal at 94°F. A resident expressed dissatisfaction with the cold and unappetizing food. The Dietary Supervisor noted the issue was due to travel time from the kitchen, which could impact residents' food intake.
A facility failed to document the condition and treatments of a resident found unresponsive, leading to an incomplete medical record. The resident, with diagnoses including sepsis, COPD, and type 2 diabetes, was found non-responsive by a CNA, who initiated a code blue. However, vital signs and treatments were not documented, contrary to the facility's policy requiring detailed documentation of care and changes in condition.
A facility failed to maintain an effective infection control program by not labeling a nasal cannula and a urinal bottle, as required by policy. A resident with acute respiratory failure had an unlabeled nasal cannula, which should be changed weekly to prevent infection. Another resident's urinal bottle was not labeled, risking cross-contamination. These lapses were confirmed through staff interviews and observations, indicating non-compliance with infection control policies.
A facility failed to implement its Antibiotic Stewardship Program for a resident, resulting in a lack of monitoring and evaluation for the resident's metronidazole order. The resident, with chronic respiratory failure and ventilator dependence, was receiving metronidazole for a leg infection, but the necessary infection screening/evaluation form was not completed. The Infection Preventionist acknowledged the oversight, which placed the resident at risk for antibiotic resistance due to the absence of a stop date and proper evaluation.
A facility failed to accurately code the MDS for a resident's discharge, indicating a hospital discharge instead of home, as confirmed by the Discharge Summary and Progress Note. The DON acknowledged the importance of accurate MDS coding for billing and discharge planning. This discrepancy highlights a deficiency in the facility's assessment process.
A resident at risk for pressure ulcers did not receive weekly skin and wound assessments as required by facility policy. The resident, with limited mobility and multiple medical conditions, had changes in a surgical stoma wound that were not consistently monitored. Interviews with nursing staff confirmed the lapse in adherence to the facility's policy for regular assessments and documentation.
A resident receiving heparin for DVT prophylaxis was not monitored for bleeding, a known side effect, despite facility policy requiring such monitoring. The resident, with chronic respiratory failure and other conditions, received heparin injections without documented monitoring for bleeding in their MAR, as confirmed by interviews with nursing staff.
A resident's medical records were inaccurately documented in an LTC facility, with discrepancies found in the MAR after the resident was transferred to a hospital. Interviews revealed that a Respiratory Therapist recorded information on the wrong date, contrary to the facility's policy for accurate documentation.
A resident in an LTC facility experienced verbal abuse from another resident, leading to anxiety and depression. Despite the facility's policies, staff failed to report the abuse, and the resident's care plan for depression was not followed. The facility's administrator was unaware of the incident, highlighting a failure in communication and adherence to procedures.
A resident reported verbal abuse by another resident, involving derogatory comments about their sexual orientation and appearance, which caused stress and depression. Despite staff awareness, the facility's Abuse Coordinator delayed reporting the incident to the SSA by 13 days, violating the policy requiring immediate reporting within two hours.
A resident reported verbal abuse by another resident to a Social Service Assistant (SSA), but the SSA failed to document the incident in the clinical records, leading to incomplete and inaccurate documentation. The resident, with diagnoses including chronic systolic heart failure and COPD, expressed feeling stressed and depressed. The Director of Nursing confirmed the need for documentation of all resident concerns as per facility policy.
A facility failed to conduct weekly pressure ulcer assessments for a resident admitted with a deep tissue injury in the sacral region. Despite being at risk for developing pressure ulcers, the facility did not implement a care plan with the required weekly assessments for the first four weeks. Interviews and record reviews showed missing documentation for two weeks of evaluations, contrary to the facility's policy. This oversight had the potential to worsen the resident's condition.
A facility failed to implement infection control measures for a resident on enhanced barrier precautions (EBP) due to multidrug-resistant infections. A Certified Occupational Therapist Assistant assisted the resident without wearing a protective gown during a high-contact activity, despite facility policy and signage indicating the requirement for gown use. Staff interviews confirmed the oversight, and the facility's policy mandates gown use to prevent the spread of infections.
A resident with an unstageable pressure ulcer was found to have multiple layers of linen on a low air loss mattress (LALM), contrary to the manufacturer's guidelines. The CNA was not inserviced on proper LALM use, and the LVN and DON confirmed that the multiple layers defeated the LALM's purpose, potentially worsening the resident's condition.
Failure to Timely Report and Act on Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of staff-to-resident abuse to the Administrator, the State Survey Agency (CDPH), the Ombudsman, and local law enforcement within the required two-hour timeframe. The involved resident, identified as Resident 20, had multiple diagnoses including type 2 diabetes mellitus, legal blindness, and adult failure to thrive, and was assessed as having severely impaired cognition. According to the Minimum Data Set, the resident required extensive assistance with most activities of daily living. The History and Physical indicated that the resident had the capacity to understand and make decisions. On the early morning in question, at approximately 4:30 a.m., Certified Nursing Assistant (CNA) 6 was providing ADL care to Resident 20 when the resident accused CNA 6 of hitting her during care and continued to scream and repeat the accusation. CNA 6 acknowledged that such an accusation should be considered an allegation of abuse but did not report it to the charge nurse because she believed she had not hit the resident. CNA 6 continued providing care, then left to care for another resident without notifying supervisory staff. CNA 5, who was caring for the resident’s roommate, later observed Resident 20 upset and crying and heard her state in Spanish that CNA 6 was very rough with her. CNA 5 then informed Licensed Vocational Nurse (LVN) 8 that the resident was upset and requested that LVN 8 speak with the resident. LVN 8 went to the room, found Resident 20 upset, and heard the resident state that she had been hit by a CNA, but LVN 8 did not ask the resident to identify which CNA was involved. LVN 8 checked the resident for injuries, found none, and then resumed medication administration without reporting the allegation to the Administrator or Director of Nursing and without removing the alleged perpetrator from the assignment. Later that morning, the Assistant Director of Nursing (ADON) was informed by the nurse assigned to Resident 20 that the roommate reported hearing a slapping sound while Resident 20 was receiving care and that Resident 20 said she had been hit on the face by CNA 6. The ADON confirmed through interviews with CNA 5, CNA 6, and LVN 8 that the allegation occurred between approximately 4:30 a.m. and 5:00 a.m. The Administrator was not made aware of the allegation until about 9:15 a.m., at which time she learned that CNA 6 had not reported the allegation, CNA 5 had only reported to LVN 8, and LVN 8 had not escalated the allegation. The facility’s abuse policy required that any suspicion or allegation of abuse be reported immediately to the Administrator and to CDPH, the Ombudsman, and law enforcement within two hours, and that any employee accused of abuse be removed from resident contact until the investigation was complete; these requirements were not followed in this incident. The Director of Staff Development, ADON, and Administrator each confirmed during interviews that all staff are mandated reporters and that any allegation of abuse, regardless of perceived validity, must be reported immediately to the Administrator so that external reporting can occur within two hours. They also confirmed that the accused staff member should be removed from the assignment and from resident contact pending investigation. In this case, CNA 6 did not report the allegation to the nurse, CNA 5 did not report directly to the Administrator, and LVN 8 did not notify the Administrator or remove CNA 6 from caring for the resident. As a result, the facility did not follow its own policy and regulatory requirements for timely reporting of an abuse allegation involving Resident 20.
Failure to Notify Physician and Responsible Party of Discontinuation of LAL Mattress
Penalty
Summary
The deficiency involves the facility’s failure to notify the attending physician and the resident’s responsible party of a significant change in treatment when a low air loss (LAL) mattress was discontinued for a resident at high risk for pressure ulcers. The resident had been admitted and later readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 DM, and HTN. The care plan, initiated and later revised, identified the resident as at risk for unavoidable pressure ulcers related to immobility and included an intervention that the resident may have an LAL mattress for wound and skin management. An IDT wound management update documented that a lower back ulcer had resolved but still recommended an LAL mattress and off-loading. The resident’s MDS showed the resident was unable to understand and be understood and was dependent for most ADLs, and a Braden Scale assessment scored the resident at 11, indicating high risk for pressure ulcer development. On a subsequent date, the order summary report showed an active order for an LAL mattress for wound and skin management that was discontinued with the notation that the resident’s skin was intact. There was no documentation that the physician or the responsible party were notified of this change in treatment at the time the order was discontinued. Social services documentation later recorded that a family member complained that the mattress had been removed and questioned whether there was a physician’s order to remove it. The treatment nurse told the family member that no physician order was necessary because the resident did not have wounds and that the LAL mattress was not needed. The treatment nurse also stated in interview that the LAL mattress had been removed about a week earlier based on direction from the DON to discontinue LAL mattresses for residents without pressure ulcers and that neither the physician nor the family were notified because the facility followed a protocol and there was no perceived change in condition. During interview and concurrent record review, the DON acknowledged that, based on the Braden assessment, the resident needed the LAL mattress even without an active pressure ulcer and that an order was required both to initiate and discontinue the LAL mattress. The DON stated that if the treatment nurse did not notify the physician, there was an issue, and confirmed that this should have been considered a change in treatment requiring physician notification. The DON further stated that the family had the right to know when there is a change in treatment and that the responsible party should have been notified on the date the order was discontinued, and that failure to notify the resident representative of the change in treatment was a violation of the resident’s and representative’s right to know and make decisions. Facility policies on change in condition and support surface guidelines required prompt notification of the physician and resident representative when medical treatment is significantly altered and the use of appropriate support surfaces for individuals at risk for pressure ulcers.
Failure to Follow Antihypertensive Hold Parameters
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for holding antihypertensive medications for one resident. The resident was admitted with diagnoses including an unspecified thoracic vertebra wedge compression fracture, essential hypertension, and generalized muscle weakness. The physician’s orders, dated 12/3/2025, directed that atenolol 50 mg by mouth daily be held if systolic blood pressure (SBP) was less than 110 mmHg or pulse was less than 60 bpm, and that losartan 100 mg by mouth daily be held if SBP was less than 110 mmHg. The resident’s History and Physical indicated the resident had capacity to understand and make decisions, while the MDS dated 12/5/2025 documented severely impaired cognitive skills for daily decisions and dependence on staff for toileting, showering, and dressing. Review of the Medication Administration Record for 12/2025 showed that LVN 1 documented administration of atenolol and losartan on multiple dates when the resident’s SBP was below the 110 mmHg hold parameter. Specifically, atenolol and losartan were documented as given on 12/25/2025 at 9 a.m. with a BP of 109/70 mmHg, losartan was documented as given on 12/26/2025 at 9 a.m. with BP 108/72 mmHg, on 12/27/2025 at 9 a.m. with BP 106/68 mmHg, and on 12/28/2025 at 9 a.m. with BP 109/70 mmHg, and atenolol again on 12/28/2025 at 9 a.m. with BP 109/72 mmHg. During interview, LVN 1 stated that a check mark on the MAR indicated the medication was administered and claimed he had actually held the atenolol and losartan on those dates and times but could not prove this. RN 1 and the DON both stated that LVN 1 should have followed the physician’s orders and held the medications when SBP was below 110 mmHg, and the facility’s medication administration policy required medications to be administered as prescribed, including verification of vital signs when necessary.
Failure to Develop Person-Centered Care Plan for Antibiotic Therapy
Penalty
Summary
Surveyors identified a failure to develop and implement a person-centered care plan addressing the use of specific antibiotics for one resident. The resident was admitted with diagnoses including an unspecified thoracic vertebra wedge compression fracture, essential hypertension, and generalized muscle weakness. A History and Physical dated 12/5/2025 documented that the resident had capacity to understand and make decisions, while the MDS from the same date indicated severely impaired cognitive skills for daily decisions and dependence on staff for toileting, showering, and dressing. On 12/11/2025, the physician ordered cephalexin 500 mg twice daily for seven days for a UTI, following a complaint of urinary discomfort on 12/10/2025 and subsequent urinalysis results. The Medication Administration Record showed the resident received cephalexin from 12/11/2025 at 5 p.m. through 12/14/2025 at 5 p.m. A care plan dated 12/11/2025 and revised on 12/26/2025 addressed a history of UTI with general interventions to administer medications as ordered and monitor for side effects, but it did not identify or individualize care for the specific antibiotic therapy. On 12/14/2025, the physician ordered ciprofloxacin 500 mg twice daily for seven days for UTI, and the MAR showed the resident received ciprofloxacin from 12/15/2025 at 9 a.m. through 12/21/2025 at 5 p.m. During interviews and record reviews, the Infection Preventionist stated that residents on antibiotics such as cephalexin and ciprofloxacin are to be monitored every shift for signs and symptoms of infection and adverse reactions, with documentation in progress notes, and that a care plan for antibiotic use should be developed on the day antibiotics start and revised with any change in antibiotic medication. The IP confirmed there was no care plan developed for the resident’s use of cephalexin and ciprofloxacin and noted that without an updated or revised care plan, nurses might miss interventions and potentially delay care. The DON stated that nurses should update the care plan based on monitoring of the antibiotic and that the resident’s care plan should be person-centered and revised as the resident’s condition changes, consistent with the facility’s Comprehensive Person-Centered Care Plans policy, which requires measurable objectives, timeframes, and revisions as conditions change. RN 1 acknowledged that the facility updates care plans with general interventions and stated there was no direct effect on the resident if the antibiotic care plan was not revised.
Failure to Timely Notify Wound Care Physician of Existing Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with multiple pressure ulcers received care consistent with professional standards by not timely notifying the Wound Care Physician (WCP) of the resident’s wounds. The resident was admitted with diagnoses including a thoracic vertebra wedge compression fracture, essential hypertension, and pressure-induced deep tissue damage of the left heel and other sites. On admission, the resident’s assessment documented multiple pressure ulcers on the right deltoid, right lateral forearm, right lateral knee, and right upper and lower hip, and the admission orders included daily betadine and dry dressings to several of these areas. The facility’s policy required that practitioners assist in identifying ulcer type, characteristics, complications, and contributing factors. Subsequent documentation showed that the resident’s H&P identified pressure ulcers on the right shoulder, right rib area, right upper and lower hip, right elbow, and right lateral leg, and the MDS indicated the resident had severely impaired cognitive skills for daily decisions, was dependent on staff for ADLs such as toileting, showering, and dressing, and was at risk for pressure ulcers with four unstageable pressure ulcers and one DTI present on admission. Interdisciplinary Wound Management Updates on two separate dates documented “wound consult,” indicating that a wound consult was needed. However, interviews revealed that the Treatment Nurse was responsible for wound care consult orders and that the practice was to notify the WCP of wounds only when the WCP visited weekly, not on the day of admission. The WCP visited the facility on two occasions after the resident’s admission but was not informed of the resident’s pressure ulcers on those visits. The DON confirmed that the WCP stated no one had informed him of the resident’s pressure ulcers during his earlier visit. The Treatment Nurse stated that the WCP was not informed on the first two weekly visits after admission and that the WCP did not see the resident for 12 days after admission. When the WCP finally evaluated the resident, multiple pressure ulcers were assessed and a surgical debridement of the right inferior hip pressure ulcer was performed, with measurements documented before and after debridement. The DON stated that surgical debridement removes dead skin cells for proper wound healing and that a delay in debridement could affect and slow down the resident’s wound healing.
Failure to Monitor and Document Antibiotic Use and Adverse Effects
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement its antibiotic stewardship, infection surveillance, and medication administration policies for one resident receiving antibiotics. The resident was admitted with diagnoses including an unspecified thoracic vertebra wedge compression fracture, essential hypertension, and generalized muscle weakness. A History and Physical dated 12/5/2025 documented that the resident had capacity to understand and make decisions, while the MDS dated the same day indicated severely impaired cognitive skills for daily decisions and dependence on staff for toileting, showering, and dressing. On 12/11/2025, a physician’s order directed cephalexin 500 mg by mouth twice daily for seven days for a UTI, and the resident’s care plan for history of UTI included interventions to administer medications as ordered and monitor for side effects, reporting them to the physician if noted. On 12/14/2025, the physician’s order was changed to ciprofloxacin 500 mg by mouth twice daily for seven days for UTI. The MAR for December 2025 showed that the resident received cephalexin from 12/11/2025 at 5 p.m. to 12/14/2025 at 5 p.m., and ciprofloxacin from 12/15/2025 at 9 a.m. to 12/21/2025 at 5 p.m. During interviews and concurrent record review on 1/6/2026, the Infection Preventionist stated that residents on antibiotics such as cephalexin and ciprofloxacin are to be monitored every shift for signs and symptoms of infection and any adverse reactions, with documentation in progress notes. The Infection Preventionist confirmed there was no documented antibiotic monitoring for adverse effects of cephalexin on 12/11/2025 and 12/12/2025 from 3 p.m. to 11 p.m., and no documented monitoring for adverse effects of ciprofloxacin on 12/15/2025 and 12/16/2025 from 7 a.m. to 3 p.m., and on 12/18/2025 from 3 p.m. to 11 p.m. RN 1 and the DON both stated that nurses are expected to monitor antibiotic use and adverse effects every shift and document in the medical record. Facility policies on Antibiotic Stewardship, Surveillance for Infections, and Administering Medications required monitoring and documentation of antibiotic use, signs and symptoms of infection, and any complaints, symptoms, and results related to medications, which were not followed during the identified shifts.
Failure to Safeguard Resident EHR Results in Breach of Confidentiality
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to maintain the privacy and confidentiality of a resident's electronic health record (EHR) by leaving it open and unattended at a nurses' station. The LVN admitted to logging into the computer and then walking away, leaving the EHR visible and the computer out of her sight. The LVN acknowledged that she should have logged off the computer and not left it open and unattended. The resident whose information was exposed had been admitted with diagnoses including muscle weakness, a history of falling, and dementia, and required substantial assistance with daily activities. The Director of Nursing (DON) confirmed that staff are required to turn off computers when leaving them unattended to prevent unauthorized access to protected health information, as outlined in the facility's policy and procedure for safeguarding electronic protected health information (e-PHI).
Failure to Obtain Informed Consent for Bed Alarm Use
Penalty
Summary
The facility failed to obtain informed consent from a resident's responsible party (RP) prior to the use of a bed alarm, which is considered a safety device that alerts staff when a resident attempts to get out of bed. The resident in question was admitted with diagnoses including muscle weakness, a history of falls, and dementia, and was assessed as lacking the capacity to make medical decisions. Following a fall, the medical doctor ordered the use of a bed alarm, and the device was implemented immediately. However, documentation and interviews revealed that informed consent from the resident's RP was not obtained until nearly two weeks after the bed alarm was put in place. The care plan and medical records indicated that the resident was at high risk for falls and required substantial assistance with daily activities. Despite facility policy requiring written physician orders and consent from the resident or their representative before using restraints or similar safety devices, the bed alarm was used without prior consent. The Director of Nursing confirmed that consent should have been obtained at the time the bed alarm was ordered and acknowledged the lapse in following the facility's policy and procedures.
Contradictory Diet Orders and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and consistent medical records for one resident, resulting in two active physician orders that directly contradicted each other. The resident, who was admitted with diagnoses including muscle weakness, history of falls, and dementia, had orders for both 'nothing by mouth' (NPO) and a clear liquid diet at the same time. The medical record review showed that after a gastrointestinal bleed, the resident was initially placed on TPN and NPO status, with subsequent orders for clear liquids added after a surgical follow-up. However, the NPO order was not discontinued when the clear liquid diet was started, leading to both orders being active simultaneously. Staff interviews confirmed awareness of the conflicting orders, with both the Quality Assurance Nurse and the DON acknowledging that the presence of both NPO and clear liquid diet orders could cause confusion and was not accurate documentation. Observations revealed that the resident had a tray with clear liquid items at bedside that had not been consumed, and staff expressed concern that the contradictory orders could impact the resident's care. The facility's policy requires documentation to be objective, complete, and accurate, which was not met in this instance.
Failure to Document Intermittent Catheterization Procedure
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required intermittent catheterization. Specifically, although a physician's order was in place for a straight catheter to collect a urine sample, the procedure was performed by an LVN but not documented in the resident's medical record. Both the LVN and the Director of Nursing confirmed that the procedure and the resident's response should have been recorded, as this information is essential for communication regarding the resident's care and safety. The resident involved had diagnoses including anxiety disorder, urinary tract infection, and diabetes mellitus, and was assessed as having intact cognitive function and requiring maximal assistance for toileting hygiene and lower body dressing. Facility policy required detailed documentation of catheterization procedures, including date, time, staff involved, urine characteristics, resident response, and any complications. The lack of documentation was contrary to both facility policy and accepted professional standards.
Failure to Report and Document Resident Grievance Regarding X-ray Technician Conduct
Penalty
Summary
The facility failed to ensure that a resident's grievance was reported, investigated, and documented according to its established grievance policy. A resident, admitted with diagnoses including post-joint replacement aftercare, osteoarthritis, and type 2 diabetes, reported that a male x-ray technician entered her room late at night without knocking, did not introduce himself, and did not explain the procedure, causing her distress. The resident was cognitively intact and able to make decisions at the time of the incident. Despite the resident voicing her complaint to a CNA, the concern was not reported to licensed nursing staff, nor was it documented in the resident's records or on a grievance form. Interviews with facility staff confirmed that the complaint was not communicated to the appropriate personnel, and a review of facility policies indicated that all staff are required to report such grievances. The Director of Nursing acknowledged that the complaint was not addressed as required by policy, and that this failure could negatively affect the resident's mental health.
Delayed Provision of Medical Records Following Resident Requests
Penalty
Summary
The facility failed to provide copies of medical records within the required timeframe for two residents following written requests. For one resident, who had diagnoses including acute respiratory failure, end stage renal disease, and was dependent on renal dialysis, a request for medical records was made through a law office. The facility acknowledged receipt of the request, but there was a delay in sending the invoice and the records, which were ultimately provided 18 days after the initial request. The delay was attributed to the facility's attempt to collect additional records from an external dialysis center, but the invoice was eventually sent without those records. For another resident, who had chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and adult failure to thrive, a family member requested medical records and provided the necessary authorization. The facility delayed providing the invoice and did not supply the requested records within the 48-hour policy window. The Medical Records Director confirmed that the records were not provided in a timely manner and could not provide documentation that the records had been sent as of the date of the interview. The facility's policy required records to be provided within 48 hours, excluding weekends and holidays, but this was not followed in both cases.
Failure to Maintain Complete Medical Records for Dialysis Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident when the resident's Dialysis Communication Records binder went missing. The resident, who had diagnoses including acute respiratory failure, end stage renal disease, and was dependent on renal dialysis, was admitted and later readmitted to the facility. The resident required substantial to maximal assistance with daily activities and had a scheduled dialysis regimen. On a specified date, the resident was transferred from the dialysis center to a general acute care hospital due to altered mental status and did not return to the facility, resulting in the facility not receiving the Dialysis Communication binder back. Interviews with facility staff revealed that the binder, which is used to document and communicate care between the facility and the dialysis center, was not retrieved after the resident's transfer. The Director of Nursing confirmed that nurses are responsible for ensuring the binder accompanies the resident and is returned, but in this case, the binder was not recovered and staff did not communicate with the dialysis center to retrieve it. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, but the missing binder resulted in incomplete records for the resident.
Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify the attending physician and the resident's representative when a significant change in condition occurred for one resident. The resident, who had a history of prostate cancer, chronic kidney disease stage 3, and acute respiratory failure with hypoxia, was admitted and later readmitted to the facility. On a specific date, the resident was noted to have hematuria (blood in the urine), which constituted a significant change in condition as defined by the facility's policy. Review of the resident's records showed that a urinalysis and urine culture were ordered and sent to the laboratory due to the presence of blood in the urine and lower abdominal pain. Laboratory results indicated elevated white and red blood cells and a positive urine culture for proteus mirabilis, a common cause of urinary tract infections. Although the urinalysis result was reported to the physician, there was no documentation that a Change of Condition (COC) note was created at the time the hematuria was first observed, nor was there evidence that the resident's representative was notified as required by facility policy. Interviews with the Quality Assurance Nurse and the Director of Nursing confirmed that the facility's protocol required immediate creation of a COC note, notification of the physician, and notification of the resident's representative when a significant change in condition was identified. Both staff members acknowledged that these steps were not documented or verifiable for the date when the hematuria was first observed, indicating a failure to follow established procedures for timely notification.
Failure to Develop and Implement Care Plan for Change in Condition
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who experienced a change in condition, specifically hematuria (blood in the urine). The resident, who had a history of prostate cancer, chronic kidney disease stage 3, and acute respiratory failure with hypoxia, was admitted and later readmitted to the facility. On the date of the change in condition, a physician's order for urinalysis was obtained due to hematuria, and a subsequent order for urine culture was placed for lower abdominal pain. However, there was no care plan created or revised to address the new onset of hematuria at that time. The resident's existing care plan addressed frequent incontinence and related issues but did not include interventions specific to the new condition of hematuria. Progress notes indicated that the urinalysis result was reported to the physician, but no new orders were given, and no change in condition (COC) note was created for the hematuria event. The lack of a COC note meant that the care planning process was not initiated for this new issue, and interventions to monitor and address hematuria were not implemented until several days later, after a positive urine culture result. Facility staff confirmed that the absence of a timely care plan for hematuria could result in a lack of monitoring and appropriate interventions.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting an injury of unknown origin for a resident. The resident, who had severe cognitive impairment and multiple diagnoses including dysphagia, anxiety, and type 2 diabetes, was admitted to the facility and later found with a bruise and swelling on the right side of the face. The injury was first noted by a CNA and reported to an LVN, who then informed an RN. Despite the facility's policy requiring immediate reporting of such injuries to local, state, and federal agencies, the injury was only reported to a doctor and not to the Survey State Agency. Interviews with staff revealed that the injury was not associated with a reported fall, and the Director of Nursing confirmed that the unknown injury was not reported to the appropriate authorities as required. The facility's policy, revised in September 2022, mandates that all reports of resident abuse, including injuries of unknown origin, be reported immediately to the administrator and other officials according to state law. This failure to report the injury as per the policy placed the resident at risk for further injury.
Failure to Develop Baseline Care Plan for Resident with Epilepsy
Penalty
Summary
The facility failed to develop a baseline individualized care plan for a resident with a history of epilepsy within 48 hours of admission. The resident, who was admitted with diagnoses including unspecified epilepsy, Alzheimer's disease, and other coordination issues, did not have a care plan addressing safety precautions related to their seizure history. The resident's medical records indicated severe cognitive impairment and a need for maximum assistance with daily activities, yet the care plan only included basic interventions such as notifying family and physicians, administering medications, and consulting neurology as ordered. The resident experienced seizures on multiple occasions, with the first documented seizure occurring shortly after admission. Despite the resident being on multiple antiepileptic medications, the care plan lacked specific seizure precautions such as padded side rails and foam padding on sharp edges to prevent injury. Interviews with facility staff, including a Licensed Vocational Nurse and a Registered Nurse, revealed that there was no care plan for seizure precautions or fall risk, which should have been created upon admission. The Director of Nursing and the MDS Nurse acknowledged the absence of a care plan for seizure history and emphasized the importance of individualized care plans to ensure resident safety. The facility's policy and procedure documents indicated that a baseline care plan should be developed within 48 hours of admission to address immediate health and safety needs, but this was not done for the resident in question. The lack of a comprehensive care plan for seizure precautions and fall risk compromised the quality of care provided to the resident.
Failure to Maintain Cleanliness and Adequate Room Temperatures
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the condition of Resident 22's electric fan and the room temperatures for Residents 71, 95, and 17. Resident 22, who was readmitted with acute on chronic respiratory failure and required total assistance with activities of daily living, had an electric fan in their room that was visibly dusty. The Registered Nurse confirmed the presence of gray powder-like material on the fan, which was identified as dust. The Maintenance Supervisor and Director of Nursing acknowledged that housekeeping was responsible for cleaning such equipment, and the failure to do so could lead to unclean air circulation and potential allergens. Additionally, the facility did not maintain the required room temperature range of 71 to 81 degrees Fahrenheit for Residents 71, 95, and 17. Resident 95 reported difficulty sleeping due to the cold room temperature, while Resident 17 expressed frustration over the cold air blowing from the air conditioning at night. Despite complaints, the Maintenance Supervisor only checked room temperatures during the day and did not address the nighttime temperature issues. Resident 71 also reported feeling cold at night and requested extra blankets. Interviews with staff, including the Licensed Vocational Nurse and Director of Nursing, confirmed that the maintenance department was informed of the temperature issues, but the problem persisted. The facility's policy on maintaining a homelike environment, which includes comfortable and safe temperatures, was not adhered to, potentially affecting the residents' quality of life.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential delays in necessary care and services. One resident, who was admitted with hemiplegia, hemiparesis, and diabetes mellitus, required continuous supplemental oxygen. However, there was no care plan addressing the use of oxygen, despite the resident's behavior of frequently removing the nasal cannula. This oversight was confirmed by multiple staff members, including a Registered Nurse and the Director of Nursing, who acknowledged the importance of having a care plan to ensure proper oxygen administration and resident safety. Another deficiency involved the same resident who was receiving treatment for diabetes mellitus. The facility did not have a care plan for managing the resident's diabetes, which is crucial for monitoring blood sugar levels and administering medications like insulin and metformin. The absence of a care plan for diabetes was noted by the Minimum Data Set Coordinator and the Director of Nursing, who emphasized the risk of missing critical interventions without a documented plan. Additionally, the facility failed to develop a care plan for a resident using upper grab bars/side rails, which are considered physical restraints. There was no physician's order, assessment, or informed consent for the use of these devices, and no care plan was in place to ensure their necessity and safety. Furthermore, another resident diagnosed with depression and prescribed amitriptyline did not have a care plan with measurable goals for monitoring the effectiveness of the medication. The Director of Nursing confirmed the lack of a care plan for depression and medication use, highlighting the facility's failure to provide patient-centered care and monitor treatment outcomes effectively.
Failure to Provide Adequate ROM and Mobility Services
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in range of motion (ROM) and mobility for three residents. For one resident, the Restorative Nursing Aides (RNAs) did not perform passive range of motion (PROM) exercises on the knees as ordered by the physician, citing that the knees could not bend. This was not reported to the therapy staff, which was a requirement if any part of the order could not be completed. The resident's care plan indicated a risk for further decline in ROM, and the order summary report specified PROM exercises for all extremities, which were not fully executed. Another resident did not receive appropriate monitoring of ROM by therapy staff on a quarterly basis. The facility's system for monitoring ROM was ineffective, as it relied on visual assessments and staff interviews rather than objective measurements. The Director of Rehabilitation (DOR) acknowledged that the current system would not show if a resident developed a contracture, as it lacked objective measures with degrees of movement at each joint. The facility's policy indicated that residents with limited ROM should receive treatment to prevent further decrease, but this was not effectively implemented. A third resident had an RNA order discrepancy, where PROM exercises were ordered five times a week, but splint application was ordered six times a week. The DOR stated that PROM should be performed before splint application to ensure proper joint movement and prevent injury. The facility's policy indicated that residents with limited mobility should receive appropriate services to maintain or improve mobility, but this was not adhered to in practice.
Facility Fails to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents. For two residents, fall mats designed to prevent injury were improperly used, with side tables placed on top of them, creating instability and potential for injury. This was confirmed by CNAs and the Director of Nursing (DON), who acknowledged that such placement could lead to the tables falling on residents. The facility's policy on managing falls and fall risks was not adhered to, as it emphasizes the need for safe room arrangements to prevent falls. Another resident's bed pad alarm, intended to alert staff when the resident leaves the bed, was found non-functional. Despite the resident being at risk for falls, the alarm did not sound when the resident was out of bed. CNAs acknowledged the malfunction and the responsibility to ensure alarms are operational. The DON confirmed that staff should test alarms daily to prevent unsupervised bed exits, as outlined in the facility's policy. Additional hazards included frayed wires on a resident's bed remote control, which posed a risk of electrical shock. The maintenance department was responsible for addressing such issues, but the incident was not reported promptly. Furthermore, a resident's bed was left in an elevated position, increasing the risk of severe injury from falls. The DON confirmed that beds should be kept low to minimize injury risk. Lastly, an oxygen concentrator was improperly placed on a floor mat, risking instability and potential accidents. The facility's policies on hazardous areas and equipment were not followed, as heavy items should not be placed on floor mats to ensure resident safety.
Deficiencies in Enteral Feeding Management
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for two of three sampled residents. For Resident 94, the Licensed Vocational Nurse (LVN 4) did not check for residuals before administering the gastrostomy tube feeding, despite physician orders requiring this step. The resident, who had a history of hemiplegia and dysphagia, was dependent on enteral feeding. During an observation, LVN 4 admitted to not checking for residuals due to nervousness, acknowledging the importance of this step to prevent potential complications such as aspiration pneumonia. For Resident 60, the facility did not label the water flush bag with the rate of delivery, which is crucial for ensuring the correct amount of water is administered. The resident, who had dysphagia and diabetes, was dependent on tube feeding and unable to make decisions. During an interview, the Director of Nursing (DON) confirmed the omission and emphasized the importance of labeling to prevent over or under hydration. Resident 68's enteral feeding and water flush bags were not labeled with the administration rate, contrary to facility policy. The resident, with a history of acute respiratory failure and severely impaired cognition, required total assistance with daily activities. Observations revealed that the bags were missing critical information, which was confirmed by both LVN 1 and RN 1. The DON reiterated the necessity of accurate labeling to ensure the resident receives the prescribed amount of nutrition and hydration.
Improper Medication Disposal and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to properly dispose of medications in one of the inspected medication rooms, as observed during a survey. Medications were found in a pharmaceutical waste bin in their original manufacturer packaging, as well as loose tablets and capsules, without any liquid poured over them to render them irretrievable. This was contrary to the facility's policy, which requires medications to be disposed of in a manner that prevents retrieval, such as by pouring liquid over them. The Registered Nurse (RN) acknowledged that the medications were not disposed of properly, which could lead to potential misuse and diversion. Additionally, the facility did not include verifying signatures of two licensed nurses on the Medication Disposition Record/Pass Log for six logged records. Both the RN and the Director of Nursing (DON) confirmed the absence of witness signatures, which is a requirement according to the facility's policy. The DON acknowledged that the failure to include witness signatures and properly dispose of medications could lead to medication diversion and accidental exposure, affecting the safety of residents and staff.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to monitor the side effects of Trazodone for Resident 17, who was prescribed the medication for depression and insomnia. Despite the care plan indicating the need to monitor for side effects such as nausea, vomiting, anxiety, and dizziness, there was no documentation in the clinical chart from November 1, 2024, to December 4, 2024, indicating whether Resident 17 experienced any adverse consequences from the use of Trazodone. The Director of Nursing confirmed the absence of documentation and acknowledged the importance of monitoring to ensure the resident was free from unnecessary medications and adverse consequences. Additionally, the facility did not ensure that PRN orders for psychotropic medications were limited to 14 days for Resident 353. The resident was prescribed lorazepam for anxiety, but the order did not specify a duration, and there was no documented rationale for indefinite use. The facility's policy requires PRN orders for psychotropic drugs to be limited to 14 days unless the attending physician documents a rationale for extending the order. The Registered Nurse and Director of Nursing both acknowledged the lack of documentation and the potential risk of unnecessary medication use. The facility's policies and procedures emphasize the importance of monitoring for adverse consequences and ensuring that PRN psychotropic medications have a specified duration. However, in the cases of Residents 17 and 353, these protocols were not followed, leading to deficiencies in medication management and monitoring. The lack of documentation and adherence to policy put the residents at risk for unnecessary medication use and potential adverse effects.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 17.86% due to five errors observed out of 28 opportunities. The errors involved incorrect administration of medications to three residents. One resident received a different dose of Omega-3 Fatty Acid than prescribed, while another resident did not receive their prescribed metformin and pioglitazone for diabetes management and was given a different form of multivitamin. A third resident received a multivitamin with minerals instead of the prescribed form. The errors were observed during medication administration rounds. Licensed Vocational Nurse 5 (LVN 5) failed to administer metformin and pioglitazone to a resident and gave an incorrect multivitamin. LVN 6 administered the wrong dose of Omega-3 Fatty Acid to another resident and the wrong multivitamin to a third resident. These actions were contrary to the facility's policy and procedures, which require medications to be administered as prescribed and within one hour of the scheduled time, with the medication label checked three times to ensure the right resident, medication, dosage, time, and method of administration. Interviews with the involved nurses and the Director of Nursing (DON) confirmed the medication errors. The DON acknowledged that the nurses failed to follow the facility's medication administration guidelines and the 5 rights of medication administration. The facility's policy defines a medication error as any preparation or administration of drugs not in accordance with physician's orders, manufacturer specifications, or accepted professional standards, which includes omissions, wrong doses, and wrong drugs.
Failure to Prepare Puree Foods to Required Consistency
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a puree diet, specifically level four, which requires food to be soft and pudding-like in consistency. During an observation of the lunch trayline, it was noted that the puree Boston baked beans did not hold their shape when served, and the puree cabbage was weeping liquid on the resident's plate. This inconsistency in food texture was confirmed during a test tray evaluation with the Dietary Supervisor and Diet Aide, who acknowledged that the puree foods should hold their shape and not be watery. The facility's policies and procedures, as well as the diet manual, specify that therapeutic diets, including textured-modified diets, should be prepared and served using safe, sanitary food practices, and the puree diet should be lump-free, not firm or sticky, and hold its shape on a plate. The facility's recipe for puree Boston baked beans and steamed cabbage included the use of a thickener to ensure the correct consistency, but the finished products did not meet the required standards. The International Dysphagia Diet Standardization Initiative (IDDSI) guidelines for Level 4 Pureed foods state that the food should fall off a spoon in a single spoonful when tilted and continue to hold its shape on the plate, with no separation of liquid from solid. The failure to adhere to these guidelines and recipes resulted in the potential for adverse outcomes for 11 of the 76 residents on a puree/level 4 diet, as the improper food texture could lead to issues such as aspiration, weight loss, and malnutrition.
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. There were multiple instances of chipped, cracked, and rusted kitchen utensils and equipment, including two of five shelves in the walk-in refrigerator that had cracks and rust. A chopping board was found with food stains, cracks, and scratches, which could lead to cross-contamination. The Dietary Supervisor (DS) acknowledged these issues, stating that they could result in bacterial growth and potential foodborne illness. Food preparation surfaces and kitchen equipment were not properly cleaned and sanitized. The reach-in refrigerator had food debris, dirt, and dust buildup around the gasket, and the dry storage racks had dust buildup with food debris and dirt on the floor. The coffee machine spout had dried-up coffee and mineral water buildup, and the condiments storage area had food debris and sugar spills. The mixer was found with dry food splatter and residue. The DS confirmed these observations, noting that the lack of cleanliness could lead to cross-contamination and foodborne illnesses. Additional deficiencies included improper hand hygiene and utensil handling by staff. A staff member was observed wearing jewelry while preparing food, which is against the facility's policy. Another staff member washed their hands improperly and used a two-compartment sink with dish soap instead of handwashing soap. Utensils were not air-dried after sanitization, which could lead to chemical contamination. The DS acknowledged these practices were not in line with the facility's policies and could result in foodborne illnesses for the residents.
Discrepancy in Code Status Orders for a Resident
Penalty
Summary
The facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment, specifically for a resident with full code status. The deficiency was identified when a review of the resident's records revealed a discrepancy between the resident's POLST, which indicated full treatment and resuscitation, and an active physician's order for DNR/DNI. This inconsistency had the potential to result in the resident's wishes not being known, thereby placing the resident at risk for a delay in life-saving treatment. The resident in question, who was admitted with conditions including hemiplegia, hemiparesis, and dysphagia, was dependent on staff for various activities and required tube feeding. The resident's POLST, signed by both the physician and the resident's representative, clearly indicated a preference for full treatment and resuscitation. However, the Order Summary Report contained a conflicting order for DNR/DNI, which was entered by the DON without reviewing the POLST. Interviews with facility staff, including a registered nurse and the DON, confirmed the confusion caused by the contradictory orders. The DON acknowledged the error, stating that the physician's order for DNR/DNI was entered based on the resident's previous code status and without checking the updated POLST. This oversight was a violation of the facility's policies and procedures regarding resident rights and advance directives, which emphasize the importance of respecting and following a resident's treatment preferences.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, identified as Resident 75, who was unable to complete passive range of motion (PROM) exercises for both knees during a Restorative Nursing Aide (RNA) program. This deficiency was observed during a session where two RNAs attempted to perform PROM exercises on the resident's upper and lower extremities but did not attempt to move the knees, citing that they could not bend. The resident's medical records indicated a history of acute respiratory failure, dependence on a respirator, and unspecified joint contracture, with a care plan goal to maintain current range of motion (ROM) in all extremities. The resident's Minimum Data Set (MDS) and care plan indicated severe cognitive impairment and a requirement for dependent assistance in daily activities, with a specific order for PROM exercises to all extremities six times a week. Despite this, the RNA Weekly Summary did not document any issues with the resident's knees, and the Director of Staff Development (DSD) confirmed that no reports of decline in knee ROM were made during RNA meetings. Interviews with the RNAs revealed that they did not report the inability to perform PROM on the knees, which was considered a change in condition (COC) that should have been communicated to the physician. Further interviews with the Director of Rehabilitation (DOR), Physical Therapist (PT), and Director of Nursing (DON) highlighted the expectation for RNAs to report any inability to perform PROM exercises as it could indicate a need for medical intervention. The facility's policy required notification of the physician for significant changes in a resident's physical condition, which was not adhered to in this case. The failure to report the decline in ROM for Resident 75's knees potentially delayed necessary assessment and intervention, risking further decline in the resident's joint mobility.
Failure to Develop Baseline Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a baseline care plan for a resident, identified as Resident 353, who was admitted with significant medical conditions including chronic respiratory failure, tracheostomy status, and dependence on a ventilator. The resident was prescribed lorazepam, a psychotropic medication, to manage anxiety symptoms such as tachypnea leading to shortness of breath or desaturation. However, the facility did not include the use of lorazepam in the baseline care plan, which is essential for guiding staff in the resident's care. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the baseline care plan should have included the use of lorazepam to ensure the resident's immediate care needs were met. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, but this was not done for Resident 353. This oversight had the potential to result in a delay in care or lack of delivery of care and services for the resident.
Failure to Provide Personal Hygiene Supplies to Resident
Penalty
Summary
The facility failed to provide necessary personal hygiene care for a female resident, identified as Resident 77, who was not offered shaving equipment or assistance for grooming facial hair. The resident was initially admitted on 10/27/2023 and readmitted on 11/5/2024, with a diagnosis of weakness. According to the Minimum Data Set (MDS) dated 10/29/2024, the resident was capable of understanding and making decisions and required setup assistance with personal hygiene tasks. Despite this, observations on 12/3/2024 and 12/4/2024 revealed that the resident had noticeable facial hair, indicating a lack of grooming assistance. The resident expressed that she could manage her personal hygiene if provided with the necessary supplies, but had not been offered a razor since her initial admission. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON), confirmed that the resident should have been offered a razor daily, given her alertness and ability to perform self-care with setup assistance. The DON acknowledged that failing to provide such equipment could negatively impact the resident's dignity and psychosocial well-being. The facility's policy on Activities of Daily Living (ADL) supports providing care to maintain or improve residents' ability to perform ADLs, yet this was not adhered to in the case of Resident 77.
Failure to Label Oxygen Humidifier
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for Resident 97, who was admitted with acute respiratory failure, gastrostomy status, and tracheostomy status. The deficiency was identified when it was observed that the oxygen humidifier connected to Resident 97's tracheostomy did not have a label indicating the date it was last changed. This oversight was confirmed during interviews with both a respiratory therapist and a registered nurse, who stated that the humidifiers are supposed to be changed twice a week and labeled with the date of the last change. The facility's policy requires disposable equipment, such as oxygen humidifiers, to be labeled with the patient's name and the date it was last changed, and to be replaced every Monday and Thursday by the night shift staff. The absence of a date on the humidifier placed Resident 97 at risk for infection, as it was unclear whether the equipment had been changed according to the schedule. Both the respiratory therapist and the registered nurse acknowledged the importance of labeling to ensure compliance with the facility's policy and to prevent potential health risks to the resident.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the use of grab bars/bed rails, which includes evaluating the risks of entrapment and obtaining informed consent from the resident or their representative. This deficiency was identified for one resident who was observed with grab bars/side rails in use without a physician's order, informed consent, or an updated Side Rail Utilization Assessment. The resident, admitted with diagnoses including encephalopathy and a history of falls, was noted to have the ability to make needs known but not decisions, according to their History and Physical. However, their Minimum Data Set indicated they could understand and be understood by others, requiring partial assistance with mobility and activities of daily living. During an observation, it was found that the resident was lying in bed with both upper grab bars/side rails applied, despite the Side Rail Utilization Assessment indicating that these were not in use or requested. A Registered Nurse confirmed the absence of a physician's order, informed consent, and a care plan for the use of the grab bars/side rails. The facility's policy on bed safety and bed rails, which prohibits the use of bed rails unless specific criteria are met, was not adhered to, placing the resident at risk for potential accidents such as entrapment or falls.
Inadequate Food Temperature Management in Station 3
Penalty
Summary
The facility failed to maintain appropriate food temperatures for breakfast in Station 3, affecting 34 of 77 residents, including a resident with a regular diet and thin liquid consistency. Observations revealed that the food temperatures were below acceptable levels, with fried eggs at 114°F, oatmeal at 94°F, milk at 51°F, and juice at 69°F. These temperatures were recorded during a test tray evaluation by the Dietary Supervisor, who acknowledged that the food was cold, particularly the oatmeal, and attributed this to the travel time from the kitchen to Station 3. The resident involved had a history of hypothyroidism, hyperlipidemia, and essential hypertension, and required assistance with setup and cleanup during meals. The resident expressed dissatisfaction with the food, stating it was sometimes cold and not tasty. The facility's policy indicated that menus should meet resident choices and follow national guidelines for nutritional adequacy, but the observed food temperatures did not align with these standards, potentially impacting residents' food intake and nutritional status.
Failure to Document Resident's Condition and Treatment
Penalty
Summary
The facility failed to document the condition and treatments administered to a resident who was found unresponsive, which was identified during a review of the resident's medical records. The resident, who had been admitted with diagnoses including sepsis, COPD, and type 2 diabetes mellitus, was found non-responsive by a CNA, who then called the charge nurse's attention and initiated the code blue protocol. However, there was no documentation of the resident's vital signs or the treatments provided during this emergency situation. Interviews with the Director of Staff Development and the Director of Nursing revealed that the licensed nurse who responded to the emergency should have documented the assessment, including vital signs and the resident's status, to prove the resident's condition at that moment. The facility's policy and procedure on charting and documentation require that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. The lack of documentation resulted in an incomplete medical record for the resident.
Infection Control Deficiencies in Equipment Labeling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific deficiencies. Firstly, the facility did not ensure that the nasal cannula (NC) used for a resident receiving supplemental oxygen was labeled with the date it was last changed. This oversight was observed in a resident who was dependent on staff for all activities of daily living and had significant medical conditions, including hemiplegia and acute respiratory failure. The facility's policy required NCs to be changed weekly and labeled with the date to prevent infection, but this was not adhered to, as confirmed by staff interviews and observations. Additionally, the facility did not label a urinal bottle with the resident's name and room number, which is necessary to prevent cross-contamination and infection. This was observed in a resident with diabetes and encephalopathy, who required assistance with daily activities. The lack of labeling was acknowledged by a CNA and the Director of Nursing, who confirmed that the urinal should be personalized for infection control purposes. These deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in the facility's adherence to its infection control policies. The facility's infection control policies were intended to maintain a safe and sanitary environment, but the failure to label and change equipment as required posed a risk of infection transmission among residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) for a resident, leading to a deficiency in monitoring and completing the infection surveillance evaluation for the resident's metronidazole order. The resident, who had been admitted with chronic respiratory failure, tracheostomy status, and ventilator dependence, was receiving metronidazole for a leg infection. However, the infection screening/evaluation form was not completed for the antibiotic orders dated 9/17/2024 and 9/24/2024. The Infection Preventionist (IP) acknowledged that the evaluation was necessary to determine if the antibiotic was indicated and to prevent potential antibiotic resistance. The facility's policy required that all clinical infections treated with antibiotics undergo review by the IP or designee, and that all antibiotic regimens be documented on a surveillance tracking form. The Director of Nursing (DON) confirmed that the ASP is used to monitor antibiotic use and prevent unnecessary antibiotic administration. The failure to follow the ASP and complete the necessary documentation placed the resident at risk for microbial resistance and reduced outcomes, as the antibiotic order lacked a stop date and was not properly evaluated.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's discharge status, as evidenced by the incorrect coding of the Minimum Data Set (MDS) for a resident who was discharged home. The MDS inaccurately indicated that the resident was discharged to a hospital, despite documentation in the Discharge Summary and Progress Note confirming the resident was discharged home with family. This discrepancy was identified during a review of the resident's records, which included the Admission Record, Discharge Summary, and MDS, as well as an interview with the Minimum Data Set Coordinator (MDSC 1). The Director of Nursing (DON) confirmed that the MDS should accurately reflect the resident's discharge status, as it is used for billing purposes and informs discharge planning. The facility's policy and procedure on Resident Assessments, aligned with the CMS Resident Assessment Instrument (RAI) Version 3.0 Manual, requires that the MDS accurately document the discharge location. The failure to correctly code the MDS for the resident's discharge status represents a deficiency in the facility's assessment process, potentially impacting the resident's care and services.
Failure to Conduct Weekly Skin and Wound Assessments
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for a resident, identified as Resident 1. The deficiency was identified through interviews and record reviews, which revealed that the facility did not conduct weekly skin and wound assessments for Resident 1, who was at risk for developing pressure ulcers due to limited mobility and other medical conditions. The resident was admitted with chronic respiratory failure, a tracheostomy, and essential hypertension, and was noted to be nonverbal, disoriented, and functionally quadriplegic, requiring extensive assistance for all activities of daily living. The record review showed that Resident 1's skin and wound evaluations were not performed weekly as required. Specifically, there was a lack of documentation for the evaluation on 10/31/2024, which was confirmed by the Treatment Nurse. The evaluations that were conducted showed changes in the surgical stoma wound on the resident's abdomen, indicating the importance of regular assessments to monitor the wound's response to treatment and to detect any signs of infection or deterioration. Interviews with the nursing staff, including a Registered Nurse and the Director of Nursing, confirmed that the facility's policy required weekly skin and wound assessments, which were not adhered to in this case. The facility's policies on pressure injury risk assessment and wound care documentation emphasized the need for regular assessments and detailed documentation to ensure proper care and monitoring of residents at risk for pressure ulcers.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring for side effects of heparin, an anticoagulant medication, in one of the sampled residents. The resident, who was admitted with chronic respiratory failure, a tracheostomy, and essential hypertension, was not alert, disoriented, and nonverbal. The resident's physician had ordered heparin injections for deep vein thrombosis prophylaxis, which were administered from late October to mid-November 2024. However, there was no documented monitoring for bleeding, a known side effect of heparin, in the resident's Medication Administration Record (MAR) during this period. Interviews with the Registered Nurse and the Director of Nursing confirmed the lack of documentation and emphasized the importance of monitoring for bleeding to prevent complications such as a decrease in hemoglobin. The facility's policy on anticoagulant therapy, which was last reviewed in September 2024, required staff to monitor for signs of bleeding and to consult with a physician if such signs were present. Despite this policy, the necessary monitoring was not conducted, leading to a deficiency in the resident's care.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, leading to a deficiency. The resident, who was admitted with chronic respiratory failure, a tracheostomy, and essential hypertension, was documented as disoriented and nonverbal. The Minimum Data Set indicated that the resident's cognitive skills for daily decisions were severely impaired, requiring extensive assistance for all activities of daily living. However, discrepancies were found in the medical records, particularly in the Medication Administration Record (MAR), which inaccurately documented the resident's oxygen saturation after the resident had been transferred to a General Acute Care Hospital. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that the documentation error was made by a Respiratory Therapist who recorded information on the wrong date. The facility's policy on charting and documentation emphasizes the need for accurate, complete, and objective records to facilitate communication among the interdisciplinary team. Despite this policy, the inaccurate documentation in the resident's medical record was identified, highlighting a failure to adhere to the facility's standards for maintaining medical records.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, resulting in the affected resident experiencing anxiety, depression, and stress. The incident involved Resident 1, who reported being verbally abused by Resident 2, including being called derogatory names and being publicly humiliated. Despite Resident 1's intact cognition and existing care plan for depression, the facility did not monitor or address the signs and symptoms of depression as required. Resident 2 had a documented history of verbally offensive and aggressive behavior, with care plans indicating the potential for such behavior and interventions to notify the attending physician of any changes. However, the facility staff, including a certified nursing assistant and a social service assistant, failed to report the verbal abuse allegations to the administrator or other officials as per the facility's policy. This lack of reporting and documentation meant that Resident 1's concerns were not addressed, and the potential for further abuse was not mitigated. Interviews with various staff members, including a licensed vocational nurse, a physical therapist, and the director of nursing, revealed that the facility did not follow its policy on reporting and investigating abuse. The facility's policy required immediate reporting of suspected abuse, defined as within two hours of the allegation. The administrator, who was the facility's abuse coordinator, was unaware of the allegations, indicating a breakdown in communication and adherence to the facility's procedures for handling abuse allegations.
Failure to Timely Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident verbal abuse to the State Survey Agency (SSA) in a timely manner. Resident 1, who was admitted with chronic systolic heart failure, COPD, and essential hypertension, reported being verbally abused by Resident 2. The abuse involved derogatory comments about Resident 1's sexual orientation and physical appearance, which caused Resident 1 to feel stressed and depressed. Despite being informed of the incident on 10/16/2024, the facility's Abuse Coordinator did not report the allegation to the SSA until 10/29/2024, 13 days later. Interviews with staff members, including a Certified Nursing Assistant (CNA 1), a Physical Therapist (PT 1), and a Social Service Assistant (SSA 1), confirmed that the verbal abuse was witnessed and acknowledged as a form of abuse. However, SSA 1 admitted to not documenting or reporting the incident, which was a violation of the facility's policy requiring immediate reporting of abuse allegations. The facility's policy defined 'immediately' as within two hours of the allegation. The delay in reporting had the potential to result in unidentified abuse and failure to protect other residents from similar incidents.
Failure to Document Resident's Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the clinical records for one of the residents. On a specific date, a resident reported an incident of alleged verbal abuse by another resident to a Social Service Assistant (SSA). However, the SSA did not document this conversation in the resident's clinical record, resulting in incomplete and inaccurate information. The resident had been admitted with diagnoses including chronic systolic heart failure, chronic obstructive pulmonary disease, and essential hypertension, and was noted to have intact cognition but exhibited signs of depression. During interviews, the resident expressed feeling stressed and depressed due to derogatory remarks made by another resident. The SSA acknowledged the failure to document the resident's report of verbal abuse, which was considered a form of verbal bullying. The Director of Nursing confirmed that all resident concerns and conversations should be documented in the clinical records, as per the facility's policy. The facility's policy on charting and documentation emphasized the importance of documenting all services, progress, and changes in the resident's condition to facilitate communication among the interdisciplinary team.
Failure to Conduct Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers in a resident admitted with a deep tissue injury in the sacral region. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and pressure-induced deep tissue damage, was identified as at risk for developing pressure ulcers. Despite this, the facility did not develop and implement a resident-centered care plan that included a weekly pressure injury risk assessment for the first four weeks as required by their policy. The care plan initiated did not specify the frequency of wound assessments, which should have been conducted weekly. Interviews and record reviews revealed that the facility did not document weekly pressure ulcer evaluations for two weeks following the resident's admission. The treatment nurse acknowledged the absence of documentation and stated that the facility's policy required weekly reassessment of wounds to monitor their progress and inform the physician if the wounds were not improving. The Assistant Director of Nursing confirmed that the facility's policy required weekly risk assessments for the first four weeks and that the care plan should have indicated this frequency. The lack of adherence to these procedures had the potential to result in the development and worsening of pressure ulcers for the resident.
Failure to Implement Infection Control Measures for Resident on EBP
Penalty
Summary
The facility failed to implement proper infection control measures for a resident who was placed on enhanced barrier precautions (EBP) due to infections with multidrug-resistant organisms. The resident had a history of surgical aftercare, recurrent enterocolitis due to Clostridium difficile, and unspecified sepsis. The resident's care plan required the use of gowns and gloves during high-contact activities to prevent the spread of infection. During an observation, a Certified Occupational Therapist Assistant (COTA) was seen assisting the resident without wearing a protective gown, despite the presence of signage indicating the need for such precautions. The COTA was observed placing her hands on the resident while helping them get out of bed, which is considered a high-contact activity requiring gown use under the facility's policy. Interviews with staff, including a Certified Nursing Assistant (CNA), a Licensed Vocational Nurse (LVN), and the Infection Preventionist, confirmed that the COTA should have worn a gown during this interaction. The Director of Staff Development and the Director of Nursing both acknowledged that the facility's policy mandates gown use for high-contact activities with residents on EBP. The facility's policy and procedure document, last reviewed in October 2023, clearly states that enhanced barrier precautions are necessary to reduce the spread of multidrug-resistant organisms, and that gowns and gloves should be used during high-contact activities such as transferring residents.
Failure to Follow LALM Guidelines for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for a resident by not adhering to the manufacturer's guidelines for the use of a low air loss mattress (LALM). The resident, who was admitted with an unstageable pressure ulcer and had diagnoses including cerebral infarction and type two diabetes mellitus, was found to have multiple layers of linen on the LALM. Specifically, the resident had one linen, two disposable underpads, and a sheet folded in two, totaling five layers. This was contrary to the manufacturer's guidelines, which recommend only one sheet to be placed on the LALM to ensure its effectiveness in preventing skin breakdown and treating pressure ulcers. The Certified Nursing Assistant (CNA) responsible for the resident's care admitted to not being inserviced on the proper use of the LALM, and the Licensed Vocational Nurse (LVN) and Director of Nursing (DON) confirmed that the multiple layers of linen defeated the purpose of the LALM. The deficiency was identified through observation, interview, and record review. The CNA was unaware of the proper protocol, and the LVN was not informed about the multiple layers of linen. The DON acknowledged that residents on LALM should have a maximum of two layers, including the incontinent brief, for effective wound management. A study cited in the report indicated that additional linens or underpads on LALM surfaces could adversely affect skin temperature and moisture, thereby reducing the pressure ulcer prevention potential of these surfaces. This failure to follow professional standards of practice had the potential to worsen the resident's pressure ulcers and prevent effective treatment.
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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