Napa Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Napa, California.
- Location
- 705 Trancas St., Napa, California 94558
- CMS Provider Number
- 056153
- Inspections on file
- 31
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 28 (1 serious)
Citation history
Health deficiencies cited at Napa Post Acute during CMS and state inspections, most recent first.
The facility failed to maintain an effective infection prevention and control program, resulting in a C. diff outbreak affecting multiple residents and significant lapses in basic infection control practices. The IP could not describe a communicable disease surveillance system or produce tracking logs, and the infection control manual lacked a specific C. diff policy or national standards references. Staff interviews and observations showed inconsistent and often incorrect use of disinfectants and shared vital sign equipment in isolation rooms, absence of dedicated BP cuffs, improper or omitted hand hygiene, and direct care to residents on contact precautions without appropriate PPE. Residents with C. diff shared bathrooms with non-infected residents without a defined process for bleach cleaning after each use, and leaders could not explain how bedside commodes would be safely managed. Record reviews revealed delays in initiating isolation for residents with suspected or confirmed C. diff despite documented loose stools and positive lab results. Separately, water testing showed very high levels of Legionella with documented immediate risk, yet there was no functioning water management program, no ongoing monitoring, and no ICC or QAPI follow-up. An open sewage pipe area in a communal shower room, stuffed with wet paper towels and used to store medical equipment, was identified by the IP as an infection risk, further evidencing environmental control failures.
The facility’s QAPI Committee did not identify or address multiple quality of care issues, including systemic infection control and prevention problems, despite a written plan stating that data from various sources would be used to monitor care and services in areas such as infections and medications. The Administrator reported that the QAPI Committee met monthly and relied on input from department heads, grievances, the resident council, staff meetings, and an anonymous suggestion box, and that only ongoing struggles were escalated for QAPI monitoring. A performance improvement project for infection prevention was initiated only after surveyors were already on-site, and no other quality of care issues later found by surveyors had been captured by the QAPI Committee as areas for improvement, resulting in a systemic breakdown of the infection control and prevention program with potential for resident harm.
Surveyors found that the medical director failed to provide effective oversight of infection prevention and control, informed consent for psychotropic medications, and diagnostic evaluation for serious mental illness. The Infection Prevention and Control Program, including antibiotic stewardship and monitoring for C. diff and Legionella, lacked active medical director oversight. Two residents receiving psychotropic medications had informed consent forms that were unsigned by their representatives and lacked documentation of verbal consent, while their representatives reported not being contacted about these medications. In addition, two residents were newly assigned diagnoses of schizophrenia or schizoaffective disorder based largely on medication use and behavior, without documentation of comprehensive, evidence-based assessments as required by facility policy, and without consistent confirmation of these diagnoses in behavioral health or psychology notes.
Surveyors found that residents’ rights to dignity, communication, and access to assistance and visitors were not honored. A cognitively intact resident reported night staff yelling profanities outside his room and staff frequently speaking a foreign language in front of him, while a nurse was repeatedly observed vaping at the main entrance despite prior discipline for unprofessional behavior. The grievance log documented numerous complaints about unprofessional staff conduct, but Social Services, the DON, and the Administrator reported being unaware of such issues and did not review the log for trends as required by policy. Three residents were observed without accessible call lights—one with left-sided weakness after a stroke and others reporting long waits for toileting care—while a nurse confirmed none of them could reach their call systems. Another resident, who depended on substantial ADL assistance, tearfully expressed a desire to see her daughter, but the facility blocked the daughter’s visits based on DPOA instructions. Multiple cognitively intact residents also reported staff speaking foreign languages in hallways, shared rooms, and during direct care, making them uncomfortable because they could not understand what was being said, despite facility expectations that staff use a language understood by residents.
Surveyors found widespread environmental disrepair and unsanitary conditions, including cracked and missing floor tiles, chipped paint, exposed plaster, unsealed concrete, and damaged wood and laminate surfaces in resident rooms, nursing stations, utility rooms, and laundry areas. Hand-washing sinks at both nursing stations had exposed, damaged plaster behind faucets, and a medication cart had a cracked surface with exposed wood. In the laundry area, only one washer and two of three dryers were functional, with the operating washer showing corrosion and the room containing rusty fixtures, broken tiles, and exposed plaster. A red hose was plumbed through a wall opening to the outside, leaving a visible gap and causing water to pool on the exterior cement. Staff, including an LPN, the IP, the DON, and department heads, acknowledged these conditions, expressed uncertainty about disinfecting damaged and corroded surfaces, and confirmed that leadership was aware of many of the unresolved environmental issues.
A resident with multiple neurologic and swallowing impairments, fed via G-tube and assessed as high risk for constipation, was care planned to have bowel movements every 1–3 days with medications per physician order, yet no routine bowel regimen was ordered or provided, and only PRN MiraLax was obtained and given after five days without a documented BM. Bowel records showed a small stool followed by no further BMs, and the resident was later hospitalized with findings of no BM for several days, feculent G-tube output, abdominal distention, and imaging suggesting ileus versus bowel obstruction. The DON reported that nurses were expected to monitor last BMs via the eMR alert, initiate bowel care after three days without a BM, and secure routine bowel care orders when a constipation care plan is developed, consistent with facility policy requiring assessment and documentation of lower GI symptoms including fecal impaction and abdominal status.
A resident with heart disease, muscle weakness, need for assistance with personal care, and unspecified psychosis eloped from the facility through front doors that opened onto a busy street. Staff believed the resident was in his room, and an RN later reported she was at lunch when he went missing and that he did not have a wander alarm in place despite an assessment indicating one was indicated. The resident’s elopement risk score was documented as low, the DON later called the wander-alarm recommendation a mistake, and the care plan included a wander alarm but no specific supervision or monitoring interventions beyond a falls care plan instruction to keep the resident within supervised view as much as possible. The resident left the building unnoticed and was found and returned by police.
The facility failed to provide adequate nursing staff and services to ensure residents’ hydration, toileting, and skin care needs were met. Several cognitively intact residents with conditions such as heart failure, ESRD, DM, metabolic encephalopathy, and hemiplegia had care plans requiring encouragement of fluids, frequent fluid offerings, incontinence care, and assistance with repositioning and transfers, yet reported that water was only changed once daily, left from the prior evening, warm, or out of reach, and that they received additional water only if they specifically asked. Multiple residents described waiting 30–60 minutes for call lights to be answered, particularly on swing and night shifts, resulting in them remaining in soiled briefs with associated skin burning and redness and feelings of lost dignity. Resident Council minutes documented ongoing concerns about insufficient CNAs, night shift staff not answering call lights, and CNAs sleeping or using phones in rooms. A surveyor directly observed a call light remaining on for 20 minutes while staff passed by or briefly entered only to take supplies without addressing the resident’s need, despite facility policy and leadership statements that staffing and timely call-light response should be adequate to meet residents’ needs.
A resident was admitted with multiple conditions, including obstructive/reflux uropathy and urinary retention, and had an indwelling urinary catheter in place after a failed voiding trial. Despite this, licensed nurses did not initiate a baseline, person-centered care plan addressing UTI risk related to the catheter, and the MDS later confirmed the presence of the catheter and stool incontinence. The resident subsequently developed fever and hypoxia and was sent to the ED, where sepsis due to UTI was diagnosed based on vital signs, elevated WBC, and urinalysis showing many bacteria and large leukocyte esterase. The DON acknowledged there was no catheter-related care plan or documentation of catheter care, while the DSD stated catheter care was not charted because it was considered standard of care, contrary to facility policy requiring care plan review and detailed documentation of catheter care and assessments.
The facility failed to ensure the most recent survey results were accessible to residents, as required by policy. The survey results binder was not found during observations, and staff interviews revealed a lack of awareness and communication about its location. The DON admitted to taking the binder to update it and forgot to return it, resulting in its unavailability for a week.
The facility failed to allow residents to file grievances anonymously, contrary to its policy. Grievance forms were not publicly accessible, requiring residents to request them from staff, compromising anonymity. Interviews with the grievance officer and observations confirmed that forms were stored in non-public areas, and residents had to ask for assistance to access them. The Administrator and DON acknowledged the need for anonymous grievance filing.
The facility failed to ensure accurate MDS assessments for three residents, leading to incorrect discharge statuses and unrecorded use of a WanderGuard device. One resident was incorrectly documented as discharged to a hospital instead of home, another was inaccurately recorded as discharged home instead of to a hospital, and a third resident's use of a WanderGuard device was not reflected in their MDS despite being at risk for elopement.
A facility failed to ensure a resident's PASRR accurately captured their diagnosis of unspecified psychosis, an SMI. The resident's PASRR Level I Screening incorrectly indicated no SMI, despite the facility's policy requiring accurate screening for mental disorders. Staff interviews revealed the PASRR process should have addressed discrepancies upon admission, but the issue was only corrected after a survey identified the deficiency.
A resident with limited ROM did not receive ordered passive ROM therapy due to a lack of communication and follow-through by facility staff. Despite a doctor's order for rehabilitation services, there was no documentation of the order being completed, and the resident expressed a desire for therapy to aid mobility. Interviews revealed that staff were unaware of the order, leading to the resident not receiving necessary care.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to improper application of a WanderGuard device, which was attached to the metal part of their wheelchair, potentially interfering with its function. The staff failed to monitor the resident adequately and did not follow the manufacturer's guidelines for the device. Additionally, a supply closet containing medical supplies was found unlocked, posing a risk to wandering residents.
A medication cart was found unlocked and unattended outside a room, contrary to the facility's policy requiring secure storage of medications. An RN confirmed she was out of eyesight from the cart and acknowledged the oversight. The DON reiterated that medication carts should not be left unlocked and unattended.
A resident's medication order for Pred Forte was not discontinued in their clinical record despite a physician's directive. The resident, with a history of type two diabetes, had a follow-up appointment where the discontinuation was noted. However, the facility staff failed to review and update the order, leaving it active in the records. The oversight was confirmed by the LVN and Medical Records Director, who noted the physician's note was not reviewed before being scanned into the EMR.
A facility failed to provide adequate oral care for three residents, leading to poor oral hygiene and malodorous breath. One resident's daughter reported neglect, noting her father's mouth appeared to be rotting. Another resident did not receive oral care supplies for nine days, despite requests. A third resident received inadequate oral care, which was not documented. The facility's policy requires assistance with ADLs, including oral hygiene.
Expired medications and supplies were found in the treatment cart of an LTC facility, including silver nitrate applicators, barrier cream, and Providone Iodine solution. The charge treatment nurse responsible for checking the cart was on leave, and the facility's policy for handling expired items was not followed.
A resident reported a broken bed frame and damaged electronic tablet, but the facility failed to resolve these grievances, leading to discomfort and frustration. The Social Services staff did not follow up on the complaints, violating the facility's grievance policy.
A resident was unable to receive private phone calls due to a malfunctioning phone system and staff inaction, leading to a family member calling the police for a wellness check. The facility's phone issues were known to staff and the administrator, affecting communication and violating residents' rights.
A resident with anxiety disorder and alcohol dependence did not receive five doses of Chlordiazepoxide due to a delay in reordering the medication. The facility's policy required timely reordering to ensure an adequate supply, but the medication was not reordered in time, leading to missed doses.
A resident experienced severe weight loss and dehydration during a 3.5-week stay at the facility. Nursing staff and the RD failed to notify the physician, NP, or family about the weight loss, did not document it, and did not discuss it during relevant meetings. The resident's family removed him AMA, and he was admitted to the ICU with severe dehydration, malnutrition, and other complications.
A resident experienced a severe weight loss of 30.8 pounds within 18 days of admission, and the facility staff failed to notify the physician or implement interventions. The resident's family took him to a hospital, where he was admitted to the ICU in critical condition. Despite the weight loss being documented and presented at a QAPI meeting, it was not addressed, preventing the facility from identifying system failures and implementing necessary changes.
Failure of Infection Control Program Leading to C. diff Outbreak, Legionella Risk, and Environmental Contamination
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain an effective infection prevention and control program, resulting in a C. difficile (C. diff) outbreak and multiple lapses in basic infection control practices. Eight residents were confirmed positive for C. diff between 11/12/25 and 1/24/26, and three residents had active C. diff infections on the survey entrance date. The Infection Preventionist (IP) could not describe the facility’s surveillance program for communicable diseases and was unable to provide a tracking log for such infections. The facility’s Infection Prevention Policy and Procedure Manual lacked a specific policy or protocol for C. diff and did not cite national standards for infection control, despite referencing regulatory requirements that call for written standards, policies, and procedures, including when and how isolation should be used and what hand hygiene procedures staff must follow. Staff interviews and observations showed widespread confusion and inconsistency regarding appropriate disinfectants and equipment use for C. diff. Multiple unlicensed staff and housekeeping personnel reported or were observed using products not effective against C. diff, such as Clorox disinfectant spray and Medline MicroKill One alcohol-based wipes with violet or lavender tops, instead of bleach-based products labeled as killing C. diff spores. Some staff stated that residents on C. diff precautions should have dedicated vital signs equipment, but in practice, shared vital sign towers and reusable stethoscopes were routinely brought into isolation rooms and then wiped down, often with non-bleach products. In several C. diff isolation rooms, no dedicated blood pressure cuffs or vital sign equipment were present, and staff acknowledged that there were only a few vital sign towers in the facility, preventing them from being left in isolation rooms as dedicated equipment. Hand hygiene and isolation practices were also deficient. Staff were observed exiting resident rooms, including those on contact precautions, without performing hand hygiene, and some staff admitted forgetting to wash their hands or not knowing that soap and water for 20 seconds were required for contact precautions. A nurse was observed attempting to wash hands at a nurses’ station sink that did not have warm water or paper towels, and a nurse practitioner stated she did not wash hands in a contact precaution room’s bathroom because she considered it contaminated, without being able to state the facility’s hand hygiene policy. Staff were observed providing direct care to residents on contact precautions without gowns, and bedside care staff could not consistently verbalize appropriate PPE use or the correct disinfectant for shared equipment in C. diff rooms. Resident placement and bathroom use for C. diff-positive residents were not managed according to the facility’s own written expectations for individualized room placement and dedicated equipment. Two residents with C. diff shared a bathroom with residents who did not have C. diff, and the DON and IP could not describe a clear process for ensuring the bathroom was cleaned with bleach after each use or how staff would monitor and document such cleaning, especially when residents used the bathroom independently. The DON stated she was not concerned about a C. diff resident sharing a bathroom with non-C. diff residents and acknowledged there was no process to ensure cleaning after each use. When discussing the use of bedside commodes for C. diff residents, both the DON and IP were unable to explain how staff would empty the commodes if the shared bathroom was not to be used, and there was no clear plan for preventing cross-contamination in these scenarios. Medical record reviews showed delays and inconsistencies in initiating isolation precautions for residents with suspected or confirmed C. diff. For one resident, a positive C. diff result was obtained on 11/6/25, but the resident was not moved to an isolation room until 11/10/25. Another resident had loose stools documented on CNA task sheets, with a stool specimen collected and later confirmed positive for C. diff, and contact precautions were not initiated until days after the specimen was sent and the positive result obtained. For another resident, documentation indicated multiple episodes of loose, foul-smelling stools and a positive C. diff result, with contact precautions initiated only after the result was received, despite CDC guidance that patients with three or more stools in 24 hours should be isolated immediately when C. diff is suspected. These delays occurred in the context of a documented outbreak, with 11 C. diff cases identified over a one-year period on the facility’s surveillance log. The facility also failed to implement an effective water management program for Legionella as part of its infection control system. The water system was tested in February 2025, and 9 of 10 samples were positive for Legionella, with documentation describing excessively high levels of Legionella, low to zero chlorine residuals, very high occupant susceptibility, and an immediate risk to patient health. The testing company strongly recommended immediate implementation of a water management program and noted that such a program is mandated by CMS. However, the IP could not fully describe the facility’s Legionella prevention program or monitoring activities, did not know the test results, and confirmed that Legionella monitoring and prevention were not discussed in Infection Control Committee (ICC) meetings. The Administrator and Regional Corporate Director acknowledged that the water system had not been retested for Legionella between February 2025 and early 2026, and QAPI minutes showed that although a performance improvement plan was initiated in March 2025 to monitor weekly hot water flushing and implement a water management program, there was no further documented follow-up, discussion, or recommendations through the end of 2025. In addition, environmental infection control in a communal shower room was deficient. During an observation of the northwest resident shower room, the IP noted that the room appeared dim and that a large diameter pipe near the floor, in an area where a toilet might have been, was stuffed with wet paper towels. The IP stated it was an infection risk to have wet paper towels in that location. The shower room was also used to store medical equipment, compounding the concern about contamination from an open sewage pipe area that had been plugged with wet paper products. This condition existed in a shared space used for resident hygiene and equipment storage, further demonstrating the facility’s failure to maintain a sanitary environment as part of its infection prevention and control program.
Removal Plan
- Update the C. Diff policy and procedure to include bathroom use and the frequency of cleaning and disinfecting equipment, rooms, and bathrooms.
- Train the Infection Preventionist on the infection surveillance program for monitoring and tracking and on the facility's Infection Control and Prevention Program.
- Provide in-services to all Licensed Nurses and Certified Nursing Assistants on the C. diff policy and procedure, including appropriate use of personal protective equipment.
- Ensure every isolation room has dedicated vital signs equipment and cleaning solution.
- Review all residents' medical records to determine whether they have had any change of condition that would indicate C. diff infection.
- Have the Medical Director provide solutions and measures to prevent the spread of infections.
Failure of QAPI Committee to Identify Systemic Infection Control and Quality of Care Issues
Penalty
Summary
The facility’s Quality Assurance Performance Improvement (QAPI) Committee failed to identify multiple quality of care issues, including systemic infection control and prevention problems, despite having a written QAPI plan stating that the facility would monitor care and services using data from multiple sources and consider areas such as infections and medications. During interview, the Administrator reported that the QAPI Committee met monthly and relied on information from department heads, grievances, the resident council, monthly all-staff meetings, and an anonymous suggestion box, and that issues considered ongoing struggles would be taken to QAPI for monitoring. The Administrator further stated that a performance improvement project for infection prevention was only initiated after the survey had already begun, and confirmed that none of the other quality of care issues identified by the survey team had been captured by the QAPI Committee as areas needing improvement. This failure of the QAPI and Quality Assessment and Assurance (QAA) processes to detect and address multiple quality of care concerns, including infection prevention and control, was cited as resulting in a systemic breakdown of the infection control and prevention program, which potentially could have led to harm of vulnerable residents and other poor outcomes for residents in the facility’s care.
Failure of Medical Director Oversight for Infection Control, Informed Consent, and Serious Mental Illness Diagnoses
Penalty
Summary
The deficiency involves the failure of the designated medical director, Physician R, to effectively participate in and oversee resident medical care, including infection prevention and control, informed consent for psychotropic medications, and appropriate diagnostic evaluation for serious mental illness. Surveyors determined that the Infection Prevention and Control Program for a census of 116 residents did not receive oversight by Physician R for antibiotic stewardship and monitoring of infectious diseases, including measures designed to slow and prevent the spread of C. difficile and to address waterborne illness risks related to positive Legionella results. This lack of medical director oversight was cross-referenced to F880. For informed consent, the facility’s own policy titled “Psychotropic: Medication Use,” revised 02/25, required that prior to initiating, increasing, or switching psychotropic medications, staff and the physician review non-pharmacological alternatives, indications and rationale, potential risks and benefits (including side effects, adverse consequences, and black box warnings), and the resident or representative’s right to accept or decline treatment. Record review showed that Resident 12 had an informed consent form dated 3/16/25 for Risperidone for visual hallucinations that was not signed by the resident’s representative and did not indicate verbal consent. A second informed consent form dated 9/11/25 for Mirtazapine for depression and Risperidone for visual hallucinations was also not signed by the representative and did not indicate verbal consent. Resident 10’s representative reported never hearing from the medical doctor and not signing any forms concerning psychotropic medications, stating she felt she was not kept informed. Resident 12’s representative stated she had not spoken to anyone about psychotropic medications and would have declined them because she felt they made Resident 12 less functional. The DON stated her expectation was that Physician R would contact representatives for education and treatment planning before nurses obtained confirmation and signatures, and she was surprised the representatives had not heard from him. In contrast, Physician R stated he could not do all the education and depended on nurses to teach and notify him if representatives had concerns. The deficiency also included inadequate diagnostic evaluation for new diagnoses of serious mental illness, specifically schizophrenia and schizoaffective disorder, for two residents. Resident 10 was admitted with dementia, major depressive disorder (MDD), and unspecified psychosis, and had severe cognitive impairment per an MDS dated 12/22/25. Her physician order summary listed Seroquel for schizoaffective disorder manifested by visual hallucinations. However, a CHE Behavioral Health psychiatry note dated 9/13/23 listed active diagnoses of dementia and MDD with no auditory hallucinations, and a SOAP note by Physician R dated 10/12/23 listed no new diagnosis of schizoaffective disorder. On 10/16/23, facility staff faxed Physician R noting Resident 10 was taking Seroquel without an assigned diagnosis and requested an updated diagnosis list; schizoaffective disorder was added that same day by Physician R. Subsequent CHE psychiatry notes, including 12/27/23 and 12/24/25, continued to list dementia and MDD, recommended a Seroquel dose decrease, and did not mention schizoaffective disorder. The DON stated a serious mental illness diagnosis should not be added solely for medication and should be properly diagnosed by behavioral health, and that mislabeling could inappropriately label residents. Resident 10’s representative stated the resident had no history of schizoaffective disorder and she had never spoken to a medical doctor about this diagnosis. Physician R stated residents with schizoaffective disorder are referred to psychiatry and, if psychiatry did not confirm the diagnosis, it should have been removed; he further stated he may have added the diagnosis based on evolving symptoms. Resident 2’s record showed admission with cerebral infarction with right-sided weakness, epilepsy, diabetes, anxiety, and psychotic disorder with delusions. On 2/6/24, a schizophrenia diagnosis was entered. A behavioral health note dated 11/29/23 by NP LL recommended starting Risperdal 0.25 mg daily for delusions and paranoia but did not list schizophrenia. Review of physician and behavioral health notes from November 2023 through May 2024 revealed no mention of schizophrenia. NP KK, from the behavioral health group, confirmed that NP LL’s notes did not mention schizophrenia at the time Risperdal was prescribed and that her own December 2024 note was the first documentation of schizophrenia as a diagnosis. A fax dated 2/6/24 from MDS Nurse NN to Physician R asked if the diagnosis list could be updated to include schizophrenia for a resident on Risperdal; Physician R responded “Yes” with his signature. NP KK stated the schizophrenia diagnosis was based on delusions, a BIMS score of 3, and symptom improvement on Risperdal. Psychologist MM, Resident 2’s psychologist, stated his notes documented a delusional disorder, not schizophrenia, and that the two diagnoses are not interchangeable; his progress notes did not mention schizophrenia. MDS Nurse NN stated she sent the fax because the MDS system required a matching diagnosis for the antipsychotic and that she was not aware of any clinician documentation diagnosing schizophrenia at that time. MDS Nurse OO similarly stated there was no documentation that a clinician had diagnosed schizophrenia when the diagnosis was entered in February 2024. The facility’s “Schizophrenia and Related Disorders – Clinical Protocol,” revised 3/2025, required that practitioners not newly diagnose serious mental illness without evidence-based criteria documented in the record, including comprehensive assessment findings, DSM-consistent symptoms and duration, exclusion of other causes, and documentation of the effect on function. These requirements were not met in the documentation surrounding the new schizophrenia diagnoses for Residents 2 and 10.
Failure to Honor Resident Rights to Dignity, Communication, Call-Light Access, and Visitation
Penalty
Summary
The deficiency involves multiple failures to honor resident rights to dignity, self-determination, communication, and access to persons and services. A cognitively intact resident with chronic ulcer, cellulitis, dialysis, and diabetes reported that night nurses yelled profanities such as "F**k you" outside his room and that staff frequently spoke Spanish or another foreign language in front of him, which he felt was unprofessional and made him feel staff did not care. The same nurse was later observed multiple times exiting through the main lobby and exhaling vapor from a device immediately outside the main entrance where residents and families enter, and was described by the Administrator as having prior disciplinary action for being loud and lacking professionalism. The Activity Director stated staff were not supposed to be on the phone during patient care hours or speak a foreign language in front of residents or families, and Social Services stated she handled grievances but reported she had not heard of unprofessional staff behavior, despite a grievance log documenting 25 instances of unprofessional staff behavior, including 13 related to staff tone, HIPAA issues, inappropriate bedside manner, and lack of professionalism. The DON and Administrator both stated they were unaware of grievances about unprofessional behavior and did not review the grievance log for trends, even though the facility’s grievance policy required the Administrator to review findings with the grievance officer. The deficiency also includes failures to ensure residents had access to call lights for assistance and emergencies. One resident stated staff moved his call light away, forcing him to yell for help, and his call light was not visible near his bed. Another resident’s call light was observed on the floor on the far side of his bedside table, out of his reach; he reported having a bowel movement and waiting two hours to be changed and said this happened frequently and made him feel staff did not want to help him. A third resident with left-sided weakness after a stroke had his call light pinned to the wall on his affected side, far out of reach, and he believed staff pinned it away on purpose so he could not call for help. A nurse confirmed that none of the residents in the room had access to their call lights and acknowledged this could lead to delays in care and be dangerous in an emergency. The DON stated call lights should always be within reach and that having them anchored out of reach or on the floor did not meet her expectations, and the facility’s call system policy required each resident to have a means to call staff directly from bed and that calls be answered immediately. Another component of the deficiency concerns denial of access to visitors and communication practices that affected residents’ sense of dignity. A resident with osteoarthritis, heart disease, chronic pain, glaucoma, degenerative nerve syndrome, cognitive impairment, and substantial ADL assistance needs expressed a clear desire to see her daughter, stating her daughter helped her get out of bed, clean, and eat, and she cried and pleaded for her daughter to be brought back. Social Services and the Administrator stated they were following the guidance of the resident’s DPOA, who instructed the facility to prevent the daughter from visiting due to alleged interference with care and detriment to the resident’s well-being, and the facility was not allowing the daughter to visit. Additionally, four cognitively intact residents reported that staff frequently spoke foreign languages in hallways, in shared rooms, and during direct care, which made them uncomfortable and, in some cases, bothered them especially when it occurred during their own care because they did not know what staff were saying or whether they were being talked about. A nurse acknowledged staff occasionally spoke foreign languages and that there had been an in-service on the issue, and the DON stated staff were expected to speak the same language as the resident, especially around resident care areas. An in-service record documented that staff were expected to speak only in a language recognized and understood by residents after the training.
Environmental Disrepair and Unsanitary Surfaces in Resident Care and Laundry Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, sanitary, and homelike environment in multiple resident care and support areas. Surveyors observed chipped and cracked floor tiles and chipped paint on doors and door jambs in several resident rooms on different hallways, as well as exposed plaster and unsealed surfaces in high-touch areas. At both the east and west nursing station hand-washing sinks, there was exposed and damaged plaster behind the faucets and handles. In the clean and soiled utility rooms, surveyors noted chipped paint, exposed plaster, unsealed concrete, and visibly dirty, sticky high-touch areas, including black and grey residue around door handles and jambs. The medication cart at the west nursing station was observed to have a crack and open area on the work surface with exposed wood, and staff, including a licensed nurse and the Infection Preventionist, stated they were unsure whether such exposed wood and damaged surfaces could be disinfected. In the laundry area, only one of two washing machines was functioning, and the operating machine had a heavy band of white, rusty, powdery material resembling corrosion. The ceiling in the washing room had a rough, rusty metal box that had been painted over, and the dryer area had broken floor tiles, scratched walls with exposed plaster, and a ceiling with a large rough area of exposed plaster. The folding table used for clean resident laundry had exposed unsealed wood edges and a cracked, bubbled laminate surface. Surveyors also observed a red hose and spigot plumbed through a hole in the wall from the laundry room to the outside dirty laundry sorting area, with a visible gap around the hose allowing sunlight into the room and a steady drip of water forming a pool on the outside cement. Staff, including the Housekeeping Director and Infection Preventionist, repeatedly stated they did not know if exposed plaster, chipped paint, rust, corrosion, unsealed wood, or exposed concrete could be disinfected or sanitized. The Administrator, DON, and Maintenance Director acknowledged awareness of various environmental issues, including non-functioning equipment, damaged floors, chipped paint, exposed plaster, and a non-functioning shower room light, while also indicating that repairs were delayed or pending, and that resident rooms were often occupied, making floor repairs difficult. These conditions were cited as creating an environment that did not appear homelike and increased the risk of cross contamination and spread of contagious disease.
Failure to Implement Bowel Regimen for High-Risk Tube-Fed Resident
Penalty
Summary
A resident in their 70s with traumatic subdural hemorrhage, facial fractures, aphasia, dysphagia, and a G-tube was assessed on admission as high risk for constipation and care planned on 1/10/26 with a goal of having satisfactory bowel movements every 1 to 3 days, including an intervention to administer medications per physician order. Despite this, the physician orders contained no routine bowel regimen (such as laxatives or stool softeners) other than a PRN MiraLax order obtained on 1/26/26 after the resident had already gone five days without a bowel movement. Bowel movement documentation showed a small, putty-like stool on 1/21/26 with no subsequent BMs recorded, and the resident had no bowel care medications in place during this period, contrary to the care plan focus on constipation risk. On 1/26/26, after recognizing that the resident had not had a BM for five days and had no bowel care orders, a nurse contacted the physician and obtained a PRN MiraLax order, which was administered on 1/26/26 and 1/27/26. The nurse acknowledged that going five days without a BM was significant and could lead to serious complications. The resident, who had been readmitted from the hospital on 1/21/26, was transferred back to the hospital on 1/27/26 when he became unresponsive. Hospital records from 1/30/26 documented no BM since 1/21/26, black/feculent G-tube output, a distended and tense abdomen, and imaging showing a large amount of gas and fecal material in the colon suggesting an ileus, with notes indicating bowel obstruction versus ileus. The DON stated her expectation that nurses monitor last BMs using the eMR alert, initiate bowel care if more than three days pass without a BM, and obtain routine bowel care orders when a constipation care plan is developed, and facility policy required assessment and documentation of lower GI symptoms including fecal impaction and abdominal assessment.
Failure to Adequately Supervise Resident Leading to Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and monitoring to prevent an elopement for one resident. The resident was admitted with diagnoses including heart disease, aftercare following circulatory surgery, muscle weakness, need for assistance with personal care, and unspecified psychosis. The facility’s front doors opened onto a busy street with consistent traffic. On the date of the incident, the resident left the facility unnoticed by staff and was later found outside the facility by police, who returned him. The resident’s public guardian reported being informed by facility staff that the resident had eloped over a weekend. According to the guardian, a licensed nurse had believed the resident was in his room with the door shut and did not know he was actually missing. The Infection Preventionist stated she saw a group text message indicating the resident was missing, that staff had looked for him, and that police had been called. Another licensed nurse stated she was at lunch when the resident went missing, confirmed the resident did not have a wander alarm at that time, and stated that if a wander alarm had been recommended on the wandering and elopement assessment, it should have been applied right away and would have prevented the elopement. The DON stated the resident’s original elopement and wandering assessment score was 8, which the facility considered low risk, and that a score above 10 was considered high risk. The DON also stated that the assessment dated the day of the incident recommended a wander alarm, but she characterized that recommendation as a mistake. She reported that the nurse assigned to the resident had observed him in his room after morning medications and did not notice when he left his room and exited the facility, and acknowledged there was not enough supervision to prevent the elopement. The Administrator similarly stated that staff did not see the resident exit his room and leave the facility and that the facility did not supervise the resident closely enough to prevent him from leaving. The facility’s wandering and elopement policy required that residents identified as at risk have care plan strategies and interventions to maintain safety. The resident’s elopement and wandering risk assessment scored him as low risk but indicated that a wander alarm was indicated, and his care plan included a wander alarm intervention without any specific supervision or monitoring interventions, while a separate falls care plan instructed staff to keep him within supervised view as much as possible.
Failure to Provide Adequate Nursing Staff, Timely Call-Light Response, and Hydration Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff and services to meet residents’ hydration, skin care, toileting, and safety needs, despite care plans and policies requiring such care. Multiple residents with intact cognition and documented risks for dehydration, skin breakdown, and falls reported that water was not refreshed regularly and that they had to wait extended periods for call lights to be answered, particularly on night and swing shifts. Care plans for several residents required staff to encourage fluids, offer fluids between meals and at snack times, provide additional fluids during activities, and keep water within reach, as well as to monitor for incontinence and provide pericare after each incontinent episode, but observations and interviews showed these expectations were not consistently met. One resident with acute on chronic heart failure, end stage renal disease, and diabetes, who had a care plan for dehydration risk and skin breakdown, stated that her water was from the previous evening, was room temperature, and that she had to ask staff for fresh water. She reported needing assistance with toileting and that call lights, especially at night, took about 30 minutes to be answered, resulting in her sitting in her own bowel movement long enough for it to burn her skin and cause pain. Another resident with cholecystitis, cystitis, and hemiplegia, who was care planned for dehydration, skin breakdown, and falls, reported that on swing shift his call light had once been answered an hour after activation when he had an incontinent bowel movement, and that similar events had occurred two or three additional times in recent months. He described his skin turning red and his groin burning, and his water bottle was observed nearly full but placed out of his reach, requiring him to call a CNA for help. A third resident with metabolic encephalopathy, care planned for dehydration, skin breakdown, and falls, reported being dependent on staff for brief changes and stated she removed her own brief when soiled because staff took too long to respond to call lights, estimating a 15‑minute wait, which she felt was too long when needing a bowel movement. At her bedside, one water bottle was empty and another contained only a small amount of room‑temperature water, which she stated was from the previous evening, and she reported that residents only received additional water if they asked. A fourth resident with hemiplegia, care planned for dehydration, bowel incontinence, and skin breakdown, stated his water bottle was only changed and filled once per day, that the water present had been brought the previous night, and that he would not drink it when it was warm because it tasted bad. He reported that staff sometimes took up to an hour to answer call lights, especially on the graveyard shift, and that he had to sit in his own bowel movement and urine on several occasions, too many times to count. Additional evidence of inadequate staffing and delayed response to resident needs was documented through Resident Council minutes and direct observation. Resident Council minutes over several months reflected repeated resident concerns about CNAs, including CNAs going into rooms to sleep or charge phones, questions about when facility CNAs would replace registry staff, reports that night shift CNAs did not answer call lights, and repeated requests to hire more CNAs and to have CNAs available to help. During one observation, a surveyor heard a call light sounding and saw the corresponding light illuminated above a resident’s doorway; one staff member entered the doorway only to take gloves and left without entering the room or addressing the resident’s need, and multiple staff walked past without checking on the resident. The call light remained on for 20 minutes before a staff member finally responded. Interviews with CNA staff and the DON confirmed that residents should have water refreshed every shift, fluids offered with each care intervention, and call lights answered quickly, and that leaving residents in soiled briefs was unacceptable, while the Administrator in Training confirmed there were no staffing waivers on file, despite the facility’s policy stating it would maintain adequate staffing on each shift to meet residents’ needs.
Failure to Initiate Baseline Care Plan and Document Care for Indwelling Urinary Catheter
Penalty
Summary
The deficiency involves the facility’s failure to initiate a baseline, person-centered care plan addressing an indwelling urinary catheter for one newly admitted resident. The resident was admitted with multiple diagnoses, including obstructive and reflux uropathy and a need for assistance with personal care, and had an indwelling urinary catheter in place for urinary retention following a failed voiding trial. Review of the resident’s care plans dated several days after admission showed there was no care plan addressing the risk of UTI related to the indwelling catheter. The SNF admission History & Physical documented that the catheter was in place and that a voiding trial would be considered the following week, and the MDS assessment confirmed the presence of an indwelling catheter and that the resident was always incontinent of stool. Subsequently, the resident developed a fever and low oxygen saturation, prompting a physician order for oxygen and transfer to the hospital. At the emergency department, the resident was found to have an elevated temperature, tachycardia, tachypnea, low-normal blood pressure, tacky mucous membranes, and an elevated white blood cell count consistent with infection. Urinalysis showed many bacteria and large leukocyte esterase, and the resident was admitted with sepsis due to a UTI. During interviews, the DON stated she could not find documentation of catheter care and confirmed there was no documented evidence of a person-centered care plan for the indwelling catheter, despite stating that a UTI risk care plan should be in place for all residents with indwelling catheters. The DSD reported that catheter care was not documented in residents’ charts because it was considered a standard of care. Facility policy on urinary catheter care required review of the resident’s care plan for special needs and detailed documentation of catheter care and related assessments, which was not reflected in this resident’s record.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible for all residents to review, as required by their policy. The policy, revised in April 2017, stated that a copy of the most recent survey report and any plans of correction should be kept in a binder in the residents' dayroom. However, during observations on March 5, 2025, the survey results could not be found in the facility. Interviews with various staff members revealed a lack of awareness and communication regarding the location of the survey results binder. The Activities Director was unaware of the requirement for the survey results to be available without asking, and the Social Services Director last saw the binder three weeks prior when the state surveyors were present. Further interviews indicated that the Administrator and the Director of Nursing (DON) were also unaware of the binder's current location. The DON admitted to taking the binder on March 3, 2025, to update it with the most recent survey and forgot to return it to its designated location. This oversight resulted in the survey results binder not being available in its usual location for that week. The Administrator and DON both confirmed that the survey results binder should be accessible to all residents, highlighting a breakdown in the facility's process for maintaining compliance with their policy on survey result accessibility.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were affected by the deficient practice. Within 5 minutes the survey binder was located and put in the correct position. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Once we were notified that the survey binder was missing, it was located within two minutes and returned to the front desk of the facility. The survey binder had only been away from the front for less than 24 hours. It was temporarily taken to the copier for updates following a deficiency received through RSS on February 28th. During the rush of the survey, the facility inadvertently forgot to place it back at the front. To prevent recurrence of this issue, we have placed a laminated sign that reads "DO NOT REMOVE SURVEY BINDER FROM TABLE FOR ANY REASON." In instances where the survey binder needs updating, staff will ensure it is promptly returned to the front desk. In addition, the facility educated all staff in-service on 3/28/25, emphasizing where the survey binder is located and the importance of residents and residents' families having access to these results. How the facility plans to monitor its performance to make sure that solutions are sustained: For the next three months, the Activities Director will conduct a weekly audit to ensure that the survey binder is consistently located on the front table by the entrance of the building. Additionally, these audit findings will be discussed during monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvements are made as necessary. Include dates when corrective actions will be completed: All corrective actions will be completed by March 28, 2025.
Failure to Provide Anonymous Grievance Filing
Penalty
Summary
The facility failed to protect the rights of residents and their representatives to file grievances anonymously, as required by their own policy. The policy, dated 2001, stated that grievances could be submitted orally or in writing and could be filed anonymously. However, during observations, it was found that grievance forms were not available for public use, and there was no way for residents to take a grievance form anonymously to fill out and submit. The grievance forms were stored in locations that required residents to ask staff for access, which compromised anonymity. Interviews with the Social Worker (SW) #16, who was the grievance officer, revealed that the facility practice required residents to inform staff or the SW if they wished to file a grievance. The SW stated that grievances could not be addressed without knowing who made them, although she claimed to keep grievances confidential. Observations confirmed that grievance forms were kept behind nursing stations or in closed cabinets, requiring residents to request assistance to access them. Interviews with the Administrator and the Director of Nursing (DON) confirmed that there should be an option for residents and their families to file grievances anonymously, which was not being facilitated by the current practice.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were affected by the deficient practice. We have promptly implemented corrective actions for all residents in the facility to enhance the grievance process. This includes: **Increased Access to Grievance Forms:** Grievance forms are now readily available in public areas, allowing both residents and family members to easily access and submit their concerns anonymously. **Placement of Grievance Forms:** The forms are strategically posted at the reception desk, in front of the activities room, and at the East Social Service office for maximum visibility. **Secure Grievance Submission:** A locked grievance box has been installed at both the East and West Nurses stations, ensuring confidentiality. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. How the facility plans to monitor its performance to make sure that solutions are sustained: To ensure that the identified deficiencies do not recur, the facility will implement the following systemic changes: **Enhanced Accessibility to Grievance Forms:** Grievance forms are now readily available in public areas, ensuring both residents and family members can easily access them. **Strategic Placement:** Grievance forms have been posted in visible locations, including the reception desk, the activities room, and the East Social Service office, to facilitate convenient access. **Secure Submission Process:** Locked grievance boxes have been installed at both the East and West Nurses stations, ensuring that grievances can be submitted confidentially. **Education of Staff:** The Social Services and Activities Departments have been reeducated on 3/7/25 and 3/19/25 on residents' rights to file grievances anonymously, reinforcing the importance of this practice in supporting resident empowerment. **Communication:** The locations of the grievance forms and locked boxes were clearly communicated during the resident council meeting, ensuring that all residents are aware of how to voice their concerns. These measures aim to create a transparent and effective grievance process that empowers residents and their families, ultimately contributing to ongoing quality improvement within the facility. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: The grievance form clipboards and locked grievance boxes are monitored Monday-Friday by the social service director throughout the week to ensure that forms remain available and that any grievances submitted are promptly received and processed. Furthermore, the facility will implement a monthly review of the grievance logs as part of its Quality Assurance and Performance Improvement (QAPI) program. This proactive approach will help to ensure that the grievance management systems are functioning effectively and efficiently. Include dates when corrective actions will be completed: 3/24/2025 What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: The grievance form clipboards and locked grievance boxes are monitored Monday-Friday by the social service director throughout the week to ensure that forms remain available and that any grievances submitted are promptly received and processed. Furthermore, the facility will implement a monthly review of the grievance logs as part of its Quality Assurance and Performance Improvement (QAPI) program. This proactive approach will help to ensure that the grievance management systems are functioning effectively and efficiently. Include dates when corrective actions will be completed: 3/24/2025
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their discharge statuses and care plans. Resident #107 was inaccurately recorded as being discharged to a hospital, while the Post-Discharge Plan of Care indicated a discharge to home with home health services. Interviews with the MDS Nurse, Director of Nursing (DON), and Administrator confirmed the error, acknowledging that the MDS was incorrectly coded and did not reflect the resident's actual discharge status. Resident #106's MDS inaccurately documented a discharge to home/community, despite the resident being sent to a hospital due to breathing difficulties. The physician's order and progress notes confirmed the hospital discharge, but the MDS was signed off as accurate by LVN Manager #2, who later admitted the error. Both the MDS Nurse and the DON emphasized the expectation for MDS accuracy, which was not met in this instance. Resident #61's quarterly MDS assessments failed to indicate the use of a WanderGuard device, despite orders and care plans specifying its necessity due to the resident's risk of elopement. The device was ordered to be checked regularly, yet this was not reflected in the MDS. Interviews with the MDS Nurse and DON highlighted the oversight, with the DON reiterating the need for MDS assessments to accurately reflect the resident's condition and care requirements.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The MDS coding for Resident #107 has been corrected to accurately reflect that the resident discharged home from the facility on 3/07/25. The MDS updated coding for Resident #106 on 3/07/25 to correctly indicate the resident discharged to a hospital. The MDS coding for Resident #61 has been revised on 3/07/25 to ensure accurate documentation of the WanderGuard assessments. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents may potentially be impacted by this deficient practice. MDS Regional completed the review on 3/7-3/10/25 of all residents who had discharged assessment completed in the last 90 days for accuracy to ensure that assessments reflect the correct discharged status, and no residents' assessments were identified with the same deficient practice. RAI specialist completed the review on 3/26/25 of MDS assessments of all residents currently with a Wanderguard order; to verify coding accuracy of Wanderguard on section P and no other residents' assessments were identified with incorrect coding. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On March 19, 2025, an informative in-service training session was conducted specifically for the two MDS nurses at the facility. The primary objective of this in-service was to provide comprehensive reeducation on the critical importance of accurately coding Minimum Data Set (MDS) assessments. This training emphasized how precise MDS coding can significantly affect the quality of patient care and overall healthcare outcomes for residents. Lead MDS Nurse will cross-check all MDS completed to ensure accuracy of coding before letting the MDS regional know for a second review and signing of the MDS for completion and accuracy. The Regional Resident Assessment Instrument (RAI) Specialist, and MDS Coordinator developed a quarterly training program for the facility MDS Coordinators that complete MDS's for coding accuracy. RAI Specialist will complete a monthly MDS audit for accuracy to ensure compliance and that resident conditions are accurately captured on each MDS assessment. The results will be sent to the facility MDS, Admin, and DON. Any inaccuracies or coding errors will be discussed with the MDS, and follow-up training will be scheduled as needed. Ongoing training sessions will be organized for MDS nurses and relevant staff to reinforce best practices in coding, ensuring they stay updated on any changes in regulations or procedures. This commitment to continuous education will help maintain high standards of coding practice. How the facility plans to monitor its performance to make sure that solutions are sustained: QAPI will review monthly audits performed by the Regional RAI specialist for accuracy, completeness, and thoroughness. Include dates when corrective actions will be completed: March 19, 2025
Failure to Accurately Capture SMI in PASRR
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening and Resident Review (PASRR) accurately captured an admission diagnosis of a serious mental illness (SMI). Specifically, the PASRR for a resident admitted on November 1, 2024, did not reflect their diagnosis of unspecified psychosis, which was part of their medical history. The facility's policy required participation in or completion of a Level I screen for all potential admissions to determine if the individual met the criteria for mental disorder, intellectual disability, or related condition. However, the resident's PASRR Level I Screening, dated October 15, 2024, incorrectly indicated that the resident did not have an SMI. Interviews with facility staff revealed that the PASRR process should have started on admission, and any discrepancies should have been addressed by resubmitting the PASRR to the hospital for correction. The Director of Nursing acknowledged that if a resident had an SMI diagnosis not captured by their PASRR, a new resident review should have been conducted. The deficiency was identified during a survey, prompting the facility to resubmit the PASRR on March 5, 2025, to accurately reflect the resident's diagnosis of unspecified psychosis.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The Pre-Admission Screening and Resident Review (PASRR) for Resident #64 was promptly reviewed and updated. Upon further examination, it was determined that a correction was necessary, and a revised PASRR was resubmitted on March 5, 2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents within the facility have the potential to be affected by the deficient practice. Medical Records did a facility-wide audit of current residents' PASRR for accuracy on 3/21/25 and no additional deficient practice was noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A thorough audit of residents' PASRR was conducted by medical records to identify individuals who may have experienced any adverse effects on 3/21/2025, no additional issues were found. On 3/19/2025, an in-service was given by the Director of Nursing to all those involved in the PASRR screening process, including the medical records team, nursing management team, and admissions team. The purpose of this in-service was to reeducate those involved on the process and importance of PASRR screening regarding patient care and facility protocol. To ensure compliance with regulations, the facility will implement a system-wide change to improve the review process for all Pre-Admission Screening and Resident Review (PASRR) assessments. Going forward, the clinical team, including nurses, MDS, and other relevant healthcare professionals, will conduct a thorough review of the PASRR assessment upon each resident's admission to the facility. This review will verify that each resident's needs, including any mental health or specialized care requirements, are accurately identified and addressed in their individualized care plan. How the facility plans to monitor its performance to make sure that solutions are sustained: Upon admission, the admissions team will verify that a Pre-Admission Screening and Resident Review (PASRR) has been received, preferably via file exchange or, if necessary, as a paper copy. In cases where follow-up is required for file exchange completion, the clinical team will notify the hospital for review or a new PASRR. As part of the verification process, the clinical team immediately reviews the PASRR and checks for accuracy. A secondary screening will be performed before the PASRR is officially uploaded to the patient's chart by the medical records team. Additionally, the medical records department will review the PASRR for accuracy to ensure compliance with regulatory requirements. Furthermore, the unit manager will reassess any PASRRs requiring follow-up, with all follow-up actions being systematically tracked through the Interdisciplinary Plan of Care (IPOC) by medical records. To maintain accountability and ensure accuracy, the medical records department will conduct regular audits of PASRR. Additionally, when the facility does the resident review for new admits, if an inaccuracy is noted, a new PASRR/resident review assessment will be created to ensure the residents' PASRR is accurate according to their needs. This process will be monitored by and reported to our Quality Assurance and Performance Improvement (QAPI) monthly meeting. This will stay on our QAPI for 90 days and/or 3 QAPI meetings. Include dates when corrective actions will be completed: March 21st, 2025
Failure to Provide Ordered Passive ROM for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received the necessary care and services to prevent further decline. The resident, who had a medical history of morbid obesity, unspecified joint contracture, rheumatoid arthritis, and difficulty in walking, had an order for rehabilitation services to perform passive ROM. However, there was no documentation that this order was completed. The resident expressed a desire for therapy to help with mobility, and although the doctor had ordered therapy, the resident had not received any services. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's care. The Physical Therapy Assistant indicated that the last documented visit with the resident was in 2023, and the Director of Staff Development and Human Resources was unaware of any order for restorative care. The Director of Nursing confirmed that staff should have communicated the doctor's order to the therapy department. A Certified Nursing Aide mentioned performing some passive ROM during transfers and showers but was unaware of the specific order for passive ROM. This lack of coordination and communication led to the resident not receiving the necessary care to maintain or improve their ROM.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #28 was evaluated by the therapy staff on 3/6/2025 and RNA program 3x a week or as tolerated for BUE/BLE PROM was started on 3/7/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: A comprehensive review of all residents' records performed by the Director of Nursing was started on 3/11/2025 to identify individuals with similar orders for restorative care that have not been followed. No other resident identified with the same findings/deficient practice. A weekly audit of MDS assessments and therapy orders will be implemented for all residents to ensure that any unaddressed restorative needs are promptly identified, and actions are taken. Affected residents will receive the necessary restorative interventions as determined by their care plans. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 3/21/2025, the Director of Nursing Services in serviced the Licensed nursing staff to enhance communication protocols between nursing and therapy departments to ensure that all restorative therapy orders are communicated to therapy department. Medical Record will do a daily audit for orders established to review therapy orders and restorative care compliance. This will allow the nursing manager to verify if communication was sent to therapy department. Any gaps in this communication will be flagged immediately and nursing will follow up with therapy to ensure orders are seen and acted upon. How the facility plans to monitor its performance to make sure that solutions are sustained: The Director of Nursing with the IDT will implement monthly reviews/monthly recaps of restorative care compliance, which will include tracking the timely execution of therapy orders and resident feedback on the effectiveness of interventions. Outcomes related to restorative nursing services will be discussed in monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvement. A designated staff member will be assigned to oversee the restorative nursing program and oversee continuous monitoring for adherence to policies and procedures. Include dates when corrective actions will be completed: March 21st, 2025
Resident Elopement and Unsecured Supply Closet
Penalty
Summary
The facility failed to ensure the safety of a resident who was at risk for elopement. The resident, who had a history of severe cognitive impairment and was using a WanderGuard device, managed to elope from the facility and was found in a parking lot approximately one block away. The WanderGuard device was not applied according to the manufacturer's instructions, as it was attached to the metal part of the resident's wheelchair, which could interfere with its function. Staff members, including a CNA and LVN, were unaware of how to properly check the functionality of the WanderGuard device, and the device did not alarm when the resident exited the facility. The resident had a medical history that included hemiplegia, schizophrenia, and epilepsy, among other conditions, and was known to wander frequently. Despite this, the facility's staff did not adequately monitor the resident or ensure the proper functioning of the WanderGuard device. The facility's policy on wandering and elopements was not effectively implemented, as staff failed to follow the manufacturer's guidelines for the WanderGuard device, and there was a lack of documentation and tracking of the resident's previous elopement attempts. Additionally, the facility failed to secure a supply closet containing medical supplies, which was observed to be unlocked. This posed a potential risk to residents, especially those who wandered, as they could access and potentially ingest harmful substances. The facility's policy on the storage of medications and supplies was not adhered to, as the supply closet was not locked, and staff were not aware of the importance of securing it.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/05/2025, the facility moved WanderGuard on resident #61's wheelchair to the back of the metal part of the wheelchair, away from metal or anything that could interfere with the system's function. The WanderGuard is secured and not easily movable. It is also visible to staff for licensed nurses to do placement and function checking. On 3/03/2025, maintenance switched the lock on the supply closet and converted it to auto-lock. This ensures that the door will have to be unlocked every time it is opened. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice of the storage of the supply closet. All residents exhibiting behaviors associated with elopement or wandering have the potential to be affected by the deficient practice. All residents exhibiting behaviors associated with elopement or wandering have been identified through a facility-wide assessment conducted on March 19, 2025. No other issues were found with the placement of the WanderGuard. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: All residents exhibiting behaviors associated with elopement or wandering have been identified through a facility-wide assessment conducted on March 19, 2025. All relevant care plans have been reviewed and adjusted to incorporate necessary interventions aimed at reducing elopement risks for these residents and ensuring WanderGuard is in proper placement. An in-service training and competency check related to the proper use and placement of WanderGuard devices has been conducted for all licensed nurses from March 4, 2025, to March 21, 2025. A facility-wide in-service for all nursing staff has been initiated from March 12, 2025, to March 28, 2025, to review elopement procedures and reinforce adherence to protocols. An in-service was done on 3/19/25 reeducating nurses on the importance of ensuring the supply closet stays locked when not in use. Additionally, a systemic change has been implemented requiring competency checks for all new hires as well as annual assessments for licensed nurses to ensure their understanding and ability to handle elopement concerns effectively. How the facility plans to monitor its performance to make sure that solutions are sustained: Competencies will be reviewed by the Director of Staff Development annually and upon hire on elopement prevention protocols and the effectiveness of WanderGuard device functioning and storage of medication/ensuring locked doors. All training sessions and competency checks will be documented, and return demonstrations will be done to verify understanding of the device and elopement protocol. The facility will bring forth all education done for new hires and annual competencies to its monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure continuous monitoring and improvement. This will stay in place for at least 90 days/3 QAPI meetings. An elopement drill will be conducted on different shifts twice a month for the next 3 months by the Director of Staff Development, and any findings will be reported to QAPI. Nursing management will perform twice-monthly audits for the next three months of medication storage areas to ensure they are all locked according to policy and procedure. Include dates when corrective actions will be completed: March 28, 2025.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that medication carts were locked when unattended, as observed during a survey. A policy titled 'Storage of Medications,' revised in April 2019, mandates that all drugs and biologicals be stored securely, and specifically states that unlocked medication carts should not be left unattended. During an observation, a medication cart was found unlocked and unattended outside a room, with no staff or residents nearby. A Registered Nurse confirmed she was in a resident's room and out of eyesight from the cart, acknowledging that she should have locked it. The Director of Nursing also confirmed that medication carts should not be left unlocked and unattended.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were affected by the deficient practice. Nurse was immediately informed she left her med cart unlocked and locked it right away. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice, and therefore, a comprehensive review will be initiated to assess any potential risks associated with the handling of medications. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On March 21, 2025, the Director of Nursing provided an in-service training for Licensed Nurses on the critical importance of ensuring that medication carts are locked when not in use. This training will reinforce the protocol that all medication carts must be secured properly when left unattended. How the facility plans to monitor its performance to make sure that solutions are sustained: Starting on March 21, 2025, Nursing Managers and Supervisors, including the Director of Nursing Services, Assistant Director of Nursing, Infection Preventionist, and Director of Staff Development, will begin conducting weekly audits at various times throughout the day to verify adherence to the policy requiring that medication carts are properly locked when not in use. The outcomes of these weekly audits will be discussed during monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvements are made as necessary. Include dates when corrective actions will be completed: March 21, 2025.
Failure to Discontinue Medication Order
Penalty
Summary
The facility failed to ensure that an order to discontinue a medication was properly transcribed into the clinical record for a resident. The resident, who was admitted with a medical history of type two diabetes mellitus, had a follow-up appointment with an outside physician who noted that the resident's prescription for Pred Forte should be discontinued. Despite this, the medication order remained active in the resident's records, indicating a failure to update the clinical documentation as per the physician's instructions. Interviews with facility staff revealed that the physician's note regarding the discontinuation of the medication was not reviewed by nursing staff before being scanned into the resident's electronic medical record. The Licensed Vocational Nurse and the Medical Records Director confirmed that the note was not marked as reviewed, which is a necessary step before scanning. The Director of Nursing also stated that nursing staff should have checked for new orders and updated the resident's records accordingly upon their return from the appointment, which did not occur in this instance.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 03/05/25, Resident #84 had the order for Pred Forte (prednisolone acetate) immediately discontinued in the clinical record. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice, as the failure to document and discontinue medication orders can occur for any resident with outside medical appointments. On 03/19/25, medical records conducted a comprehensive review of all appointment/consult notes for each resident to ensure they are consistent with the most recent provider instructions. No further discrepancy noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 03/21/25, the nursing and medical records staff were in-serviced on the facility's policies for reviewing, documenting, and transcribing medication orders, particularly those issued by outside providers. A new process has been implemented to ensure that all outside provider notes are promptly reviewed by nursing staff upon receipt. Nurses will be responsible for identifying and entering any new orders, including medication discontinuations, into the EMR. Medical records staff will ensure that all physician progress notes are not scanned into the EMR until they have been reviewed and acted upon by nursing staff. Before scanning and uploading to the resident's documents, Medical Records will make sure it is noted and verified by nursing staff. How the facility plans to monitor its performance to make sure that solutions are sustained: Regular audits will be conducted by Medical Records to review compliance with the new procedures. These audits will focus on ensuring that all provider orders, including medication discontinuations, are accurately documented in the clinical record and MAR. Outcomes related to restorative nursing services will be discussed in monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvement. Include dates when corrective actions will be completed: Completion date March 28th, 2025
Failure to Provide Adequate Oral Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL), specifically oral care, for three residents. Resident 1, who had been admitted with hemiplegia and hemiparesis following a cerebral infarction, was found to have a gray-white residue inside his oral cavity and malodorous breath. His daughter reported that his mouth appeared to be rotting, with broken teeth and gray saliva, indicating a lack of oral care. She expressed concerns about neglect and decided not to return him to the facility. Resident 2, also admitted with hemiplegia and hemiparesis, was observed with a significant amount of grayish-white residue on his teeth and malodorous breath. He stated that he was capable of brushing his own teeth but required staff to provide the necessary supplies, which had not been done for nine days. Despite his requests, staff failed to provide the supplies, and the assigned CNA admitted to not providing them, citing unfamiliarity with the resident. Resident 3, diagnosed with Parkinsonism and pneumonia, was observed with excessive yellow-white residue on his lips, teeth, and tongue, and malodorous breath. He reported not receiving oral care that day and expressed a desire for more frequent assistance. The assigned CNA claimed to have provided oral care using only a swab, but this was not documented. The Director of Staff Development confirmed the lack of documentation, indicating that oral care was not properly provided or recorded, contrary to the facility's policy on supporting ADLs.
Expired Medications Found in Treatment Cart
Penalty
Summary
The facility failed to ensure that expired medications were discarded from the treatment cart, which was the only cart containing supplies and treatments for resident wounds. During an interview, Licensed Staff E, a treatment nurse, confirmed that the charge treatment nurse, who was responsible for regularly checking the cart for expired medications or supplies, was on leave of absence. Upon inspection of the treatment cart, several expired medications and supplies were found, including silver nitrate applicators, a bottle of barrier cream, and bottles of Providone Iodine 10% solution. Some of these items had expiration dates that had been erased, indicating a lack of proper management and oversight. Licensed Staff E acknowledged the presence of expired products and stated she would discard them immediately. The Director of Staff Development (DSD) confirmed that the treatment nurse was responsible for checking the treatment cart for expired items and that the facility had a designated receptacle for discarding such products. The facility's policy on Medication Labeling and Storage, dated 2001, indicated that the dispensing pharmacy should be contacted for instructions regarding the return or destruction of discontinued, outdated, or deteriorated medications or biologicals. However, this policy was not followed, leading to the deficiency.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to address grievances reported by a resident, leading to unresolved issues that affected the resident's quality of life. The resident, who had medical diagnoses including hemiplegia, hemiparesis, and insomnia, reported a broken bed frame and a damaged electronic tablet to the Social Services Department. Despite these reports, the facility did not take timely action to resolve the grievances. The resident's bed frame remained broken, causing discomfort and difficulty sleeping, while the electronic tablet, essential for entertainment, was not replaced, resulting in boredom and frustration. The Social Services staff acknowledged receiving the complaints but did not follow up to ensure the issues were resolved. The facility's grievance policy requires that all grievances be investigated and resolved promptly, with the resident informed of the findings and corrective actions. However, the staff failed to adhere to this policy, as evidenced by the unresolved grievances and the lack of follow-up with the resident. The facility's inaction in addressing these grievances highlights a deficiency in ensuring residents' rights to voice grievances without discrimination or reprisal.
Deficiency in Resident Phone Access and Privacy
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to and privacy in their use of communication methods, specifically telephone calls. This deficiency was identified through observations, interviews, and record reviews. A family member of the resident was unable to contact the resident by phone, prompting them to call the police for a wellness check. The family member, who lived out of state, reported that calls to the resident went unanswered, and voicemails were not returned. The resident confirmed that the facility's phones did not work properly, and staff did not answer calls, which led to missed communication with a visitor. Further investigation revealed that the facility's phone system was problematic, with staff acknowledging that phones were not answered after certain hours due to the absence of a receptionist. Additionally, many phones in residents' rooms and the facility's overhead pager were not functioning. The facility's staff and visitors frequently complained about these issues, and the administrator was aware of the problem. This deficiency was in violation of the residents' rights to make and receive private phone calls as outlined by CMS.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, specifically Chlordiazepoxide, which is used to treat anxiety and symptoms of alcohol withdrawal. The resident, who was admitted with diagnoses of anxiety disorder and alcohol dependence with withdrawal, did not receive five scheduled doses of this medication. The resident's Minimum Data Set indicated intact cognition, and the care plan required the administration of anti-anxiety medication as ordered. However, the Medication Administration Record showed missed doses on specific dates, and notes indicated the medication was awaiting delivery from the pharmacy. The Director of Nursing confirmed that the medication was reordered after the last available dose was administered, which did not allow enough time for the order to be completed before the next dose was due. The facility's policy required medications to be given at the specified date and time in the physician's order. The policy also stated that routine medications should be reordered by the re-order date on the label to ensure an adequate supply. The failure to reorder the medication in a timely manner led to the resident missing multiple doses, potentially causing anxiety and symptoms of alcohol withdrawal.
Failure to Ensure Adequate Hydration and Nutrition
Penalty
Summary
The facility failed to ensure adequate hydration and nutrition for a resident during his 3.5-week stay. The resident, who required assistance for eating and drinking and was at risk for dehydration and malnutrition, experienced a significant weight loss of 30.8 pounds within 18 days of admission. Nursing staff and the Registered Dietitian (RD) did not notify the resident's physician, Nurse Practitioner (NP), or family about the severe weight loss, nor did they document it in the medical record or discuss it during the Weight Committee or interdisciplinary team (IDT) meetings. Additionally, Certified Nursing Assistants (CNAs) did not consistently and accurately document the resident's oral fluid intake. The resident's medical records indicated that he was admitted to the facility after a hospital stay for a right toe amputation and was at risk for dehydration and malnutrition. Despite this, the facility did not implement a Change of Condition (COC) in response to the severe weight loss. The resident's family, upon observing his deteriorated condition, removed him from the facility against medical advice (AMA) and took him to the hospital, where he was admitted to the Intensive Care Unit (ICU) with severe dehydration, malnutrition, acute kidney injury, and other complications. Interviews with facility staff revealed that the RD and nursing staff failed to take appropriate actions to address the resident's weight loss and poor fluid intake. The RD admitted that the weight loss was missed and that no interventions were implemented. The Director of Nursing (DON) confirmed that the medical record did not contain evidence of rechecked weights, notifications to the RD or DON, or documentation of the weight loss. The facility's failure to monitor and intervene in the resident's fluid status and weight loss contributed to his severe decline in health.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Committee (QAPI) failed to identify and act upon significant quality deficiencies, as evidenced by the case of a resident who experienced a severe weight loss of 30.8 pounds within 18 days of admission. The facility staff did not notify the resident's physician or nurse practitioner of the severe weight loss, nor did they implement any interventions to address the decline. The resident's family eventually took him from the facility against medical advice and transported him to a hospital, where he was admitted to the ICU in critical condition. Despite the resident's weight loss being documented and presented at a QAPI meeting, it was not addressed or discussed, preventing the facility from identifying potential system failures and implementing necessary changes to prevent similar harm to other residents. The resident's medical records from the hospital indicated that he was admitted with a right foot diabetic ulcer and had undergone a right fifth toe amputation. Upon discharge to the facility, he was placed on a pureed diet and required daily dressing changes. However, during his stay at the facility, the resident's condition deteriorated significantly, leading to severe dehydration, acute kidney injury, severe malnutrition, and other critical health issues. The facility's records showed that the resident's weight was documented multiple times, but no actions were taken to address the significant weight loss. The facility's policies on weight assessment and intervention, as well as change in a resident's condition, were not followed, and the necessary notifications and interventions were not made. Interviews with facility staff, including the Registered Dietitian (RD), Licensed Nurses (LNs), and the Director of Nursing (DON), revealed that the weight loss was missed, and no interventions were implemented. The facility's documentation showed incomplete and low fluid intake records for the resident, which were not properly monitored or addressed. The facility's administrator confirmed that the QAPI team did not conduct a root cause analysis to determine the cause of the resident's severe weight loss or the family's decision to remove him from the facility. The facility's failure to monitor and intervene in the resident's condition contributed to his severe decline and hospitalization in the ICU.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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