New Orange Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in Orange, California.
- Location
- 5017 E. Chapman Avenue, Orange, California 92869
- CMS Provider Number
- 555286
- Inspections on file
- 50
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at New Orange Hills during CMS and state inspections, most recent first.
Two residents did not receive appropriate monitoring and documentation for diabetic care. One resident was not monitored for insulin side effects or signs of hyperglycemia, and another did not have daily glucose checks completed as ordered, with no documentation explaining the missed checks. Both the RN and DON confirmed these deficiencies in care and recordkeeping.
A resident's Fall Risk Evaluation was inaccurately completed by a licensed nurse, failing to document a recent fall despite facility policy and supporting documentation indicating the incident occurred. Both RN and DON confirmed the omission during record review and interviews.
A resident with severe cognitive impairment and a history of falls was found on the floor with multiple leg fractures after their bed, which was supposed to be kept in the lowest position per care plan and physician orders, was left elevated. Staff and family confirmed the bed was hip-high at the time of the incident, and required fall prevention interventions were not fully implemented.
A resident with end stage renal disease and hypertension did not have blood pressure monitored according to physician orders and preferences. Staff used a wrist blood pressure machine, which the resident reported as inaccurate, and took readings from the resident's left arm with a hemodialysis access site, despite orders not to do so. The DON confirmed that only approved equipment should be used and that staff should follow physician orders.
A resident with a dehisced surgical wound did not have Enhanced Barrier Precautions (EBP) implemented, despite physician orders for wound care and facility policy requiring EBP for such cases. Observations revealed no PPE set-up or EBP signage, and staff confirmed that EBP was not in place. The DON and Administrator verified the absence of EBP and related precautions for the resident.
A resident with multiple complex diagnoses had severely abnormal lab results that were not properly addressed by nursing staff. An LVN reported the results to the physician without clarifying or highlighting the critical abnormalities, and no action was taken until another LVN later provided the lab values after the resident's condition worsened. Staff interviews revealed gaps in competency verification and understanding of lab value significance.
Two residents did not receive necessary care as ordered by their physicians: one was not taken to scheduled outpatient follow-up appointments due to transportation and insurance issues, and another received wound care involving betadine application without a physician's order. These failures were confirmed by facility staff, including the DON and an LVN.
A resident with anoxic brain damage and a stage 4 sacral pressure injury did not receive barrier cream as ordered, and wound assessments failed to document or address undermining. Nursing staff did not initially recognize the undermining or notify the physician, and the low air loss mattress was set incorrectly for the resident's weight, contrary to care plan and physician orders.
Surveyors found that a resident's clean isolation gown contained soiled gloves and that a soiled trach tie was not changed after wound care, despite facility policy and staff acknowledgment that soiled ties should be replaced. These lapses in infection control practices were confirmed through observation and staff interviews.
A resident's medical record showed that care tasks and medication administration were documented as completed after the resident had already been discharged. The MAR included check marks for daily heel protectors, apical pulse monitoring, pacemaker site checks, and potassium chloride ER administration, all recorded for a date following discharge. Both an LVN and the DON confirmed these inaccuracies during review.
The facility failed to provide necessary wound care for three residents, including incorrect treatment orders for a resident's wound, inappropriate mattress for another's pressure injury, and incorrect wound care sequence for a third resident. These deficiencies were confirmed by staff and involved miscommunication and failure to follow physician orders.
A facility failed to provide a resident with bilateral floor mats at the bedside as ordered by a physician, despite the resident being at high risk for falls. The absence of these mats was confirmed during an observation and interview with the ADON, and the DON verified the findings. The resident's care plan and medical records indicated the necessity of these mats following a previous fall.
The facility failed to follow physician's orders for GT feedings for two residents, starting the feedings two hours earlier than prescribed. Despite orders to begin at 1500 hours, the feedings were initiated at 1300 hours, as confirmed by LVNs and the DON. This discrepancy was acknowledged by the facility's administration.
The facility failed to maintain sanitary conditions in the kitchen, with utensils in poor condition, improper cleaning and storage of equipment, and inadequate maintenance of the ice machine and kitchen hood. These deficiencies, verified by the Dietary Manager, posed a risk of cross-contamination and foodborne illnesses for residents consuming food prepared in the facility.
The facility failed to ensure that call lights were within reach for four residents, potentially delaying care and impacting their well-being. Observations revealed call lights were out of reach for these residents, with staff only addressing the issue after verification. Two residents lacked decision-making capacity, highlighting the importance of accessible call lights. The DON acknowledged the need for staff to ensure call lights are within reach.
The facility failed to notify the physician timely about changes in two residents' conditions, leading to delayed interventions. One resident experienced difficulty swallowing, which was reported by family but not promptly communicated to the physician. Another resident had vomiting episodes and tube feeding was held without physician notification, despite low weight. The DON confirmed the need for timely physician notification.
A resident's right to a safe and comfortable environment was violated when staff searched their belongings without consent. The resident, who is legally blind but cognitively intact, was unaware of the intrusion until informed by their roommate. The DON confirmed that staff were instructed to check bedside areas but should have obtained permission first.
The facility failed to follow up on a dermatologist's recommendations for a resident's skin condition and did not monitor another resident's weight loss every shift for 72 hours as required. These oversights could have delayed necessary interventions.
A resident's new pressure ulcer was not reported or documented in a timely manner. CNA 1 observed the wound during a shower but delayed reporting it to Treatment Nurse 2 until after lunch. Treatment Nurse 1 was unaware of the wound, and CNA 2 had previously seen a callous but did not report it, assuming it was not new. This led to a delay in treatment and intervention.
A resident experienced another fall due to the facility's failure to implement the recommended two-person assistance for ADL care. Despite a previous fall and the Fall Committee's recommendation, a CNA provided bedside care alone, leading to the resident sliding off the bed. The DON confirmed the CNA's non-compliance with the two-person assistance directive.
A facility failed to prevent UTIs for a resident with an indwelling urinary catheter by positioning the urinary drainage bag above the bladder, contrary to policy. This was confirmed by a CNA and an LVN, despite the resident's care plan specifying the correct positioning to prevent complications.
A resident in an LTC facility was administered the incorrect enteral formula, receiving Vital 1.2 instead of the prescribed Vital 1.5. This error resulted in the resident receiving fewer calories than ordered, potentially impacting their well-being. The issue was identified during an observation and interview with an LVN, who noted the discrepancy after holding the feeding due to the resident vomiting.
The facility failed to provide necessary respiratory care for four residents, including not dating oxygen tubing for three residents and not administering oxygen as ordered for another. Observations and interviews confirmed these deficiencies, which did not adhere to the facility's policies, potentially putting residents at risk.
The facility failed to properly assess and document the use of side rails for three residents, leading to potential safety risks. One resident used side rails for positioning without documented alternatives being attempted. Another resident requested side rails for mobility, but the facility did not document any alternatives. A third resident had side rails despite being unable to self-position, making their use inappropriate. These deficiencies put residents at risk for entrapment and injuries.
The facility failed to ensure proper documentation and accounting of controlled medications. An inspection revealed discrepancies in the Narcotic Count Sheet and Medication Count Sheets for two residents, with missing or incorrect entries. LVN 3 admitted to errors in documentation, and the Administrator and DON acknowledged the findings.
A facility failed to accurately monitor orthostatic blood pressure for a resident on Zyprexa, as ordered by the physician. The medical records showed identical blood pressure readings for lying and sitting positions, indicating non-compliance with the procedure. Interviews with the DON and an LVN confirmed the readings should differ, and the LVN admitted to not following the correct procedure, potentially impacting the resident's treatment.
A facility's medication error rate was found to be 25%, exceeding the acceptable threshold. An LVN made eight errors by leaving residual medication in cups after administration to a resident. Additionally, the LVN incorrectly administered eye drops to another resident, applying them to only one eye instead of both as per the physician's order.
The facility failed to ensure proper storage and disposal of medications across multiple medication carts, leading to potential risks of unsafe administration and cross-contamination. Used syringes, topical creams, and various medications were improperly stored together, as confirmed by nursing staff. The Administrator and DON were informed and acknowledged these deficiencies.
A resident with intractable epilepsy had a low valproic acid level, but the facility failed to make repeated attempts to notify the physician. Despite a recommendation from the Consultant Pharmacist to clarify the medication's use and obtain a level, the medical record lacked evidence of follow-up actions. The DON stated that staff should make multiple attempts to contact the physician for abnormal lab values, but this was not documented.
The facility failed to maintain accurate medical records for four residents, leading to potential unmet care needs. A resident's IV fluid intake and weight refusal were not documented, another's MAR was incomplete, a third's hospice visitation log was missing entries, and a fourth's flu vaccination consent was improperly filed. These issues were confirmed by facility staff and acknowledged by administration.
The facility failed to implement an effective infection prevention and control program, neglecting to include residents not on antibiotics in their surveillance. Resident 775 lacked necessary precautions for wound care, and tracheostomy supplies were improperly stored. Additionally, a urinal was unlabeled, and a blood glucose meter was not cleaned after use, posing risks for infection transmission.
The facility failed to implement its Antibiotic Stewardship Program effectively, as it did not conduct proper assessments using McGeer's criteria for infections and used incorrect Surveillance Data Collection Forms for several residents. This led to inaccurate identification of infections and inappropriate antibiotic prescriptions. The IP and DON acknowledged these deficiencies.
A resident's rights were violated when a CNA used a personal cell phone while feeding a legally blind resident. Another resident observed this behavior and reported it as disrespectful. The facility's policy prohibits personal electronic device use during work hours, which the CNA acknowledged violating.
A resident with a Stage 4 sacral coccyx wound received improper wound care when an LVN failed to change gloves and perform hand hygiene between steps. The LVN did not sanitize the bedside table before placing clean supplies and acknowledged the lapse in infection control practices. The DON confirmed the breach in protocol.
The facility failed to ensure a resident's call light was within reach, as observed on multiple occasions. The resident, who had impaired speech but could verbalize needs, was found unable to reach the call light, which was wrapped around the bedrail and hanging halfway to the floor. Staff confirmed the call light should have been accessible, and the ADON acknowledged the findings.
Failure to Monitor and Document Diabetic Care and Glucose Checks
Penalty
Summary
The facility failed to provide quality care and services for two residents by not ensuring proper monitoring and documentation related to diabetic management. For one resident with Type 2 diabetes and no decision-making capacity, the facility did not document monitoring for side effects or effectiveness of prescribed insulin, nor did they monitor or document for signs and symptoms of hyperglycemia as outlined in the resident's care plan. Both the RN and DON confirmed that there was no evidence of such monitoring or documentation in the medical record, and that clarification with the physician regarding blood sugar monitoring was not obtained. For another resident, the facility did not complete physician-ordered daily glucose monitoring on several specified dates, as evidenced by missing documentation in the medication administration records. The RN verified the omissions and acknowledged that reasons for missed glucose checks were not documented. The DON also confirmed these findings, stating that refusals or other reasons should have been recorded to ensure proper tracking of the resident's blood sugar status.
Inaccurate Fall Risk Evaluation Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the Fall Risk Evaluation for one resident. The resident, who lacked decision-making capacity, experienced a fall as documented in the SBAR Communication Form. However, the Fall Risk Evaluation completed on the same day did not reflect this incident, instead indicating that the resident had no falls in the past three months. This discrepancy was confirmed during interviews and record reviews with both a registered nurse and the Director of Nursing, who acknowledged that the fall should have been included in the evaluation. Facility policies required that post-fall assessments and care plan changes be completed for all residents who experienced a fall, and that medical records provide a concise and accurate account of care and resident condition. The licensed nurse responsible for the Fall Risk Evaluation did not document the recent fall, resulting in an inaccurate record. This inaccuracy was verified by facility staff during the survey process.
Failure to Maintain Bed in Low Position Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was maintained in the low position as required by the resident's care plan. The resident, who had a diagnosis of Alzheimer's dementia, a history of falls, severe cognitive impairment, and was dependent on staff for all activities of daily living, was identified as being at high risk for falls. The care plan and physician orders specified the use of bilateral bolster pillows, floor mats, and keeping the bed in the lowest position to minimize injury risk. Despite these interventions, the bed was found elevated at the time of the incident. On the day of the event, a family member visiting the resident observed that the bed was elevated and subsequently found the resident on the floor, in pain, and with visible injuries. Multiple staff members, including CNAs and LVNs, confirmed that the bed was elevated to hip height when they responded to the incident. The resident sustained fractures to the left lower leg, as confirmed by hospital records, and required transfer to an acute care hospital for treatment. Facility documentation, interviews, and medical record reviews all indicated that the required fall prevention interventions were not fully implemented, specifically the failure to keep the bed in the low position. The facility's own policies and procedures mandated that residents at risk for falls have appropriate interventions in place, including maintaining the bed in the lowest position, but this was not adhered to at the time of the incident.
Failure to Follow Physician Orders and Use Approved Equipment for Blood Pressure Monitoring
Penalty
Summary
The facility failed to provide necessary care and services by not monitoring a resident's blood pressure according to physician orders and resident preferences. Specifically, staff used a wrist blood pressure machine, which the resident reported as inaccurate, and repeatedly obtained low systolic readings. The resident expressed concerns about the accuracy of the device and stated that nurses often had to retake his blood pressure multiple times to get an accurate reading. Additionally, the resident reported that staff were obtaining blood pressure readings from his left arm, which contained a hemodialysis access site, despite a physician order prohibiting blood pressure measurements from that site. Medical record review confirmed the resident had diagnoses of end stage renal disease on hemodialysis, hypertension, and a history of diabetes. Physician orders included instructions to hold antihypertensive medication if systolic blood pressure was below a certain threshold and a specific order not to obtain blood pressure readings from the left arm with the hemodialysis access. During interviews, a nurse admitted to using a wrist blood pressure machine and to taking readings from whichever arm the resident offered, while the DON confirmed that only facility-approved machines should be used and that staff should follow physician orders regarding blood pressure monitoring.
Failure to Implement Enhanced Barrier Precautions for Resident with Surgical Wound
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices for a resident with a surgical wound. The resident, who had a history of cranioplasty and a slowly healing, dehisced surgical wound, was admitted and readmitted to the facility. Physician orders were in place for daily wound care, including cleansing and dressing changes for both the scalp and left temple wounds. However, there was no physician order for Enhanced Barrier Precautions (EBP), which are required for residents with wounds at high risk for colonization with multidrug-resistant organisms (MDROs). During observations, the resident was found in bed with wound dressings but without any PPE set-up or EBP signage outside the room. Interviews with the LVN and Infection Preventionist (IP) confirmed that EBP was not implemented, despite both acknowledging that EBP should have been in place due to the resident's surgical wound. The IP also verified the absence of a physician's order for EBP and the lack of necessary precautions. Further review and interviews with the Director of Nursing (DON) and the Administrator confirmed that the resident had a surgical wound and that EBP, including PPE set-up and signage, was not implemented as required. The facility's failure to follow its own infection prevention and control policies and procedures resulted in the deficiency, as the necessary precautions to prevent the transmission of communicable diseases or organisms were not in place for the resident.
Plan Of Correction
F0880 signage, orders and care plans were in place. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Infection Preventionist/Designee conducted an in-service from 8/5/25 - 8/12/25 to licensed nurses regarding EBP practices and the criteria that would require implementation. Infection Preventionist will make daily rounds and audit new admissions and current residents on EBP, Monday - Friday x 3 months to ensure proper implementation of EBP on the floor that includes signage, orders and care plans are in place. DON/Designee will conduct audit for at least 3-5 residents a week x 4 weeks x 3 months to ensure Enhance Barrier Precautions have been implemented and care planned. How the facility plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 8/13/2025 DON/Designee will conduct audit for at least 3-5 residents a week x 4 weeks x 3 months to ensure Enhance Barrier Precautions have been implemented and care planned. How the facility plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 8/13/2025
Failure to Ensure Nursing Staff Competency in Interpreting and Reporting Critical Lab Values
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated the necessary competencies and skill sets to care for a resident with complex medical needs. A resident with chronic respiratory failure, tracheostomy, ventilator dependence, and anemia of chronic disease was admitted and had laboratory tests ordered. The results showed severely abnormal values, including a high WBC, low hemoglobin, and low hematocrit. The LVN on duty sent a picture of the lab results to the resident's physician via text but did not clarify or address the abnormal findings beyond reporting the results and responding to a question about water flushes. The physician's response only addressed fluid status, and no further clarification or action was taken regarding the critical lab abnormalities at that time. Later, another LVN contacted the physician due to the resident's low blood pressure and, after some confusion about the resident's identity, provided the lab values when prompted by the physician. Only then did the physician order additional diagnostic tests and treatments, including blood cultures, a urine test, chest x-ray, antibiotics, and IV fluids. The resident's condition continued to deteriorate, leading to a transfer to an acute care hospital. Interviews with facility staff revealed that the LVN responsible for initially reporting the lab results did not express concern about the abnormal values and stated she was just following orders. Other nursing staff indicated that proper procedure would have included assessing the resident, highlighting significant lab results, and ensuring the physician was aware of the critical findings. The Director of Nursing and the Director of Staff Development both acknowledged that nurses are expected to question unclear orders and have a basic understanding of lab values, but orientation only included a brief review of lab values without specific competency verification.
Plan Of Correction
How the facility plans to monitor its performance to make sure that solutions are sustained. The DON/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 7/30/25
Failure to Ensure Physician-Ordered Appointments and Wound Care
Penalty
Summary
The facility failed to provide necessary care and services for two residents, resulting in deficiencies related to physician-ordered follow-up and wound care. For one resident with acute and chronic respiratory failure, tracheostomy, and congenital malformation of the skull and facial bones, the facility did not ensure attendance at scheduled outpatient appointments for a speech evaluation and a plastic surgeon. Documentation showed that transportation for the appointments could not be arranged due to insurance issues, and the resident ultimately did not attend either appointment, despite physician orders and acknowledgment from the Director of Nursing (DON) that follow-up should have occurred. For another resident, the facility did not follow physician orders regarding wound care after surgery. The resident's order specified removal of a Prevena dressing, but during the procedure, betadine was applied to the surgical incision without a physician's order. This was confirmed by both a Licensed Vocational Nurse (LVN) and the DON, who acknowledged that betadine application required a physician's order. The Administrator and DON confirmed these findings during the survey.
Failure to Provide Proper Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for one resident. During wound care, licensed vocational nurses did not apply barrier cream to the resident's sacrum as ordered by the physician. Additionally, the wound care assessment did not document the presence of undermining in the sacrococcyx pressure injury, despite direct observation of undermining from 8 o'clock to 12 o'clock. The nurses involved did not initially recognize or document the undermining, and the physician was not notified of this change in the wound's condition at the time of assessment. The resident, who had a diagnosis of anoxic brain damage and was non-verbal, was dependent for mobility and had a documented stage 4 pressure injury to the sacrum. Medical records and care plans indicated the need for regular assessment, documentation, and communication regarding the wound's status, including the presence of undermining. However, the initial admission record lacked measurements and staging of the pressure injury, and subsequent skin evaluations did not address the undermining observed during wound care. Furthermore, the facility did not ensure that the low air loss mattress (LALM) settings were correctly adjusted according to the resident's weight. The mattress was set for a weight of 180 pounds, while the resident weighed 116 pounds. This discrepancy was confirmed by both nursing staff and the Director of Nursing, who acknowledged that the mattress settings should correspond to the resident's actual weight as part of wound management interventions.
Infection Control Deficiencies in Linen Handling and Tracheostomy Care
Penalty
Summary
Surveyors identified deficiencies in infection prevention and control practices for one of eight sampled residents. During an observation of wound care for a resident with a tracheostomy and a neck wound, a clean isolation gown was found to contain soiled gloves inside the sleeve. This was verified by the LVN present. Interviews with the infection prevention (IP) nurse and Maintenance Director revealed that gowns should be checked for foreign objects before being placed in clean linen storage, but gloves sometimes remained inside gowns after laundering, with the Maintenance Director acknowledging that gloves could melt during washing if not removed. Additionally, the same resident had a physician's order for daily tracheostomy care and wound management. During wound care, the LVN was observed moving a visibly soiled trach tie to access the wound, but did not change the tie after completing the wound care. The soiled trach tie, which had visible discoloration and debris, was only changed after the surveyor's observation and verification by staff. Interviews with the respiratory therapist, IP nurse, and DON confirmed that trach ties should be changed if soiled, regardless of the regular schedule. The facility's policies required staff to minimize the spread of infection, handle linens properly, and change trach ties as needed if soiled. The observed failures to ensure clean linens and to change a soiled trach tie after wound care did not align with these policies, resulting in a deficiency related to infection control practices.
Inaccurate Medical Record Documentation After Resident Discharge
Penalty
Summary
The facility failed to maintain accurate medical records for one of eight sampled residents. Specifically, a review of the closed medical record for a resident who had been discharged revealed that multiple care tasks and medication administrations were documented as completed on the medication administration record (MAR) for a date after the resident had already left the facility. These tasks included daily use of heel protectors, monitoring of apical pulse and pacemaker site, observation for pacemaker malfunction, and administration of potassium chloride ER tablets. Both the LVN and the DON confirmed that the MAR indicated these tasks as completed after the resident's discharge, and the facility's policy required clinical records to be a concise and accurate account of care and treatment provided.
Deficiencies in Wound Care and Treatment Orders
Penalty
Summary
The facility failed to provide necessary wound care and services for three residents, leading to deficiencies in their treatment. For Resident 2, there was a lack of communication and clarification between two physicians providing different wound care orders. The resident's treatment plan was not updated in the electronic health record (EHR) to reflect the wound specialist's recommendations, resulting in the discontinuation of mupirocin ointment without proper clarification. This oversight was confirmed by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the failure to follow the correct treatment plan. Resident 3 did not receive the appropriate bed mattress to promote healing of a pressure injury. Despite a physician's order for a Low Air Loss (LAL) mattress, the resident was observed lying on a different type of mattress. This discrepancy was verified by the DON during an observation and interview, indicating a failure to adhere to the prescribed treatment for pressure injury management. For Resident 5, the facility did not follow the correct sequence of wound care treatment as ordered by the physician. The LVN applied the xeroform dressing before the collagen sheet, contrary to the physician's instructions to apply the collagen sheet first. This error in the wound care procedure was acknowledged by the LVN and confirmed by the DON, highlighting a failure to execute the physician's orders accurately.
Failure to Provide Safety Mats for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident remained free from accident hazards by not providing the bilateral floor mats at the resident's bedside as ordered by the physician. This deficiency was identified during an observation and interview with the Assistant Director of Nursing (ADON), where it was confirmed that the resident, who was at high risk for falls, did not have the required safety mats in place. The resident's medical records indicated a physician's order for the mats dated 6/26/24, and the care plan initiated on 6/21/24 also included this intervention following an actual fall on that date. The resident's Quarterly Fall Risk Evaluation dated 12/19/24, classified them as high risk for falls, underscoring the necessity of the mats for safety. Despite these documented orders and care plans, the mats were not present during the observation on 2/26/25. The Director of Nursing (DON) was informed of these findings and verified the absence of the mats, confirming the facility's failure to adhere to the prescribed safety measures for the resident.
Failure to Follow Physician's Orders for GT Feedings
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of gastrostomy tube (GT) feedings for two residents, identified as Residents 3 and 5. According to the medical records, Resident 3 was supposed to receive enteral feeding starting at 1500 hours daily, delivering 1100 cc of Jevity 1.5 formula at a rate of 55 cc/hr for 20 hours. However, an observation on December 20th revealed that the feeding had commenced prematurely, with 39 ml already infused before the scheduled time. Similarly, Resident 5's orders indicated that enteral feeding should begin at 1500 hours, providing 1200 cc of water at 60 cc/hr for 20 hours. Despite this, the feedings for both residents were initiated at 1300 hours, two hours earlier than prescribed. Interviews with Licensed Vocational Nurses (LVNs) 1 and 3 confirmed the early administration of the feedings, with LVN 3 admitting to starting the GT feedings around 1300 hours. LVN 1 acknowledged that the feedings were ordered to start at 1500 hours, with a permissible window of one hour before and after the scheduled time. The Director of Nursing (DON) verified the discrepancy and stated that the licensed nurses should have followed the physician's orders. The facility's Administrator and DON acknowledged these findings, indicating a failure to provide necessary care and services as per the physician's directives.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during a kitchen tour. The kitchen utensils, including spatulas, whisks, and scoops, were found to be in poor condition, with chipped edges, discoloration, and residues. These conditions were verified by the Dietary Manager, who acknowledged that such utensils should not be used as they can harbor bacteria. Additionally, the cutting board was heavily marred, discolored, and peeling, making it difficult to clean and sanitize, which could lead to the accumulation of pathogenic microorganisms. The facility also failed to ensure that equipment and utensils were properly cleaned and stored. During the kitchen tour, it was observed that some utensils were stored wet and dirty, and the heavy-duty blender was not air-dried before storage. The microwave used for warming food was found to have dry, crusted food residue, and the kitchen hood had black, greasy residue, indicating inadequate cleaning. The ice machine, used by residents and staff, had ice buildup, which was acknowledged by the Maintenance Supervisor, who stated that the machine was under warranty and required maintenance by an outside company. These deficiencies in maintaining sanitary conditions in the kitchen had the potential for cross-contamination and foodborne illnesses among the residents consuming the food prepared in the facility. The Dietary Manager and Maintenance Supervisor acknowledged the findings and the need for proper cleaning and maintenance of kitchen equipment and utensils to prevent bacterial growth and ensure food safety.
Failure to Ensure Call Lights Within Residents' Reach
Penalty
Summary
The facility failed to provide reasonable accommodations for the call lights of four residents, which were not within their reach, potentially impacting their psychosocial well-being or delaying care. For Resident 96, the call light was found hanging at the back of the bed, out of reach, and was only placed within reach after verification by LVN 11. Similarly, Resident 108's call light was found underneath the pillow, out of reach, and was acknowledged by LVN 7 as needing to be accessible. Resident 775's call light was observed on the floor during two separate observations, both times out of reach, and was only placed within reach after CNA 2 verified the situation. Resident 775 was noted to lack the capacity to understand and make decisions, emphasizing the importance of having the call light accessible. Resident 78's call light was initially observed on the resident's right shoulder, not within reach, despite the resident having the ability to use the call light and movement in both hands. LVN 13 confirmed the call light's position and moved it under the resident's right hand. The Director of Nursing (DON) acknowledged that most residents in the Subacute Unit used call lights and emphasized the need for staff to place them within reach. The Administrator and DON were informed of these findings and acknowledged the deficiencies.
Failure to Timely Notify Physician of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding changes in the condition of two residents, leading to a delay in intervention and potential adverse outcomes. For Resident 51, the physician was not promptly informed about a change in the resident's swallowing status. The resident's family member had reported difficulty in swallowing liquids to the Social Services Department, which was supposed to notify the nursing staff. However, the physician was only notified several days later, after the Speech Therapist conducted a screening and recommended a swallow study. For Resident 56, the physician was not notified about the resident's episodes of vomiting and the decision to hold the resident's tube feeding. The resident had a history of vomiting, and the tube feeding was held without obtaining a physician's order, despite the resident's low weight. The nursing staff failed to communicate these changes to the physician, resulting in the resident receiving significantly less formula than ordered. The Director of Nursing confirmed that the physician should have been notified of these changes.
Unauthorized Search of Resident's Belongings
Penalty
Summary
The facility failed to honor a resident's right to a safe and comfortable environment by allowing staff to go through a resident's personal belongings without consent. This incident involved a resident who was legally blind but cognitively intact, as confirmed by their medical records. The resident was unaware of the intrusion until informed by their roommate, who witnessed the event. The roommate observed two individuals dressed like staff entering the room early in the morning, using a flashlight to search through the resident's belongings on the tray table, bedside table, and drawer while the resident was asleep. The Director of Nursing (DON) later confirmed that staff had been instructed to check residents' bedside areas for proper labeling and food expiration dates. However, the DON acknowledged that staff should have obtained permission from the resident before inspecting their belongings. This oversight led to the resident feeling upset upon learning about the unauthorized search, highlighting a breach in maintaining a homelike and respectful environment for the resident.
Failure to Follow Up on Consult Recommendations and Monitor Weight Loss
Penalty
Summary
The facility failed to provide necessary care and services to two residents, resulting in potential delays in identifying changes in their conditions and implementing appropriate interventions. For one resident, the facility did not follow up timely on skin and wound consult recommendations. The dermatologist had recommended a specific skin care regimen, including the use of fragrance-free products and avoiding harsh soaps. However, the medical record did not show that the physician was notified of these recommendations, and the resident continued to experience severe itchiness. Another resident was not monitored every shift for at least 72 hours following a noted weight loss, as required by the facility's policy. The medical record review revealed that the resident was not monitored on specific shifts, which was confirmed by the ADON and RN. This lack of monitoring could have delayed the identification of changes in the resident's condition and the implementation of necessary interventions.
Failure to Timely Report and Address Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely reporting and addressing of a new pressure ulcer for Resident 51, which was observed during a transfer to a wheelchair after a shower. The resident had an open area of approximately 2 cm on the right heel, which was not documented in the medical record. Treatment Nurse 1 was unaware of the wound, indicating a lack of communication and documentation regarding the resident's condition. CNA 1, who was assigned to Resident 51 for the first time, observed the wound during the morning shower and reported it to Treatment Nurse 2 only after lunch, which the DON acknowledged as untimely. Additionally, CNA 2, who had been assigned to the resident earlier in the week, noticed a callous on the right heel but did not report it, assuming it was not a new issue. This series of inactions and miscommunications led to a delay in treatment and intervention for the resident's pressure ulcer.
Failure to Implement Two-Person Assistance for ADL Care
Penalty
Summary
The facility failed to implement the recommended two-person assistance for Activities of Daily Living (ADL) care for a resident, which resulted in the resident experiencing another fall. The medical record review revealed that the resident had previously sustained a fall when a Certified Nursing Assistant (CNA) attempted to roll the resident in bed to place a mechanical lift sling, causing the resident to slide off the bed. Following this incident, the Fall Committee's Interdisciplinary Team (IDT) recommended two-person assistance for ADL care. Despite this recommendation, another fall occurred when a CNA was providing bedside care without assistance, and the resident began to slide off the bed. During an interview and concurrent medical record review with the Director of Nursing (DON), it was confirmed that the CNA was performing ADL care alone, contrary to the IDT's recommendation for two-person assistance.
Improper Positioning of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. During an observation, it was noted that the urinary drainage bag and tubing for the resident were positioned above the bladder, contrary to the facility's policy and procedure, which requires the drainage bag to be below the bladder to prevent UTIs and other complications. This improper positioning was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), who acknowledged that the drainage bag should be lower than the bladder. The resident in question had a care plan addressing the use of an indwelling urinary catheter for neurogenic bladder, which included specific interventions to position the catheter drainage bag and tubing below the bladder. Despite this, the drainage bag was observed to be incorrectly positioned, posing a risk for the development of UTIs. The facility's policy, revised in November 2019, clearly outlines the correct procedure for catheter drainage bag positioning, which was not adhered to in this instance.
Incorrect Enteral Formula Administered to Resident
Penalty
Summary
The facility failed to administer the correct enteral formula to a resident, identified as Resident 56, who was receiving tube feeding. The medical record review revealed a physician's order for Vital 1.5 formula to be administered at a specific rate and volume. However, during an observation and interview with an LVN, it was discovered that the resident was receiving Vital 1.2 instead of the prescribed Vital 1.5. The LVN reported that the tube feeding was held due to the resident vomiting, and upon checking, it was found that the resident had received less than the ordered calories due to the incorrect formula being used. This discrepancy had the potential to negatively impact the resident's well-being.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for four residents, as observed during a survey. For three residents, the facility did not ensure that oxygen tubing was dated, which is a requirement according to the facility's policy. This oversight was confirmed through observations and interviews with staff, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON). The facility's policy mandates that oxygen tubing should be replaced and dated every seven days, but this was not adhered to for Residents 83, 725, and 726. Additionally, the facility did not administer oxygen as ordered by the physician for Resident 65. The resident was observed receiving oxygen at a rate of 4 liters per minute, contrary to the physician's order of 3 liters per minute. This discrepancy was verified through an interview with an LVN, who confirmed that the oxygen administration did not match the physician's order. The resident's care plan also indicated the need for humidified oxygen as prescribed, which was not followed. These deficiencies were identified through a combination of observations, interviews, and medical record reviews. The facility's failure to date oxygen tubing and administer oxygen as ordered by the physician had the potential to put residents at risk for adverse effects due to inaccurate administration of oxygen and improper care of oxygen equipment. The facility's policies were not followed, as confirmed by multiple staff members, including the DON and respiratory therapists.
Inadequate Assessment and Documentation of Side Rail Use
Penalty
Summary
The facility failed to ensure accurate and complete assessments and evaluations for the use of side rails for three residents, leading to potential safety risks. Resident 18 was observed using 1/4 side rails for positioning, but the medical record did not show any measures or interventions attempted before implementing the side rails. The Assistant Director of Nursing (ADON) confirmed that the least restrictive measures were not evaluated, and the necessary documentation was incomplete. For Resident 41, the facility did not document evidence of the least restrictive alternatives implemented before the use of side rails. The resident requested side rails to assist with bed mobility, but the Director of Nursing (DON) verified that the facility did not offer or document any alternatives before implementing the side rails. The DON acknowledged that the interventions on the evaluation form were not appropriate for the resident, and the facility failed to implement the least restrictive alternatives. Resident 56 had an order for bilateral padded 1/4 side rails for positioning and mobility, but the resident did not respond to verbal stimulation and had no purposeful movement. The DON confirmed that the use of side rails was inappropriate for this resident, as they were unable to self-position. These failures in assessment and documentation put the residents at risk for entrapment and serious injuries.
Failure to Document and Account for Controlled Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services by not ensuring all controlled medications were accounted for and documented properly. During an inspection of Medication Cart A, it was found that the Narcotic Count Sheet for a specific date had entries crossed out, indicating that a controlled substances count was not performed. LVN 3 admitted to filling out the row in error and confirmed that the documentation did not show that licensed staff performed the required count on that day. Additionally, there were discrepancies in the documentation of controlled medication administration for two residents. For one resident, the Medication Count Sheet showed an incomplete entry, with the time column left blank, as LVN 3 had started filling it out in anticipation of the next dose. For another resident, the count of lorazepam tablets did not match the physical count, as a dose was administered but not documented on the Medication Count Sheet. LVN 3 acknowledged these discrepancies and confirmed that documentation should be completed at the time of administration to ensure accurate counts and prevent drug diversion. The Administrator and DON were informed and acknowledged these findings.
Failure to Accurately Monitor Orthostatic Blood Pressure
Penalty
Summary
The facility failed to accurately monitor orthostatic blood pressure for a resident prescribed Zyprexa, an antipsychotic medication, for schizophrenia. The physician had ordered orthostatic blood pressure monitoring to be conducted while the resident was lying and sitting every Monday. However, the medical administration records from August to November showed identical blood pressure readings for both positions on multiple occasions, indicating that the procedure for taking orthostatic blood pressure was not followed correctly. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the orthostatic blood pressure readings should differ between lying and sitting positions. The DON acknowledged that the readings were not accurately monitored, and the LVN admitted to taking the blood pressure readings immediately after the resident changed positions, which is contrary to the facility's policy that requires a waiting period between position changes. This inaccuracy in monitoring had the potential to affect the resident's treatment and medication adjustments.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 25% due to nine medication errors out of 36 observations. During a medication pass observation, an LVN was seen administering eight medications to a resident by crushing them and mixing them with applesauce. After administration, residual medication was found in each of the eight cups, resulting in eight medication errors. Additionally, the same LVN administered dorzolamide eye drops to another resident, applying the drops only to the right eye despite the physician's order to administer them to both eyes. The LVN acknowledged the discrepancy but stated the resident preferred drops only in the right eye. However, the resident expressed a preference for drops in both eyes, leading to another medication error.
Improper Medication Storage and Disposal in Facility
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications and biologicals across multiple medication carts, leading to potential risks of unsafe medication administration and cross-contamination. During an inspection of Medication Cart E, a used syringe of saline was found stored with unopened injection sites, and hydrocortisone cream was stored with safety needles. These findings were verified by RN 1, who acknowledged that the syringe should have been discarded and the cream should not have been stored with needles. In Medication Cart D, nitroglycerin sublingual tablets were improperly stored with lubricant jelly, which was confirmed by RN 1, who removed the medication from the cart. Medication Cart A had several issues, including a sharps container filled above the full line and various medications stored together despite different routes of administration. LVN 3 confirmed these findings, noting that such storage practices could lead to cross-contamination. Medication Cart C contained topical gel stored with pre-filled syringes and vials, and transdermal patches stored with oral supplements, with the latter observed in an unclean condition. LVN 5 verified these issues. Similarly, Medication Cart B had lubricant eye gel stored with heparin vials, and various medications with different administration routes stored together. These findings were confirmed by LVN 6 and the ADON. The Administrator and DON were informed of all these deficiencies and acknowledged them.
Failure to Follow Up on Abnormal Lab Results for Seizure Medication
Penalty
Summary
The facility failed to follow up with the physician regarding abnormal laboratory results for a resident with intractable epilepsy. The resident, who was readmitted to the facility, had a physician's order for divalproex sodium to manage seizure activity. A review of the resident's laboratory results showed a valproic acid level of 37 mcg/ml, which was below the reference range of 50-100 mcg/ml, and flagged as low. Despite this, the medical record did not show repeated attempts to notify the physician about the low laboratory results. The Consultant Pharmacist had previously recommended clarifying the use of valproic acid for seizures and obtaining a valproic acid level. A nursing note indicated that the nurse communicated with the physician about the low valproic acid level and recommended increasing the dose, but they were awaiting a response. During an interview, the Director of Nursing stated that the expectation for abnormal laboratory values was to make two to three attempts to notify the physician and, if unsuccessful, to contact the medical director. However, the facility's records did not reflect these actions.
Incomplete Medical Records and Documentation Failures
Penalty
Summary
The facility failed to maintain accurate medical records for four residents, leading to potential unmet care needs due to incomplete documentation. For Resident 33, there was no documentation of intravenous fluid intake every shift, despite orders to monitor intake and output. Additionally, Resident 33's refusal to be weighed was not documented, as the RNA did not know how to record the refusal in the PointClickCare system. This lack of documentation was verified by both RN 3 and the DON, who acknowledged the oversight. Resident 49's medication administration record (MAR) was incomplete, missing documentation for insulin administration, Prevacid, artificial tears, and the use of a left-hand mitten. LVN 15 confirmed the missing entries for two consecutive days, and the DON explained the process for medication administration and the importance of daily audits to capture missing documentation. The charge nurse was responsible for completing audits within 72 hours, but the missing entries were not addressed in a timely manner. For Resident 105, the hospice visitation log was incomplete, missing signatures and dates for visits by hospice staff. The DSD confirmed the missing entries and had contacted the hospice provider to address the issue. Additionally, Resident 41's updated flu vaccination consent was not filed in the appropriate medical records folder. The IP and DON both acknowledged that the consent should have been stored in the resident's medical record, but it was instead kept in a separate binder. These documentation failures were acknowledged by the facility's administration.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies in their practices. The infection control surveillance program was not fully implemented from January 2024 through September 2024. The facility only conducted surveillance on residents who were prescribed antimicrobials, neglecting those who showed signs and symptoms of infection but were not on antibiotics. This oversight was confirmed during an interview with the Infection Preventionist (IP), who admitted that residents not prescribed antibiotics were excluded from the surveillance logs. Additionally, the facility did not ensure proper infection control practices for specific residents. For instance, Resident 775, who had wounds, did not have a physician's order or a care plan for enhanced barrier precautions, which are necessary to prevent infection. Furthermore, tracheostomy supplies in the respiratory carts were not stored properly, as observed during an inspection with the Administrator. The supplies were found without secure closure packages, which the Administrator acknowledged should have been discarded. Other deficiencies included the failure to label a urinal for Resident 43, as required by the facility's policy on disposable equipment. The blood glucose meter in Medication Cart A was also found to be soiled and not cleaned after use, contrary to the facility's policy and the manufacturer's guidelines. These lapses in infection control practices posed a risk for not identifying infections and controlling the transmission of communicable diseases within the facility.
Deficiencies in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively, as evidenced by several deficiencies in the use of McGeer's criteria for infection assessment and the correct Surveillance Data Collection Forms. Specifically, the facility did not conduct an assessment for McGeer's criteria to determine a true infection for one nonsampled resident. Additionally, the facility used incorrect Surveillance Data Collection Forms for two final sampled residents and four nonsampled residents, which could lead to inaccurate identification of infections. Furthermore, the facility did not properly apply the Surveillance Data Collection Form criteria to indicate a true infection for one final sampled resident and three nonsampled residents. These residents were prescribed antibiotics without meeting the necessary McGeer's criteria for healthcare-associated infections (HAI), as indicated on their Surveillance Data Collection Forms. The Infection Preventionist (IP) and the Director of Nursing (DON) acknowledged these findings during interviews, confirming the failure to adhere to the established infection prevention and control protocols.
Resident Rights Violation Due to Staff Cell Phone Use
Penalty
Summary
The facility failed to respect the resident rights of a nonsampled resident, identified as Resident 35, by allowing a certified nursing assistant (CNA 3) to use a personal cell phone while feeding the resident. This action was observed and reported by another resident, Resident 325, who noted that CNA 3 was on his cell phone multiple times during the feeding process. Resident 35, who is legally blind and cognitively intact, was unaware of the CNA's actions, but Resident 325 found the behavior disrespectful. The facility's employee handbook, which CNA 3 had signed, explicitly prohibits the use of personal electronic devices during work hours. The Director of Nursing (DON) confirmed that staff should not use personal cell phones while providing resident care. During a telephone interview, CNA 3 admitted to using his cell phone three to four times while feeding Resident 35, acknowledging that this was against the facility's policy.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during a wound care dressing change for a resident with a Stage 4 sacral coccyx wound. The licensed nurse, identified as LVN 8, did not change gloves or perform hand hygiene between steps of the wound care process. Specifically, after cleaning the resident's stool with a gauze dressing and having stool on his gloves, LVN 8 proceeded to pull back the sacral coccyx wound dressing without changing gloves or performing hand hygiene. Furthermore, after removing the wound dressing, LVN 8 removed his gloves but did not perform hand hygiene before leaving the room to get supplies. Upon returning, LVN 8 donned new gloves and placed clean supplies on the bedside table without sanitizing it. He then cleaned the resident's wound with a clean gauze with saline and covered it with a new dressing. During an interview, LVN 8 acknowledged that he should have changed gloves and performed hand hygiene during the wound dressing change. The Director of Nursing confirmed that LVN 8 did not follow the facility's infection control practices by failing to change gloves and perform hand hygiene between steps of the wound care process.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure the call light for Resident 1 was within the resident's reach, which had the potential for the resident to not be able to call for assistance when needed. During an observation and interview on 5/24/24, Resident 1 was found lying in bed with the call light cord wrapped around the elevated right bedrail and the call light button hanging halfway to the floor, out of reach. Resident 1, who had impaired speech but could verbalize needs and answer simple questions, stated she did not know where her call light was. CNA 1 confirmed that the call light was not within reach and acknowledged that it should have been accessible to the resident. The facility's policy and procedure (P&P) on call lights, revised in May 2007, mandates that the call device be placed within the resident's reach before leaving the room. However, this policy was not followed in Resident 1's case. A follow-up observation on 5/30/24 revealed that Resident 1 was again unable to reach her call light, which was still wrapped around the bedrail and hanging halfway to the floor. Resident 1 was found crying and stated she wanted to be changed because she felt wet. CNA 2 also verified that the call light was not within reach and stated it should have been clipped within Resident 1's reach. The Assistant Director of Nursing (ADON) confirmed that the call device should always be within the resident's reach and acknowledged the findings. This repeated failure to ensure the call light was accessible to Resident 1 indicates a lapse in adhering to the facility's P&P, potentially compromising the resident's ability to call for assistance when needed.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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