Newport Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newport Beach, California.
- Location
- 1555 Superior Avenue, Newport Beach, California 92663
- CMS Provider Number
- 055518
- Inspections on file
- 17
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Newport Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents with known elopement risks were able to leave the facility through an exit door in the smoking area after one resident kicked the door open. No staff were present by the exit door, and the alarm system did not sound as expected. Staff only responded after hearing the door banging, and there was no maintenance log to verify regular checks of the alarm system.
The facility failed to maintain sanitary conditions in its kitchen, with issues such as a dirty ice machine, a microwave with food residue, and a grease-laden kitchen hood. Kitchen utensils were worn and dirty, and expired foods were not discarded. These deficiencies were acknowledged by the Environmental Services Director and Dietary Supervisor, highlighting potential risks of cross-contamination and foodborne illnesses.
The facility failed to maintain infection control practices, lacking documentation for Legionella risk assessment and testing protocols. CNA 1 did not change PPE or perform hand hygiene between residents, risking MDRO transmission. An unpackaged N95 respirator was improperly stored, and clean linens were placed on soiled carts, violating infection control protocols.
A facility failed to notify a physician of a change in a resident's neurological status following a fall. Despite the facility's policy requiring notification of any changes, an LVN did not inform the physician of a change in the resident's pupillary response during a neurological check. The resident had severely impaired cognition and was under specific care plan interventions for neurological evaluations. The deficiency was confirmed by the DON and acknowledged by the Administrator.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. A resident at risk for falls did not have bilateral floor mats as required, and another resident at risk for pain received only one lidocaine patch instead of the prescribed two. These oversights were confirmed by an LVN during observations and interviews.
Two residents in a facility did not receive appropriate pressure ulcer care. One resident's LAL mattress was set incorrectly for their weight, and wound treatment was not administered as per the physician's order. Another resident's mattress setting was also incorrect for their weight. The facility failed to document and monitor the mattress settings, potentially affecting wound healing and skin integrity.
The facility failed to implement fall prevention measures for two residents, leading to potential risks. A resident with a history of falls was not transferred using a gait belt as required by their care plan, despite being at moderate risk for falls. Another resident did not have bilateral floor mats as ordered by the physician, increasing their fall risk. These deficiencies were confirmed through observations and staff interviews.
A facility failed to document necessary PICC line measurements for a resident upon admission, as required by their policy. The resident's care plan indicated the need for measuring the external length of the catheter and arm circumference, but the medical record lacked this documentation. Interviews with staff confirmed the absence of these measurements, which are crucial for identifying potential complications.
A facility failed to provide safe respiratory care for a resident using a CPAP machine. The CPAP machine was not cleaned according to the manufacturer's guidelines, and there was no documentation of cleaning in the resident's medical records. Staff interviews revealed confusion about cleaning responsibilities, and the CPAP mask was not stored properly. The facility's policy required regular cleaning and documentation, which were not followed, leading to a deficiency in care.
The facility failed to provide appropriate pain management for two residents by not administering medications according to physician orders and not documenting non-pharmacological interventions (NPIs) prior to medication administration. One resident received pain medication outside prescribed levels without NPIs or physician notification, while another was given narcotics without documented NPIs. Staff interviews confirmed these deficiencies, and the facility's administration acknowledged the lack of documentation and adherence to pain management protocols.
The facility failed to administer medications on time for several residents due to unexpected circumstances and emergencies, leading to potential health risks. Additionally, there were discrepancies in the documentation of controlled substances, raising concerns about drug diversion. These deficiencies highlight issues in medication management and documentation practices.
A facility's medication error rate was found to be 16.13%, exceeding the acceptable limit of 5%. An LPN failed to administer medications as ordered for a resident, including incorrect application of lidocaine patches and omission of calcium carbonate-vitamin D and povidone-iodine swabs. Another LPN administered an incorrect dosage of calcitriol and improperly applied lidocaine patches for a second resident.
The facility failed to ensure safe storage and disposal of medications and medical supplies. Opened and unsealed items were found in medication carts, compromising sterility. Additionally, a medication disposal bin contained whole pills and other items not properly disposed of, as confirmed by LVN 5 and the DON.
A resident's PHI was exposed during medication administration when an LVN left a computer screen displaying the resident's name, prescribed medications, and indications for use unattended in the hallway. This breach of confidentiality occurred despite the facility's policy to safeguard resident information, as the screen was visible to other residents passing by.
A resident did not receive their preferred beverage, milk, during a lunch meal despite it being listed on their meal ticket. The oversight was confirmed by a CNA and later acknowledged by the DSS, ADM, and DON.
A resident with a documented allergy to dairy products was served milk due to a failure in verifying food allergies during meal preparation. The oversight was confirmed by the Dietary Supervisor and DON, acknowledging the risk of severe allergic reactions.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Elopement Due to Inadequate Supervision and Faulty Exit Door Alarm
Penalty
Summary
The facility failed to maintain a safe and secure environment for two residents who were at risk for elopement. Both residents had documented histories and care plans indicating their risk for elopement, with one resident being independent in decision-making and the other unable to make medical decisions but able to express needs. Despite these risks, both residents were able to leave the premises through an exit door in the smoking area. The incident occurred when the residents were observed in the courtyard, and one resident kicked the exit door, allowing both to exit the facility. Staff only became aware of the elopement after hearing the banging of the door, and no alarm was heard at the time, even though the door was supposed to be alarmed. Interviews and video evidence confirmed that no staff were present by the exit door at the time of the incident, and the alarm system did not function as intended. The Maintenance Director stated that exit doors were checked daily but admitted there was no maintenance log to document these checks. The lack of staff supervision in the area and the failure of the alarm system contributed to the residents' ability to elope, placing them at risk for harm or injury.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as evidenced by multiple observations during a kitchen tour. The ice machine, which was used by both residents and staff, was found to have a pinkish residue on its interior top portion, indicating it was not maintained in a sanitary condition. The Environmental Services Director acknowledged this finding and confirmed that the ice would not be used due to its dirty condition. Additionally, the microwave used for warming food was observed to have dry, crusted food residue inside, which the Dietary Supervisor confirmed should have been cleaned daily and deep cleaned weekly. Further observations revealed that the kitchen hood over the stove had black, grease residue, which the Dietary Supervisor admitted was not adequately cleaned, as it should be cleaned weekly by staff and every six months by an outside company. Kitchen utensils and equipment were also found to be in poor condition, with items such as whisks, spatulas, and cutting boards being worn out, discolored, and dirty. The Dietary Supervisor acknowledged these findings, stating that the items should be discarded and replaced to prevent cross-contamination. The facility also failed to ensure proper food storage and handling practices. Expired foods were found in the refrigerator, including egg salad and various fruit and pudding cups, which were not labeled accurately or discarded as required. The Dietary Supervisor confirmed these findings, acknowledging that the items should have been labeled correctly and expired items discarded. These deficiencies in maintaining sanitary conditions and proper food handling practices had the potential to lead to cross-contamination and foodborne illnesses among the residents consuming the food prepared in the facility's kitchen.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several deficiencies observed during the survey. The facility did not have documentation of a Legionella facility risk assessment or testing protocols for Legionella and other opportunistic waterborne pathogens. The Administrator admitted that the facility lacked a flow chart of the water system and only identified the water fountain as a risk. The EVS Director confirmed that no testing for Legionella or other pathogens was conducted in areas with potential risks for standing water, such as water heaters and shower rooms. In another instance, CNA 1 did not follow proper infection control procedures when interacting with residents. After touching Resident 498, who had an indwelling medical device, CNA 1 failed to remove her gown and gloves and perform hand hygiene before assisting another resident, Resident A. This action was contrary to the physician's order and the facility's infection prevention protocols, which required changing PPE and performing hand hygiene between residents to prevent the transmission of multidrug-resistant organisms (MDROs). Additional deficiencies were noted in the handling and storage of PPE and clean linens. An unpackaged N95 respirator was found lying on top of a plastic PPE container at the entrance of a COVID-19 isolation room, with no clarity on its ownership or usage status. This improper storage posed a risk of contamination. Furthermore, CNA 6 placed a resident's shower bin containing clean items on a soiled linen cart, and clean bathrobe belts were observed lying on top of a clean linen cart, both of which violated infection control protocols.
Failure to Notify Physician of Change in Resident's Neurological Status
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) informed the physician of a change in condition for a resident (Resident 598) who was reviewed for falls. The facility's policy and procedure (P&P) required that any change in a resident's neurological status be reported to the physician. Despite this, LVN 1 did not notify the physician of a change in Resident 598's pupillary response during a neurological check on December 1, 2024, at 1100 hours. This change was significant as it indicated a potential neurological impairment following an unwitnessed fall on November 30, 2024. The resident's medical records showed severely impaired cognition, and the care plan included specific interventions for neurological evaluations following the fall. The deficiency was identified through interviews and medical record reviews, which revealed that LVN 1 did not compare the neurological assessments as required and failed to notify the physician of the change in pupillary response. The Director of Nursing (DON) confirmed that the nurse should have compared the results of the neurological checks and informed the physician of any changes. The failure to notify the physician was acknowledged by both the DON and the Administrator during interviews conducted on December 5, 2024, and December 15, 2024, respectively.
Deficiencies in Care Plan Implementation for Two Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in their care. For Resident 298, who was at risk for falls due to generalized weakness and a history of cerebrovascular accidents, the care plan required bilateral floor mats to be placed next to the bed. However, during observations, it was noted that only one side of the bed had a floor mat, contrary to the care plan's requirements. This oversight was confirmed by LVN 4 during an interview and medical record review. Similarly, the facility did not adhere to the care plan for Resident 301, who was at risk for pain due to peripheral vascular disease, osteoporosis, and generalized body pain. The care plan specified the application of two lidocaine 4% external patches for pain management. However, during a medication administration observation, LVN 4 applied only one patch to the resident's hip, instead of the prescribed two patches to the hip and foot. This discrepancy was also verified by LVN 4 during a subsequent interview and medical record review.
Failure to Ensure Proper Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of new pressure ulcers and promote the healing of existing ones for two residents. For Resident 599, the facility did not ensure that the Low Air Loss (LAL) mattress setting was consistent with the resident's weight, which was set at the 8th light bar, appropriate for a weight of 300 to 330 pounds, while the resident weighed 230 pounds. Additionally, the wound treatment for a Stage 2 pressure ulcer on the coccyx was not administered as per the physician's order, as chlorhexidine was used instead of soap and water for cleaning the wound without proper documentation or physician's order clarification. Resident 599 was admitted to the facility with a risk for developing pressure ulcers and had a Stage 2 pressure ulcer on the coccyx. The resident was cognitively intact and dependent on staff for bed mobility. The facility's failure to adjust the LAL mattress setting according to the resident's weight and to follow the physician's wound treatment order potentially affected the wound healing process. The Treatment Administration Record (TAR) lacked documentation of the LAL mattress settings and monitoring, and the care plan did not include the use of the LAL mattress as an intervention. Similarly, for Resident 598, the LAL mattress setting was not consistent with the resident's weight. The mattress was set at the 8th light bar, while the resident weighed 121 pounds, which required a setting of 2 light bars. The facility did not document the specific LAL mattress setting for the resident, and the TAR did not show monitoring of the mattress unit. Resident 598 had severely impaired cognition and was at risk for developing pressure ulcers, requiring total assistance for bed mobility. The facility's failure to ensure the correct mattress setting could have impacted the resident's comfort and skin integrity.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 298 and 600, were free from accident hazards, which placed them at risk for serious injury. For Resident 600, the facility did not adhere to the fall risk evaluation and care plan that required the use of a gait belt during transfers. On multiple occasions, CNAs did not use the gait belt when transferring Resident 600 to the commode, despite the resident's history of falls and the care plan's specific instructions. Interviews with the CNAs revealed that they were aware of the fall risk but chose not to use the gait belt, believing the resident was stable enough without it. Resident 600 had a history of falls and was at moderate risk for falls due to impaired gait and balance, as noted in the fall risk evaluations. The care plan specified the use of a gait belt and other assistive devices during transfers. However, during an observation, a CNA was seen transferring Resident 600 without the gait belt, which was confirmed by the CNA's admission of not using it despite being informed of the necessity by the charge nurse. The Occupational Therapist also confirmed the protocol for using a gait belt during transfers for Resident 600. For Resident 298, the facility failed to implement the physician's order for bilateral floor mats for fall prevention. During an observation, it was noted that only one side of Resident 298's bed had a floor mat, contrary to the care plan that required mats on both sides. This oversight was verified by an LVN, who acknowledged that the mats should have been placed on both sides to reduce the risk of injury, as Resident 298 was at risk for falls due to generalized weakness and a history of CVA and TIA.
Failure to Document PICC Line Measurements
Penalty
Summary
The facility failed to provide necessary care and services to maintain the IV access for a resident, specifically in the management of a PICC line. The facility's policy and procedure for Central Venous Catheter Care and Dressing Changes, dated 2001, requires the measurement of the external central vascular access device with each dressing change and when catheter dislodgement is suspected. Additionally, for PICCs, arm circumference should be measured and compared to baseline to assess for edema and possible deep-vein thrombosis. However, upon review, it was found that the facility did not document the PICC line external catheter and arm circumference measurements for the resident upon admission, as required by the facility's policy. The resident's medical record, including the History and Physical examination and the Order Summary Report, lacked documentation of these measurements. The resident's care plan indicated the presence of a PICC line on the right upper arm and required the measurement of the external length of the catheter and upper arm circumference. Despite this, the IV Administration Record showed incomplete documentation, with the arm circumference recorded as 32 cm and the catheter length as zero. Interviews with RN 1 and the DON confirmed the absence of these critical measurements upon admission, which are essential for identifying signs of infection, swelling, blood clots, and catheter dislodgement.
Failure to Provide Safe Respiratory Care for a Resident Using CPAP
Penalty
Summary
The facility failed to provide safe respiratory care for a resident using a CPAP machine, as observed during a survey. The CPAP machine, belonging to Resident 12, was not cleaned according to the manufacturer's guidelines, which require regular cleaning to prevent contamination and respiratory complications. The resident reported that staff had not cleaned the CPAP machine since its use began at the facility. Observations confirmed that the CPAP mask was not stored properly, and there was no evidence of cleaning or maintenance in the resident's medical records. The facility's policy and procedure for CPAP/BiPAP support, revised in 2015, outlined specific cleaning instructions, including weekly cleaning of the machine and daily cleaning of components like masks and tubing. However, these procedures were not followed for Resident 12. Interviews with staff, including a CNA and the Director of Staff Development (DSD), revealed a lack of clarity regarding responsibility for cleaning the CPAP equipment. The DSD confirmed that there were no physician's orders or documentation regarding the cleaning of the CPAP machine and its components in the resident's care plan. Further interviews with the Director of Nursing (DON) indicated that both CNAs and LVNs could clean the CPAP mask, but it should be documented by licensed nurses. The DON acknowledged that the CPAP mask and machine should be cleaned routinely and stored properly when not in use. The facility's failure to adhere to these procedures and document the cleaning process resulted in a deficiency in providing safe respiratory care for Resident 12.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, Resident 12 and Resident 599, as identified through interviews, medical record reviews, and facility policy reviews. For Resident 12, the facility did not administer pain medication according to the physician's order and failed to ensure non-pharmacological interventions (NPIs) were provided or documented prior to administering pain medications. Resident 12, who was admitted following shoulder surgery, was given acetaminophen and oxycodone outside the prescribed pain levels without documentation of NPIs or physician notification. Resident 12's medical records showed instances where acetaminophen was administered for pain levels that did not match the physician's orders, and there was a lack of documentation for NPIs. Interviews with staff, including a CNA and an LVN, confirmed that pain medications were administered without following the ordered parameters, and there was no documentation of NPIs or physician notification when medications were given outside the prescribed pain levels. The LVN acknowledged the absence of documentation for NPIs and the lack of communication with the physician regarding deviations from the prescribed pain management plan. Similarly, for Resident 599, the facility failed to consistently provide NPIs before administering narcotic pain medication. Resident 599, who developed a bedsore during her stay, was given Roxicodone for moderate to severe pain without documented evidence of attempted NPIs. The DON confirmed that medications should be administered as ordered, with NPIs documented prior to administration. The absence of documentation for NPIs and the administration of pain medications outside the ordered parameters were acknowledged by the facility's administration.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide timely administration of medications as per their policy and procedures for several residents. Licensed Vocational Nurse (LVN) 2 did not administer the 0900 hours medications within the required 60-minute window for two residents, 601 and 602. This delay was attributed to unexpected circumstances and resident emergencies, which led to the medications being administered late. Resident 601, who had recently suffered a stroke, expressed the importance of timely medication to prevent further health complications. Similarly, Resident 602 questioned the delay in receiving his medications, highlighting the expectation for timely administration. LVN 4 also failed to administer medications on time for three residents, 42, 302, and 305, due to attending to another resident's emergency. The medications scheduled for 0900 hours were administered significantly later, with some being given as late as 1341 hours. This delay in medication administration could potentially lead to adverse health effects, especially for residents with conditions such as hypertension and heart failure, who rely on timely medication to manage their health. Additionally, the facility did not accurately document the administration of controlled substances for three residents, 14, 302, and 303. The Drug Control Receipt/Record/Disposition Forms for these residents showed discrepancies in the count of medications, indicating a failure to record the removal of certain tablets. This lack of accurate documentation raises concerns about potential drug diversion and the facility's ability to monitor and reconcile controlled substances effectively.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 16.13%. This deficiency was identified through observations, interviews, and medical record reviews. LVN 2 did not administer three medications as ordered by the physician for Resident 602. Specifically, LVN 2 applied only one lidocaine 4% external patch instead of the prescribed two patches, and failed to administer calcium carbonate-vitamin D and povidone-iodine swabs. LVN 2 acknowledged these errors and noted the absence of the correct calcium carbonate-vitamin D dose in the medication cart or central supply. Additionally, LVN 4 administered incorrect dosages and failed to follow physician orders for Resident 301. LVN 4 gave two capsules of calcitriol 0.5 micrograms instead of the ordered two capsules of calcitriol 0.25 micrograms, effectively doubling the prescribed dose. Furthermore, LVN 4 applied only one lidocaine 4% external patch to Resident 301's hip, contrary to the order to apply two patches to the right hip and right foot. These actions were verified by LVN 4 during a concurrent interview and medical record review.
Improper Storage and Disposal of Medications and Supplies
Penalty
Summary
The facility failed to store drugs, biologicals, and medical supplies safely, as evidenced by improper disposal of opened medical supplies in Medication Carts B and C. During an inspection, it was observed that a sterile glove was opened and unsealed in Medication Cart B, compromising its sterility. In Medication Cart C, several items, including a foam dressing, abdominal pad dressing, xeroform petrolatum dressing, foam wound dressing, and a urethral catheterization tray, were found opened, breaking their sterility. LVN 5 confirmed these findings and acknowledged that all licensed nurses are responsible for cleaning the cart and discarding compromised items. Additionally, the facility failed to properly dispose of discontinued medications. In Medication room [ROOM NUMBER], a medication disposal bin contained multiple whole pills not fully dissolved, an unidentified bottle, insulin pens, nasal spray, an inhaler, and syringes. LVN 5 acknowledged that the medications in the disposal bin were not fully dissolved and that the lid was removable, which is not in compliance with the facility's policy. The DON verified these findings and stated that liquids should have been poured out, and bottles should not have been kept in the disposal bin.
Resident PHI Exposed During Medication Administration
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's personal health information (PHI) during medication administration. During an observation, a Licensed Vocational Nurse (LVN) prepared medications for a resident and left the medication cart unattended in the hallway. The computer attached to the cart displayed the resident's PHI, including their name, prescribed medications, and the indications for use. This information was visible to other residents passing by, as the screen was facing the hallway. The facility's policy and procedure on confidentiality, revised in October 2017, mandates the protection and safeguarding of residents' personal and medical records, limiting access to authorized staff only. However, the LVN acknowledged the oversight and confirmed that the displayed information was indeed private health information. The LVN admitted that she should have ensured the computer screen did not display the resident's PHI when she was away from the medication cart.
Failure to Provide Resident's Preferred Beverage
Penalty
Summary
The facility failed to accommodate the drink preferences for one of the residents, identified as Resident 12, during a lunch meal. On the specified date, Resident 12 was observed in his room with a lunch tray that did not include the four ounces of whole milk as per his standing order on the meal ticket. Instead, the tray contained chicken salad, water, cranberry juice, chocolate ice cream, and an applesauce bar. Resident 12 expressed his preference for having milk with his lunch, which was not initially provided. A Certified Nursing Assistant (CNA 5) confirmed that the meal ticket indicated the resident's preference for milk, and acknowledged the oversight. The CNA subsequently provided the milk to Resident 12. The Dietary Services Supervisor (DSS) later confirmed that if milk was listed on the meal ticket, it should have been included on the tray. The Administrator (ADM) and Director of Nursing (DON) were informed of these findings, acknowledging the deficiency in meeting the resident's dietary preferences.
Failure to Adhere to Resident's Documented Food Allergies
Penalty
Summary
The facility failed to adhere to a resident's documented food allergies, resulting in the resident being served dairy products despite having a known allergy. The deficiency was identified through interviews, medical record reviews, and policy and procedure reviews. The resident, who had an allergy to dairy products, was served milk during meals, which could have negatively impacted their well-being. This oversight occurred because the kitchen staff did not verify the resident's food allergies when preparing the meal tray, as the allergy section of the dietary communication card was obscured by a ring hook. The resident's medical records, including an acute care hospital history and physical examination, clearly indicated an allergy to dairy products, which was also noted in the resident's plan of care. Despite this, the resident was served whole milk, leading to a complaint from the resident's family member. The Dietary Supervisor and the Director of Nursing confirmed the oversight and acknowledged that the resident should not have been served dairy products, as it could result in severe allergic reactions.
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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