Noble Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 2740 North California Street, Stockton, California 95204
- CMS Provider Number
- 555105
- Inspections on file
- 54
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Noble Care Center during CMS and state inspections, most recent first.
A resident with a history of dementia, schizophrenia, and noncompliance with psychotropic medications exhibited escalating aggression, including verbal and physical outbursts, but was placed in a shared room with another resident who also had behavioral issues. Staff observed and documented the aggressive behaviors and medication refusals, yet the facility did not implement effective interventions or separate the residents. This inaction led to a violent assault, resulting in significant injuries to one resident and requiring hospital treatment.
A resident with dementia and behavioral disturbances refused food, medications, and exhibited aggressive behavior over multiple days. Despite these significant changes, the LPN did not notify the MD, as confirmed by both the DON and the MD. Facility policy required notification of the MD for such changes, but this was not followed, resulting in the MD being unaware and unable to assess or intervene.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences. The necessary steps to assess and address the individual's requirements during the transition were not followed.
A resident with cognitive impairment, recent falls, and high ADL needs was allowed to leave AMA without proper notification to the physician, social services, ombudsman, or APS. Staff did not document alternative options or risks, and the resident left without necessary assistive devices or a safe transportation plan, later being found confused and unable to care for himself several miles from the facility.
Two garbage dumpsters outside the kitchen service entrance were repeatedly observed with open lids, contrary to facility policy and FDA Food Code requirements. The Certified Dietary Manager confirmed that leaving the dumpsters uncovered was standard practice, which could attract insects and rodents.
Multiple rooms and shared bathrooms were found with damaged walls, mismatched paint, exposed drywall, cracked caulking, broken toilet seats, and soiled privacy curtains. Residents and staff confirmed these issues, noting that repairs were incomplete and the environment was not homelike. The maintenance director reported being the only staff member responsible for repairs, with work delayed until later in the year.
Surveyors identified multiple deficiencies in medication storage and labeling, including a resident keeping expired and unapproved OTC medications at bedside without assessment or physician order, an E-kit being accessed without required documentation or notification to the pharmacy, and an opened multi-dose vial of Heparin lacking an opened or use-by date. These findings were confirmed by nursing staff and the DON, and were not in accordance with facility policy or professional standards.
Staff served pureed chicken and noodles to residents on pureed and dysphagia mechanical diets using scoops that were smaller than the physician-ordered portion sizes, resulting in 24 residents receiving less than the prescribed amount of nutrients. The error was confirmed by both the RD and CDM, who noted that the incorrect utensils led to improper nutrient delivery.
Surveyors identified multiple deficiencies in food storage, preparation, and equipment sanitation, including unreadable or missing food labels, improper storage of food containers on the floor, unsealed food items, and inadequate cleaning of kitchen surfaces and equipment. Worn and damaged utensils were found in use, and wet pans were stacked without air drying, all of which failed to meet professional standards for food safety.
The facility did not develop or implement QAPI action plans after identifying that background checks for three staff members, including two CNAs and an LN, were completed 22-24 months after hire. Despite recognizing the issue and conducting audits, the QAPI committee failed to address or monitor the deficiency as required by facility policy.
A resident with Alzheimer's and dementia was admitted with an Advance Directive, but the facility failed to upload this document into the EHR and left the relevant section of the POLST form blank. The Social Services Director acknowledged receiving unclear photos of the Advance Directive from the responsible party but did not document the conversation or ensure the document was on file, contrary to facility policy and expectations.
A resident with schizophrenia was admitted with a hospital-completed PASRR Level I screening, which was valid for 30 days. The facility did not resubmit the required PASRR Level I assessment after the initial 30-day period, despite policy and state guidance. The oversight was confirmed by both the SSD and DON, and the assessment was not completed until several months later, delaying the identification of the need for a Level II Mental Health Evaluation.
A resident with dementia who could not communicate in English was admitted, but the facility did not develop a baseline care plan within 48 hours to address the resident's specific communication needs. Staff interviews and record reviews confirmed the resident's language barrier, yet the care plan lacked interventions for communication, contrary to facility policy and procedures.
A resident with a history of bilateral below-knee and finger amputations was prescribed Apixaban and Aspirin for blood clot prevention, but the facility did not develop or implement a care plan addressing anticoagulant care needs. Despite physician orders for monitoring and facility policy requiring such a care plan, staff confirmed that no care plan was in place, and the required monitoring was not documented as specified.
A resident with multiple chronic conditions did not receive scheduled quarterly IDT care conferences because of changes in social services staffing. As a result, the resident's care plan was not reviewed or updated as required, and care interventions may have been missed, as confirmed by facility staff and policy review.
A resident with cognitive impairment sustained a left hand injury and received a STAT order for an x-ray to rule out fracture. The x-ray was delayed for two days due to the x-ray company's lack of technician availability, and staff did not promptly notify the physician or document the delay. This resulted in the resident experiencing prolonged pain and delayed diagnosis.
A resident's bed had a broken footboard with exposed splinters and sharp edges facing the resident, partially covered with tape that did not fully protect against injury. The hazard was confirmed by an LPN, the maintenance director, and the administrator, all of whom acknowledged the risk of harm. Facility policy requires staff to identify and address such hazards.
Two residents did not receive proper pharmaceutical services when one had undocumented doses of an IV antibiotic and another went six days without a physician-ordered nicotine patch due to unavailability. Nursing staff did not document missed doses or notify the physician as required, and facility policies for medication administration and follow-up with the pharmacy were not followed.
A resident receiving an antidepressant for depression was not monitored for side effects or behavioral changes, and staff did not document any such monitoring in the medical record. Despite a consultant pharmacist's recommendation to review and consider reducing the medication dose, the physician did not respond in a timely manner. Both nursing staff and the DON confirmed the absence of required monitoring and documentation, which was contrary to facility policy.
A resident receiving medications for both hypertension and hypotension was administered midodrine and labetalol without proper monitoring of BP and HR, with staff failing to follow physician hold parameters, using the same vital sign readings for multiple doses, and giving both medications at the same or close times. These actions were confirmed by interviews and record reviews, and were not in accordance with facility policy or professional standards.
Dietary staff did not use standardized recipes or measure ingredients during meal preparation, instead adding unmeasured amounts of butter, oil, salt, and seasonings to vegetables and noodles and placing vegetables in the steam table hours before service. The Registered Dietitian and Certified Dietary Manager confirmed that recipes and measurement tools should be used to ensure nutritional consistency and that the observed practices could reduce the nutritive value of meals.
The facility did not ensure that the alternative meal option of a grilled cheese sandwich provided protein content equivalent to the main entree, as confirmed by the RD and menu review. This resulted in residents choosing the sandwich potentially receiving less protein than those selecting the main entree.
During a closed record review, a resident's medical documents were found in another resident's file, resulting in a breach of confidentiality. The error was confirmed by the medical records clerk and acknowledged as a HIPAA violation by facility leadership.
Surveyors observed an LPN cleaning a glucometer for only 15 seconds instead of the required two minutes and not following the manufacturer's instructions for disinfection. In a separate incident, a urinal containing urine was left on a bedside table next to a resident's drinking water, despite the resident's earlier request for it to be emptied. The urinal was not removed during medication administration, and the designated holder was missing. Both incidents were confirmed by the DON as not following facility policy and posing infection control risks.
A resident was prescribed antibiotics for a UTI without a required urine culture and sensitivity test, and the antibiotic time-out was conducted outside the 48-72 hour window specified by facility policy and national guidelines. The Infection Preventionist and DON confirmed these steps were not followed, resulting in noncompliance with the facility's Antibiotic Stewardship Program.
Surveyors found that multiple shared bedrooms did not meet the required 80 sq. ft. per resident, with thirty-three rooms measuring below this standard. Despite interviews with staff and residents indicating no concerns about room size, the deficiency was cited based on documented measurements.
A resident with a history of alcohol abuse and withdrawal seizures was admitted without a care plan addressing alcohol withdrawal and elopement prevention. The resident eloped twice due to the facility's failure to conduct adequate assessments and implement necessary monitoring, despite existing policies requiring such measures.
A resident requested his discharge paperwork, but the facility failed to provide the records within the required two-day timeframe. Despite the facility's policy, the Medical Records department did not follow up on the approval to send the documents, resulting in a delay. The Administrator was unaware of the request, highlighting a breakdown in the process.
A resident did not receive their prescribed Gabapentin for diabetic neuropathy due to a failure in timely reordering and delivery of the medication. Staff interviews highlighted the importance of timely medication administration and the oversight in not checking the Emergency Kit or following up with the pharmacy.
A facility failed to notify the LTC Ombudsman of a resident's discharge, leading to the resident becoming homeless. The resident was informed of their discharge due to improved health but was not told about their right to appeal. The Ombudsman learned of the discharge during a visit and assisted in initiating an appeal. Despite being notified not to discharge the resident before a hearing, the facility proceeded with the discharge. Staff interviews revealed a delay in sending discharge notices to the Ombudsman, contrary to facility policy.
A resident with a history of nicotine dependence was observed smoking without a smoking apron, and their smoking safety evaluation record was not signed until over two weeks after it was initiated. Interviews with facility staff confirmed the delay, which was against the facility's policy requiring timely documentation.
A resident with dementia and Alzheimer's disease was physically abused by a CNA when the resident became combative while being redirected. The CNA struck the resident in the face, causing bleeding and discoloration to the lip. Staff and administration acknowledged the incident and confirmed it was preventable.
The facility failed to develop care plans for two residents following altercations. One resident with bipolar disorder claimed another resident threatened to kill her, and another resident with schizophrenia was splashed with water by her roommate. The DON confirmed that care plans should have been developed to address these incidents.
A resident with a history of epilepsy and Alzheimer's disease sustained a cervical fracture, which was not communicated to the medical provider for 18 days due to incomplete review of discharge documents. This delay in treatment put the resident at risk for improper healing and worsening of the injury.
The facility failed to protect residents from verbal and physical abuse, as evidenced by an incident where a resident with moderate cognitive impairment hit another resident after being shouted and cursed at. The altercation resulted in physical pain for the victim, who was given medication for relief. Staff and resident interviews confirmed the details of the incident, highlighting a deficiency in the facility's ability to prevent abuse.
A resident with multiple diagnoses and a history of falls had his call light out of reach, leading to unmet needs and a recent fall. Staff failed to inform the resident about the call light's purpose, and facility policy on call light accessibility was not followed.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Behavioral Management
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when it did not address the escalating behaviors and medication noncompliance of another resident, resulting in a violent incident. One resident, with a history of dementia, schizophrenia, noncompliance with medical treatment, and traumatic brain injury, exhibited increasing aggression, including verbal outbursts, throwing objects, breaking equipment, and refusing psychotropic medications. Despite these behaviors and multiple staff observations of his unpredictability and aggression, the resident was placed in a shared room with another resident who also had a history of agitation, violent behavior, and psychiatric symptoms. Staff interviews and record reviews revealed that both residents had known behavioral issues, and several staff members expressed concerns that they should not have been placed together. The aggressive resident's refusal to take prescribed psychotropic medications was documented, and his behavior escalated from verbal to physical aggression, including breaking facility property and threatening others. Although staff recognized the risk, the interdisciplinary team did not address the issue during meetings, and no effective interventions were implemented to separate the residents or ensure appropriate monitoring. The situation culminated in a physical assault, where the aggressive resident repeatedly struck his roommate, causing multiple facial injuries that required hospital treatment. Documentation and interviews confirmed that the facility's failure to assess, plan, and intervene appropriately in response to the escalating behaviors and medication noncompliance directly led to the incident. The facility's own policy required ongoing assessment and care planning for residents with behaviors that might lead to conflict, but this was not followed, resulting in harm to a resident.
Failure to Notify MD of Resident's Significant Condition Changes
Penalty
Summary
The facility failed to notify the Medical Director (MD) of significant changes in a resident's condition, specifically when the resident refused to eat, refused all medications, and exhibited aggressive behavior. The resident, who had diagnoses including dementia with behavioral disturbance and suicidal ideations, was observed over two consecutive days to be non-compliant with care and displaying concerning behaviors. Progress notes documented the resident lying in bed facing the wall, refusing food, medications, and a Covid booster, as well as acting aggressively by pretending to take medication and then discarding it. Despite these documented changes, the licensed nurse did not inform the MD, as confirmed during interviews. The Director of Nursing (DON) acknowledged that the nursing staff should have notified the MD about the resident's behavioral changes and refusals, as per facility policy. The MD also confirmed that he was not notified and would have wanted to be informed to consider further evaluation or interventions. Review of the facility's policy indicated that the nurse is required to notify the physician or nurse practitioner of significant changes in a resident's condition or when there is a need to alter medical treatment. The failure to notify the MD resulted in the MD being unable to assess the resident's health status and potentially delayed treatment.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident-centered care and safe transition planning.
Failure to Ensure Safe Discharge Planning for Resident Leaving AMA
Penalty
Summary
The facility failed to ensure a safe discharge plan for a resident who expressed a desire to leave against medical advice (AMA). The resident, who had a recent history of falls, a brain bleed, cognitive impairment, and required assistance with activities of daily living (ADLs), was allowed to leave the facility without appropriate interventions or notifications. The resident was restless, confused, and repeatedly stated his intention to leave, but staff did not adequately intervene or follow established protocols for AMA discharges. The licensed nurse on duty did not notify the physician in a timely manner, nor did she contact the social services director, ombudsman, or Adult Protective Services (APS) when the resident expressed the desire to leave. There was no documentation of alternative options offered to the resident, nor was there a record of discussions regarding the risks of leaving AMA. The resident left the facility without necessary assistive devices, such as a walker, and without medications or a safe transportation plan. Staff failed to document the time of departure or the resident's intended destination. Following the resident's departure, he was found several miles from the facility, confused and unable to care for himself, and was subsequently placed on a 72-hour evaluation hold. Interviews with facility staff and review of policies revealed that required notifications and documentation were not completed, and the interdisciplinary team was not involved in attempting to ensure a safe discharge. The facility's own policies required physician notification, documentation of discussions and alternatives, and notification of APS in cases of suspected self-neglect, none of which were followed in this incident.
Improper Disposal of Garbage and Refuse Due to Uncovered Dumpsters
Penalty
Summary
Surveyors observed that two garbage dumpsters located outside the kitchen service entrance were left with their lids open on two separate occasions. The dumpsters were situated in the facility's parking lot and were locked behind a gate, but the lids remained uncovered. During an interview conducted at the time of observation, the Certified Dietary Manager (CDM) confirmed that leaving the dumpster lids open was a common practice and had been ongoing since she began working at the facility. The CDM acknowledged that this practice could potentially lead to insect and rodent infestation. A review of the facility's policy and procedure on the disposal of garbage and refuse indicated that outside refuse containers and dumpsters should have tightly fitting lids, doors, or covers and should be kept covered to minimize debris accumulation and insect or rodent attraction. Additionally, the US Food and Drug Administration Food Code 2022 specifies that outdoor refuse receptacles must have tight-fitting lids to prevent debris accumulation and pest attraction. The facility's failure to keep the dumpster lids closed was not in accordance with these policies and regulations.
Failure to Maintain a Clean, Comfortable, and Homelike Environment
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain a clean, comfortable, and homelike environment for its residents. In several resident rooms, there were large areas of wall damage that had been patched unevenly with spackle, mismatched paint, exposed drywall, and stains. These repairs were not completed to match the existing wall colors, resulting in a visibly inconsistent and unfinished appearance. Residents expressed dissatisfaction with the condition of their rooms, noting that the walls should be properly repaired and that the environment did not feel homelike. Shared bathrooms between resident rooms were also found to be in poor condition. Observations included sinks pulling away from the wall with cracked caulking, large gashes in the walls, chipped and missing paint, exposed drywall, and broken raised toilet seats. The caulking and spackle repairs in these areas were uneven and did not match the surrounding surfaces. Damaged baseboards, dented doorframes, and soiled privacy curtains were also noted, further detracting from the cleanliness and comfort of the environment. Interviews with residents, a licensed nurse, and the maintenance director confirmed the presence of these deficiencies. The maintenance director acknowledged being the only maintenance staff member and confirmed that repairs were delayed, with plans to begin addressing the issues later in the year. The administrator stated that the observed damage did not meet his expectations or facility policy for a homelike environment. Facility policy reviewed by surveyors indicated that maintenance services should be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as required by professional standards and facility policy. In one instance, two over-the-counter medication bottles, including an expired bottle of fish oil and a bottle of Centrum Multi-Vitamin, were found in open view on a resident's bedside table in a multi-resident room. The resident had not been assessed for self-administration, did not have a physician's order for these medications, and the medications were not listed on the resident's medication list. Both the licensed nurse and the DON confirmed that facility policy prohibits residents from keeping medications at bedside without proper assessment and order, and acknowledged the risk of unmonitored drug interactions and access by other residents. In another instance, an Emergency Kit (E-kit) in the medication room was found to have been opened, with a missing syringe of Normal Saline, but there was no documentation or paper slip indicating who accessed the kit, what was removed, or when it was used. The required documentation was not found in the binder, inside the E-kit, or in the log, and the DON confirmed that the facility's policy for documenting E-kit access and notifying the pharmacy was not followed. The DON stated that none of the nurses reported using the kit, and the lack of documentation was a violation of facility procedures. Additionally, an opened multi-dose vial of Heparin was observed on a medication cart without an opened or use-by date. The licensed nurse confirmed the vial should have been labeled with a use-by date, and the DON stated that it was her expectation that all multi-dose vials be labeled upon opening to prevent use beyond the manufacturer's recommended period. The Heparin package instructions and CDC guidelines both require opened vials to be dated and discarded within 28 days unless otherwise specified.
Incorrect Portion Sizes Provided for Pureed and Dysphagia Mechanical Diets
Penalty
Summary
The facility failed to ensure that residents on pureed and dysphagia mechanical diets received the correct portion sizes as prescribed by their physicians. During a lunch meal observation, it was noted that both pureed sweet and sour chicken and pureed noodles were served using a green handled scoop, which holds 2 2/3 ounces, rather than the prescribed serving sizes. The facility's own documentation indicated that the pureed chicken should be served in a 3/4 cup (6 ounces) portion and the pureed noodles in a 4-ounce portion using a gray handled scoop. However, only one green scoop was used for each item, resulting in smaller servings than ordered. Interviews with the Registered Dietitian and Certified Dietary Manager confirmed that the incorrect scoops were used, leading to residents receiving less than the required amount of nutrients. This affected 14 residents on a pureed diet and 10 residents receiving pureed meat on a dysphagia mechanical diet. The staff acknowledged that the use of the smaller scoop did not meet the menu's portion requirements and would result in residents not receiving the proper nutrient content as ordered by their physicians.
Deficient Food Storage, Preparation, and Equipment Sanitation
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and equipment sanitation standards for the 87 residents who consumed facility-prepared meals. Surveyors observed multiple issues during their inspection, including unreadable food labels, missing use-by dates on seasonings, and improper date marking on refrigerated items. Additionally, some food containers were left open and unsealed, and several items were stored directly on the kitchen floor, contrary to facility policy and food safety standards. The kitchen environment itself was found to be substandard, with dry storage walls that were not smooth or cleanable, an uneven and discolored floor, a refrigerator door with visible discoloration, and missing or cracked tiles in the kitchen floor, all of which hinder effective cleaning and increase the risk of contamination. Further observations revealed that food contact and non-food contact surfaces were not adequately cleaned or maintained. The dry storage floor was sticky and discolored, and equipment such as the microwave, toaster, and oven doors had visible food residue. The shelf under the dishwashing machine was also discolored and rough to the touch. Worn and damaged food preparation equipment was found in use, including a rusty strainer, a pot with food residue, discolored pans, a can opener with a missing metal tip, syrup container tops with discoloration, and bowls lacking glaze and with scratches on the eating surface. These conditions were confirmed by the Certified Dietary Manager and were not in line with facility policies or FDA Food Code requirements. Additionally, improper dishwashing and storage practices were noted, with steam table pans being stacked while still wet, which can promote microbial growth. The facility's own policies require air drying of dishes before stacking, but this was not followed. The Registered Dietitian and Certified Dietary Manager acknowledged the importance of proper labeling, storage, and equipment maintenance to prevent contamination and ensure food safety, but these standards were not consistently met during the survey period.
Failure to Implement QAPI Action Plans for Delayed Staff Background Checks
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) committee failed to develop and implement action plans for a problem identified in June 2024, specifically regarding delayed background checks for newly hired staff. Record reviews revealed that three out of eight sampled employee files, including two Certified Nurse Assistants and one Licensed Nurse, did not contain completed background checks until 22-24 months after their respective hire dates. The Director of Staff Development confirmed the significant delay in obtaining these background checks, acknowledging that the checks are essential to ensure staff do not have a history of criminal activity that could impact their job performance. Interviews with the Director of Nurses indicated that, although audits were being performed, the facility had not initiated a QAPI process to address the delayed background checks. The issue had been identified months prior, but no formal QAPI action was taken to monitor or correct the deficiency. Facility policy requires the development and implementation of action plans to address identified quality deficiencies, but this was not followed in the case of the delayed background checks.
Failure to Maintain and Document Resident Advance Directive
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's Advance Directive was available and properly documented in the medical record. The resident, who was admitted with Alzheimer's, dementia, and a cognitive communication deficit, had an Advance Directive according to their responsible party. However, the Advance Directive was not uploaded into the electronic health record, and the relevant section of the resident's POLST form regarding Advance Directives was left blank. The Social Services Director confirmed that although the responsible party had sent photos of the Advance Directive via email, the images were unclear and not uploaded, and there was no documentation of the conversation with the responsible party about the Advance Directive. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed that it was expected for the Advance Directive to be on file and for the POLST form to be completed during the admission process. The facility's policy required inquiry about the existence of an Advance Directive upon admission and for this information to be prominently displayed in the medical record. Despite these expectations and policies, the Advance Directive was not available in the resident's chart, and the interdisciplinary team had not reviewed or documented the resident's wishes as required.
Failure to Timely Resubmit PASRR Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to resubmit the required Pre-Admission Screening and Resident Review (PASRR) Level I assessment for a resident with a diagnosis of schizophrenia within the mandated 30-day timeframe following admission. The resident was initially admitted with a hospital-completed PASRR Level I screening, which was valid for 30 days under the 30-Day Exempted Hospital Discharge provision. Documentation from the State of California indicated that if the resident remained in the facility beyond 30 days, a new Level I screening was required on the 31st day. Interviews with the Social Services Director (SSD) and Director of Nursing (DON) confirmed that the PASRR Level I assessment was not resubmitted within the required period. The SSD acknowledged that the initial hospital PASRR Level I was only valid for 30 days and that a new assessment should have been completed after this period if the resident remained in the facility. The DON also confirmed the lapse, stating that the responsibility for ensuring timely PASRR assessments fell to the SSD, and that the assessment was not completed until several months after the required date. A subsequent PASRR Level I screening was eventually completed, which indicated the need for a Level II Mental Health Evaluation due to the resident's serious mental illness. Facility policy required coordination with the PASRR program to ensure timely assessments and referrals, but this process was not followed as required, resulting in a delay in identifying and addressing the resident's mental health needs as determined by the PASRR process.
Failure to Develop Baseline Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission to address the specific communication needs of a resident who was admitted with dementia and could not communicate in English. The resident's admission records and social services assessment identified that the resident's primary language was not English, and multiple staff interviews confirmed that the resident was unable to communicate in English and required language assistance. Despite this, the baseline care plan did not include any interventions or strategies to address the resident's communication needs. Observations and interviews with staff, including a respiratory therapist and a licensed nurse, confirmed that the resident spoke a different language and that staff typically relied on interpreters or bilingual staff to communicate. The Director of Nursing acknowledged during a record review that the facility's policy required the identification and documentation of communication needs in the care plan, but this was not done for the resident in question. The facility's policy on culturally competent care also outlined the need to assess and document language needs and communication tools, which was not followed in this case.
Failure to Develop and Implement Anticoagulant Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-specific care plan intervention for one resident who was prescribed anticoagulant medications, specifically Apixaban and Aspirin, for the prevention and treatment of blood clots. The resident had a significant medical history, including bilateral below-knee amputations and finger amputations due to frostbite. Despite physician orders that included monitoring for signs and symptoms of bleeding and thromboembolism, there was no care plan in place addressing the resident's anticoagulant care needs. Interviews with the Director of Nursing (DON) and a Licensed Nurse (LN) confirmed that the facility's expectation and policy required a care plan for residents on anticoagulants, and that monitoring for bleeding should be documented in the Medication Administration Record (MAR) and progress notes. The DON acknowledged that the facility policy was not followed, and the absence of a care plan for anticoagulant use was confirmed during the review of the resident's records.
Missed Quarterly IDT Care Conferences Due to Staffing Changes
Penalty
Summary
The facility failed to conduct scheduled quarterly Interdisciplinary Team (IDT) care conferences for one resident who was admitted with multiple diagnoses, including diabetes and hyperlipidemia. According to the Social Services Director (SSD) and the Director of Nursing (DON), the care conferences for this resident were not held as scheduled in April and October 2024 due to a change in social services staffing. Both the SSD and DON confirmed that these meetings are intended to review and update the resident's care plan and to communicate with the resident and/or their representative about care interventions and medications. Review of the facility's policy indicated that residents and their representatives are to be informed of and participate in care planning at regularly scheduled conferences, with documentation of their participation. The absence of these conferences meant that the resident's care plan was not reviewed or updated as required, and care plan interventions could have been missed, as confirmed by facility staff during interviews and record reviews.
Delay in STAT X-ray and Physician Notification for Hand Injury
Penalty
Summary
A deficiency occurred when a resident with a history of encephalopathy and cognitive communication deficit developed bruising and a skin tear on the left hand after slamming a door on it. A STAT order for a left hand x-ray was placed to rule out fracture, with the expectation that the x-ray would be performed urgently. However, the x-ray was not completed until two days after the order was placed. The delay was due to the x-ray company notifying the facility that no technician was available to perform the STAT x-ray as required. Although the company communicated the delay to the facility, the information was not promptly documented in the resident's chart, and the physician was not notified of the delay until several days later. Nursing staff expected the x-ray to be completed by the next morning and did not follow up adequately on the status of the STAT order. Facility policy required timely documentation of diagnostic test scheduling, results, and physician notification. In this case, the lack of prompt follow-up and communication with the physician regarding the delay in the STAT x-ray order resulted in the resident experiencing a prolonged period without a definitive diagnosis or appropriate treatment for the hand injury.
Broken Bed Footboard with Exposed Splinters Creates Hazard
Penalty
Summary
A deficiency was identified when a resident's bed footboard was found to be broken, with exposed splinters and sharp edges facing the resident. The broken area had been partially covered with thick black tape, but the tape did not adequately cover the hazardous section. The resident reported that the footboard had been taped for some time but could not recall who had done it or when. The resident also expressed concern about the potential for injury from the exposed splinters and stated that the footboard should be repaired. During observations and interviews, a licensed nurse confirmed the footboard was broken and acknowledged it posed a risk of harm to the resident, especially when getting in or out of bed or moving a foot across it. The maintenance director was unsure why the footboard was taped and agreed that the exposed area was hazardous and could cause injury. The administrator confirmed that the footboard should not have been taped and recognized the risk of injury to the resident. Facility policy requires that the resident environment remain free of accident hazards, with all staff responsible for identifying and addressing such hazards.
Failure to Provide Pharmaceutical Services and Timely Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, resulting in deficiencies related to medication administration and availability. For one resident with a history of MRSA infection, osteomyelitis, and multiple amputations, the medical record showed that several doses of the prescribed intravenous antibiotic Daptomycin were not documented as administered on three separate days. There were no entries in the progress notes indicating that the doses were missed or refused, nor was there documentation of physician notification regarding the missed doses. The Director of Nursing confirmed that the facility's policy requiring documentation of missed medications and physician notification was not followed. For another resident, a nicotine patch ordered by the physician was not available for use for six days after the initial order. The medication administration record indicated that the patch was not given on six consecutive days, with the explanation that the medication was not available. There was no documentation that the pharmacy was contacted for follow-up or that the physician was notified about the missed doses. The resident reported feeling anxious without the nicotine patch, and the nurse confirmed that the facility's policy required contacting the pharmacy and notifying the physician when a medication was unavailable. Interviews with nursing staff and the Director of Nursing revealed that the facility's processes for medication administration, documentation, and follow-up with the pharmacy were not consistently followed. Facility policies required timely administration of medications, accurate documentation, and prompt communication with the pharmacy and physician in the event of discrepancies or unavailable medications. These policies were not adhered to in the cases of the two residents, resulting in missed or undocumented medication doses.
Failure to Monitor Antidepressant Use and Respond to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication by not monitoring for side effects or behavioral manifestations of depression while the resident was receiving an antidepressant, Selegiline. The resident, admitted with a diagnosis of depression, had an active order for Selegiline to be administered daily for verbalizations of sadness. However, there was no documentation in the electronic health record indicating that staff were monitoring the resident for side effects of the medication or for depressive behaviors, as confirmed by both a licensed nurse and the Director of Nursing. Both staff members acknowledged that such monitoring was necessary to determine the effectiveness of the medication and to identify any adverse reactions. Additionally, the consultant pharmacist had recommended a review and possible dose reduction of the antidepressant, but this recommendation was not acknowledged or acted upon by the physician in a timely manner. The Director of Nursing confirmed that there was no documentation showing the physician had reviewed the pharmacist's recommendation. Facility policies required that the use of psychotropic medications be justified by documented diagnoses and that the resident's response, including progress and adverse consequences, be monitored and recorded. The lack of monitoring and timely physician response to the pharmacist's recommendation constituted a failure to comply with these policies.
Failure to Safely Monitor and Administer Blood Pressure Medications
Penalty
Summary
The facility failed to ensure safe monitoring and assessment of blood pressure (BP) and heart rate (HR) for a resident receiving medications to treat both hypertension and hypotension. Specifically, the nursing staff did not follow the physician's prescribed hold parameters for midodrine, a medication used to raise low BP, and labetalol, a medication used to lower high BP. There were multiple documented instances where these medications were administered without obtaining or documenting the required BP and HR readings, and in several cases, the medications were given outside of the prescribed hold parameters. Additionally, the same BP and HR readings were used to determine the administration of multiple doses of these medications at different times on the same day, rather than obtaining fresh vital signs prior to each administration as required. Both midodrine and labetalol were also documented as being administered at the same time or within one to two hours of each other on numerous occasions over a two-month period, despite their opposing effects and the need for careful timing and monitoring. Interviews with licensed nurses and the Director of Nursing confirmed these practices, and the facility's own policies required obtaining and recording vital signs prior to administering such medications and holding them if readings were outside prescribed parameters. The Pharmacist Consultant also confirmed that these medications should not be given together and that vital signs must be checked prior to each dose. The failure to adhere to these protocols resulted in a deficiency related to the safe administration and monitoring of medications for blood pressure management.
Failure to Use Standardized Recipes and Proper Food Preparation Methods
Penalty
Summary
The facility failed to ensure that standardized recipes were used during food preparation, resulting in food being prepared without proper measurement of ingredients and not according to established recipes. Observations showed that a cook added unmeasured amounts of butter, oil, salt, black pepper, and garlic powder to vegetables and noodles, relying on taste rather than recipe guidelines. Vegetables were placed into the steam table approximately three hours before meal service, contrary to best practices for conserving nutritive value and flavor. The cook confirmed that she did not consistently follow recipes, instead preparing food based on taste. Interviews with the Registered Dietitian and Certified Dietary Manager confirmed that dietary staff are expected to follow recipes and use measurement tools to ensure consistency with the planned menu and nutritional requirements. The Certified Dietary Manager also noted that vegetables and starches should be cooked last to preserve texture and nutrient content, and that the observed practices could diminish the nutritive value of the food served. Review of the facility's recipe for stir fry vegetables indicated specific measurements for ingredients, which were not followed during the observed meal preparation.
Alternative Meal Option Lacked Equivalent Protein Content
Penalty
Summary
The facility failed to ensure that the alternative meal option of a grilled cheese sandwich provided a protein content equivalent to the main entree for residents receiving kitchen-prepared meals. Observations of the posted menu showed that the alternative choice was a grilled cheese sandwich without any additional protein items. Review of the recipe indicated that each sandwich contained 2 ounces of cheese, equating to 14 grams of protein, while the main entree, Sweet and Sour Chicken, was served in larger portions with higher protein content. The facility's nutritional breakdown showed a daily protein target, but the Registered Dietitian confirmed that the grilled cheese sandwich did not match the protein content of the main entree.
Confidentiality Breach: Misfiled Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of resident-identifiable information when portions of one resident's medical records were found in another resident's medical record file during a closed record review. Specifically, during a review of a discharged resident's paper medical record, documents belonging to a different resident were discovered within the file. This was confirmed by the Medical Records Clerk, who acknowledged that placing another resident's records in the wrong file constituted a violation of the Health Insurance Portability and Accountability Act (HIPAA). Further interviews revealed that the Director of Nursing expected all residents' medical records to be placed in folders with proper identifiers and stored securely. The Director of Nursing also stated that misfiling documents could result in a resident's information not being found if it was misplaced in another resident's file. The incident was identified during a routine closed record review and involved the handling and storage of paper medical records by facility staff.
Infection Control Lapses in Glucometer Disinfection and Urinal Handling
Penalty
Summary
A licensed nurse was observed cleaning a glucometer after use by wiping it with a pre-moistened disinfectant wipe for approximately 15 seconds, then placing it back on the medication cart. The nurse was unable to recall the required wet-contact time for the disinfectant, which, according to both the product instructions and facility policy, should be two minutes. The facility's policy and the glucometer manufacturer's guidelines both specify that two wipes should be used—one to clean and one to disinfect—and that the device must remain wet for the full contact time as indicated by the wipe manufacturer. The Director of Nursing confirmed that the facility's policy is to follow these guidelines to prevent the spread of infection and bloodborne pathogens. In a separate incident, a urinal that was half full of urine was found on a bedside table next to a resident's drinking water. The resident reported having asked for the urinal to be emptied earlier, but it had not been done. The nurse present confirmed that the urinal should have been emptied and placed in a designated holder, which was missing from the bedside. Despite acknowledging the risk of infection and the potential for the urinal to be mistaken for drinking water, the nurse did not remove the urinal while administering medications. The Director of Nursing stated that the urinal should not have been on the bedside table and should have been emptied immediately, as per facility policy.
Failure to Follow Antibiotic Stewardship Protocols for UTI Treatment
Penalty
Summary
The facility failed to follow its Antibiotic Stewardship Program (ASP) and national standards for one resident who was prescribed antibiotics for a urinary tract infection (UTI). Specifically, the facility did not adhere to the McGeer Criteria, as a urine culture and sensitivity (C&S) test was not performed to confirm the infection, despite this being an essential criterion in both the facility's policy and the McGeer guidelines. The Infection Preventionist (IP) confirmed that the required C&S was not done, and could not explain how the resident met the UTI surveillance definition without this test. The facility's Infection Control Log indicated that the criteria for UTI were met, but lacked supporting laboratory evidence. Additionally, the facility did not conduct the required antibiotic time-out within the 48-72 hour window after the initiation of antibiotic therapy, as specified in both the facility's policy and the McGeer Criteria. Instead, the antibiotic time-out was completed only one day after the antibiotics were started. Both the IP and the Director of Nursing (DON) confirmed that this did not meet the required timeframe and acknowledged that the purpose of the time-out is to monitor for adverse reactions and ensure the correct antibiotic is prescribed. The facility's policies and procedures, which reference CDC and McGeer guidelines, were not followed in these instances.
Shared Resident Bedrooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that shared resident bedrooms met the required minimum of 80 square feet per resident, as observed and measured by the Maintenance Director in conjunction with the Department. Thirty-three resident rooms were identified as not meeting this requirement, with actual square footage per resident ranging from approximately 71.57 to 77.33 square feet in rooms designed for two or three residents. These measurements were documented and confirmed during the recertification survey. Interviews conducted with facility staff and residents revealed that neither the housekeeper assigned to several of the affected rooms nor a resident interviewed in one of the rooms expressed concerns about the adequacy of space. Additionally, no complaints regarding room size were reported during a resident council meeting. Despite the lack of reported dissatisfaction from staff and residents, the deficiency was based on the objective measurement of room sizes falling below regulatory standards.
Failure to Address Alcohol Withdrawal and Elopement Risk
Penalty
Summary
The facility failed to develop a care plan for a resident upon admission, specifically neglecting to address the resident's needs for alcohol withdrawal management and elopement prevention. The resident, who had a history of alcohol abuse disorder and alcohol withdrawal seizures, was admitted from an acute hospital with diagnoses including alcohol use with intoxication, discitis, convulsion, and chronic obstructive pulmonary disease. Despite these conditions, the facility did not implement a care plan to manage the resident's alcohol withdrawal symptoms or to prevent elopement, even though the resident had a documented history of leaving medical facilities against medical advice. As a result of the facility's inaction, the resident eloped from the facility on two occasions. The first elopement occurred shortly after admission, and the second happened a week later. During these incidents, the facility's staff failed to conduct adequate elopement assessments and did not place the resident on special monitoring for elopement or withdrawal behaviors. The facility's policy on wandering and elopement, which requires the identification of at-risk residents and the inclusion of safety strategies in their care plans, was not followed, leading to the resident's repeated elopement and the associated risks.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a copy of medical records to Resident 1 within two days after a written request was made. Resident 1, who was his own responsible party, requested his discharge paperwork on 11/14/24. Despite the facility's policy stating that records should be provided within two working days, the records were not sent in a timely manner. The Social Services (SS) department informed Resident 1 that he needed to fill out a medical records request form, which was sent to him on 11/4/24. However, the Medical Records (MR) department did not follow up on the approval to send the documents, resulting in a delay. Interviews with facility staff revealed a breakdown in the process. The MR department received a fax number from SS to send the records to, but the MR staff did not confirm the approval to send the documents. The Administrator stated that he did not see an email for this request and emphasized that the expectation was for the MR department to gather and approve documents within two days. Despite the facility's policy and the administrator's expectations, the records were not issued to Resident 1 as required.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident when a medication used to control pain, Gabapentin, was not ordered and delivered. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus and acute and chronic respiratory failure with hypoxia, was prescribed Gabapentin for diabetic neuropathy. However, during a medication pass observation, it was noted that the medication was not available, and the resident confirmed not receiving the dose. Interviews with staff revealed that the medication was not reordered in a timely manner, as per the facility's policy, which requires reordering when six or fewer doses remain. The Infection Preventionist and Director of Staff Development emphasized the importance of timely medication administration to prevent pain. The Licensed Nurse responsible for administering the medication expressed frustration over its unavailability and admitted not checking the Emergency Kit for the medication. Another nurse indicated that follow-up with the pharmacy should have been conducted to ensure the medication was ordered and available.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide the local Long-Term Care Ombudsman with a copy of the Notice of Transfer/Discharge for a resident prior to their discharge. The resident was admitted to the facility in May 2024 and was notified of their transfer/discharge on June 21, 2024, with an effective date of June 27, 2024. The notice indicated that the resident's health had improved sufficiently to warrant the discharge. However, the facility did not inform the resident of their right to appeal the discharge, and the Ombudsman only became aware of the situation during a visit to the facility. The Ombudsman assisted the resident in initiating an appeal process, and the Office of Administrative Hearings and Appeals notified the facility not to discharge the resident before the hearing. Despite this, the resident was discharged on June 27, 2024, and subsequently became homeless. Interviews with facility staff revealed that the Social Service Director was responsible for sending discharge notices to the Ombudsman but typically did so on the day of discharge or the next business day, which was not in compliance with the requirement to notify the Ombudsman prior to discharge. The Operations Manager acknowledged that discharge notices should be sent to the Ombudsman to provide advocacy for residents. The facility's policy stated that transfer/discharge notices should be provided at least 30 days prior to a facility-initiated transfer or discharge, with exceptions for improved health, but still required notification to the Ombudsman. The failure to notify the Ombudsman in a timely manner placed the resident at risk of not receiving necessary protections and support.
Delayed Smoking Safety Evaluation Documentation
Penalty
Summary
The facility failed to ensure timely completion of a smoking safety evaluation record for a resident with a history of nicotine dependence and toxic effects from tobacco. The resident was admitted in June 2024, and during an observation in July 2024, was seen smoking without a smoking apron. The smoking safety evaluation record for this resident was initiated on June 26, 2024, but was not signed until July 12, 2024, indicating a delay in documentation. Interviews with the Medical Records Director, Director of Staff Development, and Director of Nursing confirmed the delay in signing the smoking safety evaluation record. The Director of Staff Development acknowledged signing the record on July 12, 2024, and expressed a preference for signing on the day of the evaluation. The Director of Nursing expected assessments to be completed and documented within the same shift. The facility's policy required documentation to be completed at the time of service or no later than the shift in which the service occurred.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with dementia and Alzheimer's disease who was attempting to leave the dementia unit. When the CNA tried to redirect the resident back to the dining room, the resident became combative, kicking and striking at the CNA. In response, the CNA struck the resident in the face, resulting in the resident crying and sustaining a bleeding and discolored lip. First aid was administered, and the incident was documented in the resident's clinical records and progress notes. Interviews with various staff members, including another CNA, a licensed nurse, the operations manager, the administrator, the social services director, the director of nursing, and the medical director, confirmed the occurrence of the incident. The staff acknowledged that the CNA's behavior was unacceptable and that the injury to the resident was preventable. The resident's family member was also informed and expressed distress over the incident. The facility's policy on abuse, neglect, and exploitation was reviewed, which defined abuse and outlined the facility's responsibility to prevent such incidents. The resident's care plan was updated to address the potential for increased signs and symptoms of depression or anxiety related to the recent abuse. The care plan included interventions such as allowing the resident to verbalize feelings and concerns and assessing for signs of depression and anxiety. The facility's failure to protect the resident from physical abuse by the CNA was evident, and the incident was thoroughly documented and acknowledged by the facility's staff and administration.
Failure to Develop Comprehensive Care Plans After Resident Altercations
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents following resident-to-resident altercations. Resident 1, diagnosed with bipolar disorder, was involved in an altercation where she claimed another resident threatened to kill her. Similarly, Resident 6, diagnosed with schizophrenia, experienced an incident where her roommate became angry and splashed her with water. Despite these incidents, no care plans were developed for either resident to address the altercations and ensure their safety and psychosocial needs were met. During an interview and record review, the Director of Nurses (DON) confirmed that care plans should have been developed following each incident. The facility's policy and the charge nurse's job description both indicate the necessity of initiating, reviewing, and updating care plans to meet residents' medical, nursing, and psychosocial needs. The lack of care plans for these incidents indicates a failure to adhere to these policies, potentially leaving the residents without adequate care and support.
Failure to Communicate Cervical Fracture Diagnosis
Penalty
Summary
The facility failed to ensure professional standards of care for a resident who sustained a cervical fracture. The resident, who had a history of epilepsy and Alzheimer's disease, fell and was taken to the emergency department. Upon return, the discharge documents indicated a diagnosis of frequent falls and a urinary tract infection, but also included a nondisplaced fracture of the cervical spine. The licensed nurse who received the resident back from the ED only communicated the fall and UTI diagnoses to the medical provider, missing the critical information about the cervical fracture. It was not until another nurse reviewed the discharge notes 18 days later that the cervical fracture was discovered, and the medical provider was informed. This delay in communication resulted in a delay of treatment, putting the resident at risk for improper healing and worsening of the injury. The Director of Nurses confirmed that all discharge instructions should have been reviewed immediately upon the resident's return from the hospital, and the failure to do so led to the deficiency in care provided to the resident.
Failure to Protect Residents from Verbal and Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from verbal and physical abuse, as evidenced by an incident involving two residents. Resident 3, who has a moderate cognitive impairment, hit Resident 5 on the face and shoulder after Resident 5 shouted and cursed at him to stop staring at her. This altercation resulted in physical pain for Resident 5, who was given medication for pain relief. The incident occurred in the hallway near the nurse's station and was witnessed by staff and another resident. Interviews with staff and residents confirmed the details of the altercation, with staff noting that Resident 5 had a history of verbally loud and cursing behaviors towards other residents when they came close to her space. Resident 3 was admitted to the facility in 2023 with multiple diagnoses, including head trauma and communication deficit, and scored 10 out of 15 on the most recent Brief Interview for Mental Status (BIMS) assessment, indicating moderate cognitive impairment. Resident 5, also admitted in 2023, has diagnoses of depression and anxiety and scored 15 out of 15 on the BIMS assessment, indicating she is cognitively intact. The facility's 'Abuse, Neglect, and Exploitation' policy, dated 2023, states that the facility is committed to providing protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse. However, the facility failed to prevent the altercation between Resident 3 and Resident 5, resulting in a deficiency in protecting residents from abuse.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's needs were accommodated promptly when the resident's call light was not within reach. The resident, who had multiple diagnoses including myocardial infarction, respiratory failure, weakness, and a history of falling, was found to have his call light hanging on the wall near the outlets, out of his reach. During an observation and interview, the resident expressed that he did not know how to call for help, and it was confirmed by a Certified Nursing Assistant (CNA) that the call light was not supposed to be there but should be within the resident's reach. The resident had a recent fall resulting in a laceration, and staff acknowledged that the call light should be accessible to prevent such incidents and meet the resident's needs promptly. Further interviews revealed that the resident was not informed about the call light and its purpose after being transferred from another unit. Both the Licensed Nurse (LN) and the Assistant Director of Nursing (ADON) confirmed that the resident should have been reminded about the call light regularly due to his dementia diagnosis. The facility's policy on call lights emphasized the importance of accessibility and timely response, which was not adhered to in this case. The failure to ensure the call light was within reach and to educate the resident on its use had the potential to cause harm and unmet needs for the resident.
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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