North Pointe Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 500 Jessie Avenue, Sacramento, California 95838
- CMS Provider Number
- 555400
- Inspections on file
- 60
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at North Pointe Care Center during CMS and state inspections, most recent first.
Two residents with cognitive impairment were involved in a peer-to-peer altercation when one resident pushed another to the floor, after which the injured resident complained of hip pain. A third resident, also cognitively impaired, reported witnessing the incident, and staff documented the event in progress notes and IDT documentation, including notification of the abuse coordinator, MD, responsible party, and Ombudsman. During a later interview and record review, the DON and Administrator confirmed the altercation occurred and acknowledged there was no documentation that this abuse incident was reported to the Department, despite facility policies prohibiting resident-to-resident abuse and requiring timely reporting of abuse and neglect.
The facility failed to report an allegation of resident-to-resident abuse to the state Department after two residents with cognitive impairment were involved in an altercation in which one pushed the other to the floor, causing pain to the hip area. Documentation in multiple residents’ records described the incident, including a witness report from another resident and notes indicating that the abuse coordinator, MD, responsible party, and Ombudsman were notified. During a later interview and record review, the DON and Administrator confirmed the peer-to-peer altercation and acknowledged there was no documentation that the incident was reported to the Department, despite facility policies requiring investigation and reporting of abuse, including resident-to-resident abuse, within required federal timeframes.
Surveyors found that a personal items cart containing broken glasses, dentures, and hearing aids was left unlocked and unattended in a hallway while several staff walked away and three residents passed by. A CNA reported using the cart to check out dentures, confirmed that three staff had been present before leaving it unlocked, and acknowledged that the cart should remain locked at all times. An LN confirmed that all medication and personal item carts are expected to be locked to prevent resident access, and the DON stated that all carts should be locked, that resident access could lead to accidents and missing items, and that the personal item log binder had missing pages and dates, showing items were not accurately monitored. Facility policy required minimizing environmental hazards and providing adequate supervision of assistive devices.
A resident with advanced cognitive impairment developed blisters on the right hand that were documented by the IDT as a scald injury of unknown origin, with associated pain on touch and subsequent physician orders for daily wound care. The treatment nurse and DON confirmed there was no witness and that the wound provider categorized the injury as a scald, making it an injury of unknown origin. The Administrator acknowledged that this unexplained scald injury was not reported to the state Department as required by facility policy and regulations, resulting in a delay in external investigation.
A resident with dementia and limited ability to communicate had a court-appointed conservator who stopped paying the resident’s Medi-Cal share of cost while continuing to withdraw the resident’s monthly income. Business office staff repeatedly attempted to contact the conservator, received no response, and suspected financial abuse, notifying social services and requesting that a financial abuse report be made. The SSD contacted the county Public Guardian’s Office about the inability to reach the conservator but did not consider the situation to be financial abuse and did not file any abuse report. The ADM and DON acknowledged that nonpayment and lack of contact were red flags and that facility policy requires all suspicions of abuse, including financial exploitation, to be reported to the state agency, ombudsman, APS, and law enforcement, yet no such reports were made.
A resident with dementia and significant cognitive impairment had a court-appointed conservator who stopped paying the resident’s Medi-Cal share of cost while continuing to withdraw the resident’s monthly income. Business office staff recognized this pattern, suspected financial abuse, and notified social services, but no abuse report or internal investigation was initiated. The ADM acknowledged that the unpaid share of cost and inability to reach the conservator were red flags, yet the facility did not follow its own policy requiring thorough investigation and reporting of all suspected abuse, neglect, or exploitation.
A resident with cognitive impairment and limited mobility suffered multiple facial lacerations and bruising after being struck by another resident with a known history of verbal and physical aggression. Despite repeated documentation of threats and aggressive behaviors, interventions such as monitoring and redirection were not effective in preventing the incident, leading to significant injury and pain for the affected resident.
A resident with moderate cognitive impairment became physically aggressive toward a CNA, who then pushed the resident in the face, causing a fall and unresponsiveness. The resident was transferred to the hospital for evaluation. Staff interviews confirmed the CNA's actions were abusive and not in line with facility policy or training.
A resident with dementia and schizophrenia was abused by an LPN who hit her in the face, causing abrasions, after the resident refused medication and became agitated. Witnesses reported the incident, and the facility's administrator confirmed the nurse's behavior was unacceptable, leading to her termination.
The facility failed to maintain resident dignity and privacy, as observed in several incidents. A resident with cognitive impairment was not given privacy during phone calls, while another resident reported being ignored by staff and having their privacy invaded by other residents. During meals, residents were referred to as 'feeders' and not asked about wearing bibs, and a CNA fed residents while standing. Additionally, a resident was administered medication without privacy, exposing their body to others.
The facility failed to complete and update POLST forms for several residents, leading to potential non-compliance with residents' wishes during emergencies. Two residents had unsigned POLST forms lacking Advance Directive information, while two others had discrepancies between paper records and EMR regarding code status. Staff interviews revealed a lack of clear procedures for managing POLST forms.
A facility failed to provide a homelike environment for three residents by not having clocks in their rooms, affecting their ability to engage in activities and maintain orientation to time. Residents with severe memory impairments expressed the need for clocks, and staff confirmed their absence, despite facility policies emphasizing person-centered care.
The facility failed to maintain accurate pharmacy services, with an inaccurate controlled drug destruction log and unaccounted doses of lacosamide in a medication card. The DON confirmed the oversight in logging 20 syringes of Lorazepam and acknowledged the risk of drug diversion. Additionally, a medication card contained two doses in a single unit, posing a risk of double dosing a resident.
Two residents were prescribed psychotropic medications without adequate indication or documented attempts at non-pharmacological interventions. One resident was given Zyprexa despite not exhibiting behaviors that posed a danger, and another was prescribed risperidone without clear target behaviors. The facility failed to follow its policy on antipsychotic medication use, leading to unnecessary medication administration.
A LTC facility failed to maintain a medication error rate below five percent, with errors involving two residents. One resident with diabetes received insulin after breakfast instead of before, as per physician's orders, and another resident did not receive their prescribed folic acid due to its unavailability in the medication cart. The LNs involved did not follow facility policies regarding medication administration and documentation.
A resident with Type 2 Diabetes and severe cognitive impairment received insulin aspart not in accordance with physician orders. The insulin was administered based on a blood sugar reading taken before breakfast, and after the resident had eaten, contrary to the sliding scale order. The nurse confirmed the resident had refused insulin earlier, but this was not documented. The facility's policy required verification of insulin administration and notification of refusal, which was not followed.
The facility failed to properly store and label medications, with issues including improper storage of Acidophilus, expired and discontinued medications available for use, and loose pills and supplies in the medication cart. Additionally, refrigerator temperatures for medication storage were not maintained, resulting in frozen insulin.
The facility was found to have deficiencies in food storage and sanitation procedures, including dirty kitchen vents and floors, worn and unsanitary food preparation equipment, and improperly labeled and stored food items. Kitchen staff were unable to demonstrate proper sanitation testing procedures, posing a risk of contamination and food-borne illnesses.
The facility failed to maintain infection control measures, as a CNA did not perform hand hygiene between feeding residents, and Resident 20's nasal cannula and nebulizer mask were not stored properly. Additionally, food items and nail clippers were improperly stored in a medication cart, violating facility policy.
A resident with severe cognitive impairment and multiple diagnoses experienced acute vision loss, but the LTC facility failed to send her to the hospital promptly. Despite increased confusion and inability to see, the facility opted to monitor her condition rather than seek immediate medical intervention. The resident was eventually diagnosed with bilateral retinal detachment and macular holes, highlighting a deficiency in timely care.
A resident was found with nasal spray at the bedside without an assessment or order to self-administer medication. Despite being cognitively intact, the resident used his own medication due to unaddressed requests for a prescription. The facility's policy requires documented authorization for self-administration, which was not followed.
A computer on a medication cart was left open in a hallway, displaying confidential resident information, which was confirmed as a HIPAA violation by the Wound Nurse. Licensed Nurse 1 admitted to leaving the computer open, and both the ADON and DON stated that staff are expected to lock screens when not in use to protect resident privacy.
A resident with chronic lung disease and anxiety did not receive timely allergy medication due to the facility's failure to follow up on his requests. Despite being cognitively intact and repeatedly asking for Fluticasone, the medication was not ordered or administered. Interviews revealed a communication breakdown, as a physician's note approving the medication was not transcribed into the resident's record.
A resident with severe cognitive impairment was observed with black material under her fingernails, indicating a failure in grooming services. Despite requiring moderate assistance for personal hygiene, her nails were not cleaned as per facility policy. Staff confirmed the resident's nails were dirty, and the DON stated nails should be cleaned during showers and as needed.
A facility failed to follow the activity care plan for a resident with severe cognitive impairment, as documented in their MDS. The resident was often observed without sensory stimulation or interaction, and staff interviews revealed a lack of awareness and documentation of activities. The Activity Director admitted to documentation issues due to problems with the POC system, which was the only method used. The facility's policy required documentation of activities, which was not followed, leading to a deficiency.
A resident with a physician's order for a hand roll to prevent contracture did not receive it, as observed over several days. Staff were unaware of the order, and the care plan did not address the contracture. Nurses inaccurately documented the presence of the hand roll, and the facility lacked a policy on contracture prevention.
The facility was found to have six rooms accommodating more than the allowed number of residents, with some rooms having five or six residents. Despite adequate space and privacy measures, the occupancy exceeded regulatory limits. Staff and a resident's responsible party reported no issues with space or care provision.
Two resident rooms in an LTC facility were found to be below the required 80 square feet per resident, measuring only 70.56 square feet each. Despite staff and family members expressing no concerns about space adequacy, the facility did not meet federal physical environment standards. A program flexibility approval was in place, but the deficiency was confirmed by the Maintenance Supervisor.
A resident with severe cognitive impairment was slapped by a hospitality aide (HA) during mealtime assistance, despite having a care plan to manage potential aggression. The HA admitted to reacting inappropriately due to frustration. The incident was witnessed by a CNA and confirmed by facility staff, indicating a failure to protect the resident from abuse.
A resident with severe cognitive impairment and fall risk was not provided with hip protectors as directed by their care plan, leading to a fall and hip fracture. Despite the care plan's directive, there was no documentation of hip protector use, and staff were uncertain about their availability. This deficiency in implementing the care plan contributed to the resident's injury and subsequent death.
A resident with an ileostomy experienced increased redness and irritation at the stoma site due to the facility's failure to implement and update the care plan. Despite physician's orders and a care plan noting non-compliance with treatment, interventions were not effectively followed. The resident's ileostomy bag leaked, and staff did not adequately document or report the issue, leading to further skin irritation.
The facility failed to protect residents from abuse, resulting in one resident sustaining a hip fracture after another resident pulled his walker, and another resident being punched in the face during an altercation. Both incidents involved residents with cognitive impairments and behavioral issues, highlighting a failure to monitor and manage aggressive behaviors effectively.
A resident with dementia and chronic congestive heart failure was not properly monitored for fluid intake, despite having a fluid restriction order. The resident's eMAR showed consistent overconsumption of fluids, and staff were not adequately informed or monitoring the situation. The facility's policy on fluid restriction was not followed, and there was no care plan in place to address the resident's noncompliance.
A resident with Alzheimer's and other conditions was photographed in an undignified state by facility staff after a fall. The photo, taken with an unsecured facility cell phone, showed the resident with pants down, attempting to cover himself. Interviews revealed a lack of clear procedures for photographing residents, and the facility's policies emphasize dignity and privacy, which were violated in this incident.
A resident with Alzheimer's Disease experienced an unwitnessed fall, resulting in a lip injury, but the facility failed to notify the responsible party and physician until the next day. Despite the facility's policy requiring immediate notification, staff interviews revealed a delay in following the fall protocol, leading to a deficiency in handling the incident.
A resident with Alzheimer's and other conditions experienced an unwitnessed fall, but the facility failed to document the incident or initiate immediate neurological checks as required by protocol. Interviews with staff revealed that the checks were only started the following day, contrary to the facility's policy on fall management.
A facility failed to inform a resident's representative about skin discoloration on the resident's forearms. The resident, with Alzheimer's and Bipolar II disorder, had old purplish discoloration noted during a skin assessment, but it was not communicated to the RP until the resident's daughter reported it. The DON confirmed the oversight, which was against the facility's policy requiring prompt notification of changes in a resident's condition.
Two residents with cognitive impairments were involved in a verbal and physical altercation in the facility's backyard, resulting in minor injuries. The incident occurred due to a lack of staff supervision, as confirmed by the DON and a CNA. The facility's policy on resident supervision, which should be based on individual needs, was not followed.
A facility failed to follow infection control standards for a resident with an indwelling catheter, as the catheter bag was found lying on the floor under the bed. This was confirmed by the resident, a nurse, and the Infection Preventionist, all of whom acknowledged that the catheter bag should be kept off the floor and attached to the bed frame to prevent the spread of germs.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from abuse when one resident pushed another resident to the floor, and the incident was not reported to the state agency as required. Resident 1, admitted in January 2025 with dementia and documented as having moderate cognitive impairment on an MDS dated 3/3/25, was pushed by Resident 2 on 2/6/25. A progress note for Resident 1 on that date documented that another resident (Resident 3) reported Resident 1 had been pushed by Resident 2, that Resident 1 was found lying on his back on the floor, and that when Resident 1 began walking he verbalized left hip pain. The abuse coordinator was notified. Resident 2’s record showed an admission diagnosis of bipolar disorder and severe cognitive impairment on an MDS, and a change-of-condition note dated 2/6/25 documented that Resident 3 reported Resident 2 pushed Resident 1 when he entered their shared room, causing Resident 1 to fall to the floor on his back. Staff responded after hearing loud voices and found Resident 2 standing in the room and Resident 1 lying on his back on the floor; both residents were unable to explain what happened. An IDT note for Resident 2 dated 2/7/25 reiterated that, per the licensed nurse, Resident 3 reported Resident 2 pushed Resident 1, resulting in Resident 1 falling to the floor on his back, and documented that the abuse coordinator, physician, responsible party, and Ombudsman were notified. Resident 3’s record showed admission in January 2025 with multiple left rib fractures and moderate cognitive impairment on an MDS dated 2/17/25, and a social services note dated 2/7/25 indicated Resident 3 reported witnessing a peer-to-peer altercation in her room. During an interview and concurrent record review on 3/27/25 with the DON and Administrator, they confirmed that a peer-to-peer altercation occurred between Resident 1 and Resident 2 on 2/6/25 and acknowledged there was no documented evidence that this peer-to-peer abuse incident was reported to the Department. This failure occurred despite facility policies stating that abuse of any kind, including resident-to-resident abuse, is prohibited and that allegations of abuse and neglect must be investigated and reported within required federal timeframes.
Failure to Report Resident-to-Resident Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the state Department as required by regulation after one resident was pushed to the floor by another resident. Resident 1, admitted in January 2025 with dementia and documented moderate cognitive impairment on an MDS dated 3/3/25, was involved in a peer-to-peer altercation on 2/6/25. A progress note for Resident 1 dated 2/6/25 documented that, per Resident 3, Resident 2 entered the room and pushed Resident 1, causing Resident 1 to fall to the floor on his back and complain of left hip pain. The abuse coordinator was notified, but there was no documentation that the Department was notified of this abuse incident. Resident 2, admitted with bipolar disorder and severe cognitive impairment per an MDS, had a progress note dated 2/6/25 describing that Resident 2 pushed Resident 1, resulting in Resident 1 falling to the floor. An IDT note dated 2/7/25 further documented that a licensed nurse reported the 2/6/25 incident, and that the abuse coordinator, MD, responsible party, and Ombudsman were notified. Resident 3, admitted in January 2025 with multiple left rib fractures and moderate cognitive impairment, reported in a social services note dated 2/7/25 that she witnessed the peer-to-peer altercation in her room and felt uncomfortable. During an interview and record review on 3/27/25, the DON and Administrator confirmed the 2/6/25 altercation between Resident 1 and Resident 2 and acknowledged there was no documented evidence that the peer-to-peer abuse was reported to the Department, despite facility policies requiring investigation and reporting of abuse, including resident-to-resident abuse, within required federal timeframes.
Unlocked Personal Items Cart with Hazardous Contents Left Unattended in Hallway
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when a personal items cart containing resident belongings was left unlocked and unattended in a hallway. During an observation near a resident room, three nursing staff were present at the personal items cart and then left it unlocked. A subsequent observation showed the cart still unlocked while three residents walked by it. The cart contained items such as a pair of broken glasses, resident dentures, and resident hearing aids, and was easily accessible to residents in the hallway. In a concurrent observation and interview, a CNA stated she had checked out resident dentures from the cart, confirmed that three nursing staff had been present when she left, and acknowledged that the cart remained unlocked with no staff present. The CNA stated the cart should be locked at all times and that residents could harm themselves with items such as the broken glasses or dentures if not supervised. An LN confirmed that all medication and personal item carts should be locked to prevent resident access and that accessing the personal items cart could result in an accident for residents who wander. The DON stated the expectation is for all carts in the facility to be locked, confirmed that resident access to the cart items could have led to an accident and missing resident items, and acknowledged that there were missing pages and dates in the personal item log binder, indicating items were not monitored accurately. Review of the facility’s Safety/Supervision policy showed it required making the environment as free from hazards as possible and targeting interventions to reduce risks related to environmental hazards, including adequate supervision of assistive devices.
Failure to Report Scald Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the state Department as required by regulation. A resident with Alzheimer's disease, admitted in June 2024, had an MDS dated 12/22/25 indicating no cognition score could be determined. On 2/19/26, staff notified a nurse of blisters on the resident's right hand with an unknown cause, and the resident exhibited facial grimacing when the area was touched. An IDT skin management note on the same date documented a right dorsal hand scald injury measuring 8.0 x 6.0 x 0.1 cm, with the appearance consistent with a scald injury and no documentation of the cause. A physician order dated 2/27/26 directed daily treatment to the right dorsal hand scald injury with cleansing, bacitracin ointment, xeroform, and dry dressing until 3/12/26. On 3/4/26, the resident was observed in the dining room with a bandage on the right hand. During interviews, the treatment nurse confirmed that the wound provider identified the wound as a scald injury and that the injury was of unknown cause. The DON confirmed there was no witness to the incident, that the resident sustained an injury of unknown origin, and that the wound doctor categorized the injury as a scald. The Administrator confirmed the injury was of unknown cause and acknowledged that he did not report the incident of unknown origin to the Department, resulting in a delay of the Department’s investigation. Facility policies on identifying types of abuse and unusual occurrence reporting defined physical abuse to include unexplained injuries and required reporting of allegations of abuse and unusual occurrences to appropriate agencies within 24 hours, but this incident was not reported as required.
Failure to Report Suspected Financial Exploitation to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse, neglect, and exploitation reporting policies and procedures when staff suspected financial exploitation of a resident. The resident was admitted with diagnoses including metabolic encephalopathy, dementia, and a need for assistance with personal care, and an MDS assessment indicated the resident was rarely or never understood. The business office identified that the resident’s conservator, who was also the resident’s sister and responsible person, had not paid the resident’s Medi-Cal share of cost since it began generating, while the Public Conservator’s office later found that the sister had been withdrawing the resident’s full monthly income except for bank fees. Despite these circumstances, no report of suspected financial abuse was made to the state agency, local ombudsman, APS, or law enforcement as required by facility policy and section 1150B of the Act. The Business Office Assistant stated that she called the resident’s sister weekly or every other week without response and suspected financial abuse, which she reported to the Social Services Director (SSD). The Business Office Manager confirmed that the share of cost had not been paid since March 2024 and documented an internal communication to the SSD requesting a financial abuse report for the resident. The SSD acknowledged difficulty reaching the sister and documented contacting the county Public Guardian’s Office to ask if a referral was appropriate, learning that the court had already initiated a process to transfer conservatorship. However, the SSD stated she did not suspect financial abuse at that time and confirmed that no abuse report was made regarding this resident. The Administrator reported that the facility’s process for any suspicion of abuse was to notify him first, then report the suspicion and conduct an internal investigation, and that the facility’s policy required reporting all suspicions of abuse, including financial abuse, to specified agencies. The Administrator agreed that the lack of response from the conservator and the nonpayment of share of cost for months were red flags, and confirmed that the resident’s share of cost started in March 2024 and was not paid by the conservator. The Director of Nursing stated that all suspicions of resident abuse should be reported so they can be thoroughly investigated. Review of the written policy confirmed that suspected abuse, neglect, exploitation, or misappropriation must be reported immediately to the Administrator and to state licensing/certification, the ombudsman, APS, and law enforcement, but no such reports were made in this case despite staff suspicions and internal communications referencing possible financial abuse.
Failure to Investigate and Report Suspected Financial Abuse by Conservator
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation reporting and investigation policies in response to a reasonable suspicion of financial abuse of a resident under conservatorship. The resident was admitted with diagnoses including metabolic encephalopathy, dementia, and a need for assistance with personal care, and an MDS cognitive assessment indicated the resident was rarely or never understood. A complaint letter from the Department of Justice stated that the resident’s sister, who was the conservator, had not paid the resident’s share of cost since March 2024, while bank records showed the sister withdrawing the resident’s full monthly income minus bank fees. The Business Office Assistant and Business Office Manager confirmed that the resident’s share of cost had not been paid since it began generating and that repeated calls to the resident’s sister/responsible person went unanswered. The Business Office Manager documented that she suspected financial abuse and, through the facility’s internal communication system, requested that the Social Services Director complete a financial abuse report for the resident. The Social Services Director acknowledged being contacted about the issue and stated that she reached out to the county Public Guardian’s Office because the facility could not reach the conservator and there were outstanding balances, but she reported that she did not suspect financial abuse at that time and confirmed that no investigation was conducted by the facility regarding this resident’s case. The Administrator stated that the facility’s process for any suspicion of abuse was to notify him first, then report the suspicion and conduct an internal investigation, and that the facility’s policy required all allegations of resident abuse, neglect, exploitation, or misappropriation to be reported to appropriate agencies and thoroughly investigated. The Administrator acknowledged that the lack of response from the conservator and nonpayment of the share of cost for months were red flags but stated there was no evidence of fiduciary abuse, and therefore the issue was not reported as abuse. The Administrator further confirmed that the resident’s share of cost started in March 2024 and was not paid by the conservator, that multiple attempts were made to contact the conservator, and that after contact with the Public Guardian’s Office, the facility did not conduct its own investigation into possible financial abuse. The Director of Nursing stated that all suspicions of abuse should be thoroughly investigated to prevent further abuse, underscoring that the facility did not follow its own policy and procedures in this case.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A resident with dementia and cognitive impairment, who was non-ambulatory and required staff assistance, sustained multiple facial lacerations, swelling, and bruising after being struck in the face by another resident. The injured resident was unable to explain the cause of the injuries due to cognitive limitations. Clinical documentation and staff interviews confirmed the presence of significant injuries, including lacerations to the eyebrow, nose, and cheek, as well as pain and visible bruising. The incident was reported to the resident's physician, and the resident was sent to the emergency department for evaluation. The resident who committed the abuse had a documented history of dementia, anxiety, depression, and frequent episodes of verbal and physical aggression, particularly toward his roommate. Progress notes and care plans indicated repeated threats, aggressive statements, and attempts at physical aggression toward the injured resident over several weeks. Staff and therapy personnel observed ongoing verbal aggression and threats, and the care plan for the aggressive resident included interventions such as monitoring, redirection, and reporting behaviors to the physician. Despite these interventions, the aggressive resident was able to strike his roommate, resulting in injury. Facility records and staff interviews revealed that the administration was aware of the ongoing verbal aggression and threats but had not observed prior physical violence. The facility's abuse prevention policy emphasized the right of residents to be free from abuse by anyone, including other residents. However, the measures in place were insufficient to prevent the escalation from verbal to physical abuse, resulting in harm to a vulnerable resident. The facility acknowledged responsibility for resident safety and supervision but did not provide evidence that effective interventions were implemented to prevent the incident.
Resident Physically Abused by Staff Following Aggressive Incident
Penalty
Summary
A facility staff member failed to protect a resident from physical abuse when a CNA pushed the resident in the face, causing the resident to fall to the ground. The resident, who had moderate cognitive impairment and lacked decision-making capacity, had become physically aggressive toward the CNA during care, striking the staff member in the face. In response, the CNA pushed the resident, resulting in a fall and subsequent unresponsiveness. The resident was transferred to the hospital for further evaluation after being found nonverbal and unable to move extremities, which was not at his baseline. Interviews with facility staff confirmed that the CNA's actions constituted physical abuse and were not in accordance with the facility's abuse prevention policy or the abuse training the CNA had received. The Director of Nursing acknowledged that the CNA should have known how to manage residents with dementia and that the staff member's actions placed the resident's safety at risk. Facility policy emphasized the right of residents to be free from abuse and the importance of compassionate care, particularly for those with behavioral and cognitive issues.
Resident Abuse by Licensed Nurse
Penalty
Summary
The facility failed to protect a resident from abuse when a licensed nurse hit the resident in the face, causing abrasions. The resident, who had been admitted in 2017 with diagnoses including dementia, anxiety, and schizophrenia, had a BIMS score indicating moderately impaired cognition. The resident's care plan included interventions for managing potential aggressive behaviors, such as maintaining a calm approach and respecting the resident's right to refuse care. However, during an incident in the dining room, the resident became agitated and resistive when the nurse attempted to administer medication, leading to the nurse retaliating and causing injury to the resident's face. Witnesses, including two CNAs, reported hearing a commotion and seeing the nurse hit the resident after the resident refused medication and became agitated. The resident was found crying with scratches on her face and reported being attacked by the nurse. The facility's administrator confirmed the incident and acknowledged that the nurse's behavior was unacceptable, leading to her termination. The facility's abuse prevention program emphasizes protecting residents from abuse and instructs staff on de-escalation techniques, but these measures were not effectively implemented in this case.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of several residents, as evidenced by multiple observations and interviews. Resident 77, who has severe cognitive impairment, was not provided privacy when using the phone, as he had to use the phone at the nursing station where others were present. The facility lacked handheld phones for private use, which was acknowledged by the Administrator. This lack of privacy during phone calls was contrary to the facility's policy on resident rights, which guarantees communication privacy. Resident 119, who is cognitively intact, reported being ignored by staff when seeking assistance. He described incidents where other residents entered his room uninvited, taking his belongings and invading his privacy. Despite reporting these issues to staff, he felt humiliated and disrespected, as staff laughed at his concerns. The facility's policy mandates treating residents with kindness, respect, and dignity, which was not adhered to in this case. Additional deficiencies were noted during meal times and medication administration. Residents were referred to as 'feeders' and were not asked if they wanted to wear bibs during meals, which goes against the facility's dignity policy. CNA 6 was observed feeding residents while standing, rather than sitting at eye level, which is required for a dignified dining experience. Furthermore, Resident 6 was administered medication without privacy, as the nurse exposed the resident's body in front of others, violating the facility's policy on maintaining resident privacy during treatment procedures.
Deficiencies in POLST Form Completion and EMR Updates
Penalty
Summary
The facility failed to ensure that the POLST (Physician Orders for Life-Sustaining Treatment) forms were completed and updated for several residents, which could lead to not acting in accordance with residents' wishes during emergencies. Specifically, two residents had POLST forms that were not signed by a physician or other authorized healthcare provider, rendering them invalid. Additionally, these forms lacked information regarding the existence of an Advance Directive, which is crucial for guiding healthcare decisions when a resident is incapacitated. Furthermore, the facility did not update the electronic medical records (EMR) to reflect changes in code status for two other residents after new POLST forms were completed. This discrepancy between the paper records and the EMR could result in confusion and failure to follow the correct code status during a medical emergency. The Unit Manager confirmed that the new POLST forms were not uploaded into the electronic records, and the Director of Nursing acknowledged the expectation for code status to be updated in the clinical records. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion and auditing of POLST forms. The Director of Nursing admitted that there was no specific policy and procedure for POLST forms, and the facility relied on the directions provided on the back of the POLST form itself. This lack of a formalized process contributed to the deficiencies observed, as staff were unsure of the steps needed to ensure the forms were completed and updated correctly.
Lack of Clocks in Residents' Rooms
Penalty
Summary
The facility failed to provide a homelike environment for three residents by not having clocks available in their rooms. This deficiency was identified during observations and interviews with the residents and staff. Resident 18, who has Alzheimer's disease and severe memory impairment, expressed frustration about not having a clock, which is important for her to engage in activities and choose her own bedtime. Similarly, Resident 41, with Alzheimer's disease and severe memory impairment, and Resident 74, with schizoaffective disorder and severe memory impairment, also lacked clocks in their rooms, affecting their ability to know the time and participate in activities. Interviews with the Unit Manager, Assistant Director of Nursing, and Director of Nursing confirmed the absence of clocks in the residents' rooms. The Unit Manager acknowledged the importance of orientation to time for the residents, while the Assistant Director of Nursing was unaware of the reason for the absence of clocks. The Director of Nursing stated there were no contraindications for having wall clocks in the rooms. The facility's policies on dignity and a homelike environment emphasize providing person-centered care that meets residents' comfort and personal needs, which was not adhered to in this case.
Inaccurate Pharmacy Services and Medication Management
Penalty
Summary
The facility failed to maintain accurate pharmacy services for two residents, leading to potential risks in medication management. In the first instance, the controlled drug destruction record log was found to be inaccurate. During a review, it was discovered that 20 syringes of Lorazepam gel, a controlled medication used for anxiety, were not recorded in the destruction log. The Director of Nursing (DON) confirmed that the syringes were not documented and acknowledged that this oversight could lead to the diversion of controlled drugs. The DON admitted that the medication was handed to her by a nurse but was not logged as required, which should have included two nurses' signatures. In the second instance, an inspection of a medication cart revealed that a medication card for lacosamide, used for seizures, contained two doses in a single dose unit. The Licensed Nurse (LN) confirmed that the extra dose was not accounted for in the narcotic sheet record, posing a risk of administering a double dose to a resident. The DON stated that the expectation was for the LN to contact the pharmacy to replace the medication card if issues were identified. The facility's policy on controlled medication storage, dated March 2018, requires adherence to federal, state, and other applicable laws and regulations, which was not followed in these cases.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. Resident 38 was prescribed Zyprexa, an antipsychotic medication, without specific manifested behaviors of danger to self or others. The resident, who had severe cognitive impairment and dementia-related psychosis, was observed talking to herself but was not aggressive or a danger to herself or others. Despite the care plan's directive to attempt non-pharmacological interventions before administering the medication, there was no documented evidence that such interventions were attempted. The facility's policy required that antipsychotic medications be used only when necessary to treat specific conditions and when behavioral symptoms present a danger, which was not the case for Resident 38. Resident 150 was prescribed risperidone, another antipsychotic medication, without adequate indication and target behavior. The resident had severe cognitive impairment and was diagnosed with Alzheimer's disease and dementia with behavioral disturbance. However, there was no documentation of potential indicators of psychosis or target behaviors that warranted the use of risperidone. The facility's policy stated that antipsychotic medications should only be used for specific conditions and when symptoms present a danger to the resident or others, which was not documented for Resident 150. The facility's failure to adhere to its policy on antipsychotic medication use resulted in the administration of unnecessary psychotropic medications to both residents. The facility did not document attempts at non-pharmacological interventions for Resident 38, and there was no clear indication or target behavior for the use of risperidone in Resident 150. These deficiencies could lead to adverse consequences for the residents, as the medications were not approved for the treatment of dementia-related psychosis and could increase the risk of negative side effects.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, as evidenced by two medication errors out of 29 opportunities during medication administration for two residents. Resident 6, who has Type 2 Diabetes and severe cognitive impairment, was administered 2 units of insulin aspart based on a blood sugar level reading taken at 7:07 a.m., prior to breakfast. The Licensed Nurse (LN 2) did not document that Resident 6 had refused insulin earlier in the morning, and the insulin was administered after breakfast, contrary to the physician's order and facility policy, which required insulin to be administered 15-30 minutes before meals. Resident 71, who has severe cognitive impairment and anemia, did not receive their prescribed folic acid during the morning medication pass. The Licensed Nurse (LN 1) acknowledged that the folic acid was not in the medication cart and stated that the issue would need to be followed up with the pharmacy. However, LN 1 was unable to explain why the medication was unavailable. The Director of Nursing (DON) stated that the expectation is for the LN to contact the pharmacy if a medication is not available, as per the facility's policy on administering medications.
Insulin Administration Error Due to Non-compliance with Physician Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a licensed nurse administered insulin aspart not in accordance with physician orders. The resident, who was admitted with a diagnosis of Type 2 Diabetes and had severe cognitive impairment, was observed receiving 2 units of insulin aspart based on a blood sugar level of 154 mg/dl. However, the blood glucose reading was taken at 7:07 a.m., prior to the resident eating breakfast, and the insulin was administered at 8:30 a.m., after the resident had already eaten. The nurse confirmed that the resident had refused insulin earlier in the morning, but there was no documented evidence of this refusal. The physician's orders specified a sliding scale for insulin administration, which was not followed in this instance. The Director of Nursing stated that the expectation was for blood glucose to be checked prior to insulin administration and for insulin to be given 15-30 minutes before meals. The facility's policy required verification of insulin type, dosage, and administration method before administration, and to notify a supervisor if insulin was refused. The failure to adhere to these protocols put the resident at risk for adverse consequences from the medication.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during an inspection of Medication Cart B. Medications were not stored according to manufacturer instructions, with a bottle of Acidophilus found in the cart instead of the refrigerator. Expired and discontinued medications, such as erythromycin ointment and Arformoterol nebulizer treatments, were still available for use, contrary to the facility's policy. Loose pills and medical supplies were also found in the medication cart, indicating a lack of organization and adherence to storage protocols. Additionally, the facility did not maintain appropriate refrigerator temperatures for medication storage. During inspections, the refrigerator's temperature was found to be outside the required range, with one instance showing a temperature of 51 degrees Fahrenheit and another at 29 degrees Fahrenheit, leading to frozen insulin. These findings were confirmed by the staff, who acknowledged that the medications were not safe for administration due to improper storage conditions.
Deficiencies in Food Storage and Sanitation Procedures
Penalty
Summary
The facility was found to have several deficiencies in food storage, service, and distribution, which were not in accordance with professional standards. During observations, kitchen vents, fans, and floors were noted to be dirty and dusty. The Dietary Assistant Manager (DA) and Registered Dietitian (RD) acknowledged the presence of dirt and dust, which could potentially contaminate food and clean plates. The facility's policy and the US FDA Food Code require that all equipment and surfaces be kept clean and free from contamination, but these standards were not met. Additionally, worn food preparation equipment was found in storage and not discarded, despite being unsanitary. Items such as a rusty strainer, a warped cutting board, and a damaged plastic container were identified. The DA acknowledged these items could not be properly sanitized and needed to be replaced or discarded. The facility's policy and the US FDA Food Code emphasize the importance of maintaining equipment in good repair to ensure proper sanitation. The facility also failed to properly label and store food items. Expired and improperly sealed food items were found in storage, posing a risk of contamination. The DA admitted that the labeling was incomplete and that open food packages should be sealed to prevent contamination. Furthermore, kitchen staff were unable to demonstrate the correct procedure for testing sanitation concentration levels, which is crucial for preventing cross-contamination and food-borne illnesses. The RD confirmed that all staff should be knowledgeable about sanitation procedures to ensure food safety.
Infection Control Deficiencies in Hand Hygiene and Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as observed during a dining session where a Certified Nursing Assistant (CNA) did not perform hand hygiene between feeding multiple residents. CNA 6 was seen feeding several residents consecutively without using hand sanitizer or washing hands, instead using wipes intended for peri care, which were not suitable for hand hygiene. This was confirmed by the Director of Staff Development and the Infection Preventionist, who reiterated the importance of using appropriate hand hygiene methods between tasks and residents. Additionally, the facility did not ensure that Resident 20's nasal cannula and nebulizer mask were stored in a sanitary manner. The nasal cannula and nebulizer mask were not labeled or covered, and there was no documented evidence that the nebulizer mask and tubing had been changed since the physician's order was given. The Unit Manager and Director of Nursing confirmed that the equipment should be dated, bagged, and changed regularly to prevent infection. Furthermore, the inspection revealed improper storage of food items and nail clippers inside a medication cart. Licensed Nurse 4 confirmed the presence of a sandwich, pudding, and nail clippers stored alongside medications, which is against the facility's policy. The Director of Nursing acknowledged that food items should be stored separately, and nail clippers should not be kept in medication carts due to sanitary concerns.
Failure to Address Acute Vision Loss in Resident
Penalty
Summary
The facility failed to provide timely care to maintain vision for a resident, identified as Resident 143, who experienced an acute onset of vision loss. Despite the resident's severe cognitive impairment and multiple diagnoses, including dementia and diabetes, the facility did not send her to the hospital when she exhibited signs of significant vision problems. On 7/27/24, the resident showed increased confusion and inability to see objects in front of her, prompting a nurse to assess her vision. The physician was notified, and new orders were given to monitor the condition, with instructions to send the resident to the hospital if it worsened. The resident's condition did not improve, and subsequent progress notes indicated ongoing vision difficulties. Despite this, the resident was not referred to an optometrist until 8/2/24, and an ophthalmologist diagnosed her with bilateral retinal detachment and macular holes on 8/13/24. Interviews with the resident's family and facility staff revealed that the family had requested the resident be sent to the hospital, but the facility opted to monitor her condition instead. The facility's policy required notifying the physician of significant changes in a resident's condition, but the decision to send the resident to the hospital was ultimately left to the physician and the responsible party. Interviews with the facility's staff, including the Administrator, Director of Nursing, and Medical Doctor, indicated uncertainty about the acuity of the vision loss due to the resident's dementia. The Medical Doctor acknowledged that acute vision loss should be treated as an emergency, but due to the resident's cognitive impairment, it was challenging to determine the nature of the vision change. The facility's inaction in promptly addressing the resident's acute vision loss led to a delay in receiving necessary medical intervention.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, who was observed with cold and allergy nasal spray at the bedside, was assessed and had an order to self-administer medication. The resident, admitted in August 2024 with diagnoses including chronic lung disease and anxiety, was cognitively intact according to the Minimum Data Set. Despite this, a nursing assessment indicated that the resident did not want to self-administer medications, and there was no documented evidence supporting the resident's ability to self-administer medications. During an interview, the resident explained that he had been using his own nasal spray brought from home because his request for a prescription was not followed up by the nursing staff. The nasal spray was found on the resident's nightstand, with the resident's name printed on it by a staff member. The Director of Nursing stated that it was unsafe for the resident to keep medication at the bedside, as it could be accessed by other residents. The facility's policy requires that self-administration of medications be determined safe by the interdisciplinary team and documented in the medical records, which was not done in this case.
Failure to Secure Resident Information on Computer
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records, as observed during a survey. A computer on medication cart B was left open, displaying confidential clinical information, including residents' pictures, names, and medications. This occurred in a hallway where multiple residents and staff were present, creating the potential for unauthorized access to sensitive information. The Wound Nurse confirmed the observation, acknowledging it as a HIPAA violation. Licensed Nurse 1 admitted to leaving the computer open while attending to a resident, recognizing the importance of securing such information. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the facility's expectation is for staff to lock computer screens when not in use to prevent unauthorized access. The facility's policies on dignity, resident rights, and confidentiality emphasize the protection of resident information, prohibiting unauthorized release or access.
Failure to Provide Timely Allergy Medication
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards. The resident, who was admitted with multiple diagnoses including chronic lung disease and anxiety, was cognitively intact and had no memory issues. Despite the resident's repeated requests for allergy medication over six days, the facility did not follow up on these requests. The resident expressed frustration that the staff ignored his requests, and the clinical records showed no active order for the allergy medication Fluticasone. Interviews with facility staff, including a Licensed Nurse and the Director of Nursing, revealed that there was a breakdown in communication and follow-up regarding the resident's request for medication. Although a physician's note approving the medication was found, it was undated and had not been transcribed into the resident's clinical record. This oversight resulted in the resident not receiving the prescribed allergy medication in a timely manner, highlighting a failure in the facility's process for managing medication requests and orders.
Failure to Maintain Proper Nail Hygiene for a Resident
Penalty
Summary
The facility failed to provide necessary grooming services for a resident, identified as Resident 138, who was observed with black material under her fingernails. Resident 138 was admitted to the facility with multiple diagnoses, including dementia, and had a severe cognitive impairment with a BIMS score of 5 out of 15. The resident required moderate assistance for personal hygiene, as indicated in her Minimum Data Set (MDS) assessment. Despite this need, observations on consecutive days revealed that the resident's fingernails were not cleaned, which was confirmed by both a Licensed Nurse (LN) and a Certified Nursing Assistant (CNA). The LN suggested that the black material might have been from a soiled brief, as the resident had a behavior of ripping off her brief. The CNA confirmed that the resident's nails were dirty after breakfast and acknowledged that nails should be cleaned during showers, which occur twice a week, and clipped, cleaned, and filed on Sundays. The Director of Nursing (DON) stated that nails should be cleaned during showers and as needed, according to the facility's policy. However, the failure to maintain proper nail hygiene for Resident 138 was evident, as the facility's policy required appropriate support and assistance with hygiene for residents unable to carry out activities of daily living independently.
Failure to Provide Activities for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the needs and interests of a resident, identified as Resident 44, whose activity care plan was not followed. The resident's comprehensive Minimum Data Set (MDS) indicated severe cognitive impairment and highlighted preferences for activities such as listening to music, engaging in favorite activities, and going outside. However, observations revealed that the resident was often left without any sensory stimulation or interaction, such as being placed in a hallway or lying in bed awake without access to a television or radio. Interviews with staff, including a Licensed Nurse and the Activity Director, indicated a lack of awareness and documentation regarding the resident's participation in activities. The Activity Director admitted that there was no documentation of activities for the resident for several months due to issues with the Point of Care (POC) system, which was the sole method for documenting activities. The facility's policy required room visits or group activity attendance to be documented three times a week, but this was not adhered to. The Director of Nursing confirmed that activities should be documented if performed. The lack of documentation and adherence to the care plan resulted in a deficiency that potentially affected the resident's psychosocial well-being.
Failure to Apply Hand Roll as Ordered
Penalty
Summary
The facility failed to provide appropriate care for a resident with a physician's order to apply a hand roll or soft cloth in her right hand every shift to prevent further contracture. Despite the order, observations over several days revealed that the resident did not have a hand roll in her contracted right hand, which was tightly closed with long nails digging into her skin. Interviews with multiple CNAs and a licensed nurse indicated a lack of awareness regarding the need for a hand roll, and the resident's care plan did not address the contracture or the use of a hand roll. The resident's medication administration records showed that nurses documented the presence of a hand roll every shift, except for one instance, despite the absence of the hand roll during observations. The Director of Nursing confirmed the lack of a care plan addressing the hand contracture and acknowledged that the nurses should not have documented the presence of a hand roll if it was not in place. The facility did not have a policy on the prevention of contractures, contributing to the oversight in the resident's care.
Excessive Room Occupancy in Facility
Penalty
Summary
The deficiency identified in the report pertains to the accommodation of more than four residents in certain rooms within the facility, which is contrary to the regulatory requirements. Specifically, six rooms were found to have more than the allowed number of residents, with some rooms accommodating five or six residents. This was confirmed through a review of the facility's 'Approval of Program Flexibility' letter and the facility's census, as well as direct observations during a facility tour. Despite the presence of privacy curtains and sufficient space for movement and care, the room occupancy exceeded the regulatory limits. Interviews with staff, including CNAs and LNs, indicated that there was adequate space to provide care and respond to emergencies, and no issues were reported regarding the maneuverability of assistive devices or the storage of personal belongings. Additionally, a responsible party for one of the residents noted that while the rooms could be noisy, there were no concerns about space. The facility had requested a continuation of a room waiver, contingent upon compliance with federal regulations regarding resident rights and physical environment.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The deficiency identified in the report pertains to the failure of two resident rooms in a long-term care facility to meet the minimum space requirements. Specifically, rooms 15 and 16 did not provide the required 80 square feet per resident, as they were measured to have only 70.56 square feet per resident. Despite observations indicating that the rooms were uncluttered and allowed for resident movement and care activities, the facility did not comply with the federal regulation for physical environment standards. Interviews with staff, including CNAs and a Licensed Nurse, revealed that they perceived the space as sufficient for providing care and responding to emergencies. Additionally, a Responsible Party for one of the residents expressed no concerns about the space, although they noted the noise levels due to the number of residents. The facility had previously received a program flexibility approval letter, allowing for more beds in certain rooms, contingent upon compliance with federal regulations. However, the Maintenance Supervisor confirmed that the space in rooms 15 and 16 was below the required standard, leading to the deficiency finding.
Failure to Protect Resident from Abuse by Hospitality Aide
Penalty
Summary
The facility failed to protect a resident from abuse when a hospitality aide (HA) became upset and slapped the resident on the cheek repeatedly. The resident, who was admitted with diagnoses including dementia, depression, muscle weakness, and severe cognitive impairment, required supervision or touch cueing assistance while eating. The care plan for the resident indicated potential for physical aggression and outlined strategies for staff to manage agitation, such as intervening before escalation and walking away if the response was aggressive. However, during an incident, the HA, while assisting the resident with eating, became frustrated and slapped the resident, which was witnessed by a CNA. Interviews with facility staff, including the Director of Nursing (DON), Licensed Nurse 2 (LN 2), and the Assistant Director of Nursing (ADON), confirmed the incident. The HA admitted to reacting inappropriately due to frustration and acknowledged the action was wrong. The facility's policy on abuse prevention, revised in 2011, emphasizes the responsibility of the Administrator and DON to prevent abuse and neglect. Despite this policy, the incident occurred, highlighting a failure in protecting the resident from abuse.
Failure to Implement Care Plan Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to implement and monitor a comprehensive care plan for a resident, leading to a deficiency in care. The resident, who had severe cognitive impairment and was at risk for falls, was not consistently provided with hip protectors as outlined in their care plan. Despite the care plan's directive to use hip protectors to minimize fall-related injuries, there was no documented evidence that these were applied, and staff interviews revealed uncertainty about their availability and use. The resident experienced multiple falls, including a witnessed fall that resulted in a right hip fracture. The care plan and interdisciplinary team notes indicated the need for hip protectors, but there was no documentation confirming their use at the time of the incidents. The Director of Nursing and other staff members acknowledged the lack of documentation and implementation of the hip protector intervention, which was a critical component of the resident's fall prevention strategy. The facility's policies on care plans and fall risk management emphasized the importance of implementing resident-specific interventions to prevent falls and minimize their consequences. However, the failure to document and apply the hip protectors as per the care plan contributed to the resident's fall and subsequent hip fracture, which ultimately led to the resident's death. This deficiency highlights a significant lapse in the facility's adherence to its own policies and procedures regarding fall prevention and care plan implementation.
Failure to Implement and Update Care Plan for Resident with Ileostomy
Penalty
Summary
The facility failed to ensure the comprehensive care plan was implemented and updated for a resident with an ileostomy, leading to increased redness and irritation at the ileostomy site and surrounding skin. The resident was admitted with diagnoses including dementia, Crohn's disease, and ileostomy status. Physician's orders included specific care instructions for the ileostomy site, but these were not adequately followed or documented. The care plan noted the resident's non-compliance with treatment and the abdominal binder, but interventions were not effectively implemented or updated. The resident's ileostomy bag was leaking, and there was increased redness at the stoma site. The Treatment Nurse and Licensed Nurse 1 confirmed the presence of rashes on the resident's stoma, private area, and leg. The Certified Nursing Assistant observed the leaking ileostomy bag and applied tape and cream but did not report these observations to the Licensed Nurse. The resident's care plan did not address her behavior of scratching, which contributed to the skin irritation. The Director of Nursing acknowledged the lack of a care plan for the resident's scratching behavior and expected specific behaviors to be included in the care plan. The facility's policy required documentation of ileostomy care and notification of any abnormal findings, but there was no documented evidence of the abdominal binder being offered and refused by the resident. The Treatment Nurse admitted the care plan should have been updated to reflect the resident's refusal of the abdominal binder.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in significant harm to one and potential harm to another. Resident 1, who had severe cognitive impairment and a history of physical behavioral symptoms, pulled Resident 2's walker, causing him to fall and sustain a right intertrochanteric fracture. This incident occurred despite Resident 1 having a care plan in place to monitor and manage his aggressive behaviors. The staff's inability to intervene before the altercation escalated led to Resident 2 undergoing hip arthroplasty. In a separate incident, Resident 3 punched Resident 4 in the face during an altercation. Both residents had cognitive impairments and behavioral issues, with Resident 4 exhibiting both physical and verbal aggression. The altercation was not witnessed by staff until after it had begun, indicating a failure to monitor and manage the residents' behaviors effectively. The Director of Nursing acknowledged that both residents had aggressive tendencies and that staff were expected to follow care plans to prevent such incidents. The facility's policies on resident-to-resident altercations and abuse prevention emphasize the need for staff to monitor residents for aggressive behaviors and protect them from abuse. However, the incidents involving Residents 1, 2, 3, and 4 demonstrate a failure to adhere to these policies, resulting in harm and potential harm to the residents involved.
Failure to Monitor and Communicate Fluid Intake for Resident
Penalty
Summary
The facility failed to accurately monitor and communicate the fluid intake of a resident with dementia and chronic congestive heart failure, leading to potential health risks. The resident was admitted with a fluid restriction order of 2000 ml per day, which was later changed to 1000 ml per day. However, the resident's electronic Medication Administration Record (eMAR) showed that the resident consistently consumed more than 1 liter of fluids on multiple days across several months, with no documented evidence that the physician was informed of this noncompliance. Observations and interviews revealed that the resident had access to fluids beyond the restricted amount, and there was a lack of communication and monitoring by the staff. The Certified Nursing Assistant (CNA) and Licensed Nurse (LN) were not adequately informed about the fluid restriction, and the Director of Nursing (DON) was unaware of the conflicting fluid restriction orders. The facility's policy required the removal of water pitchers from the room for residents on fluid restriction, but this was not followed, and there was no care plan in place to address the resident's noncompliance.
Resident's Dignity Violated by Unauthorized Photograph
Penalty
Summary
The facility failed to protect a resident's right to be free from mental abuse when a staff member took a photograph of the resident in an undignified state. The resident, who was admitted with Alzheimer's Disease, major depressive disorder, lack of coordination, muscle weakness, and anxiety disorder, was found lying on the floor with his pants around his ankles and without undergarments. The photograph was taken with an unsecured facility cell phone, and the resident was attempting to cover his naked buttocks with his nightshirt. This incident was observed by the resident's responsible party and the Department, who noted the undignified nature of the photograph. Interviews with facility staff revealed a lack of clear procedures regarding the photographing of residents after falls. A Certified Nursing Assistant mentioned that nurses typically take pictures of residents' positions after a fall. However, a Licensed Nurse and the Unit Manager acknowledged that taking such photographs with residents' pants down is a dignity violation. The Unit Manager stated that the practice of taking photographs was a part of the training they received, although it was not a formal policy. The Director of Nursing confirmed that there was no official process for taking photographs after falls, and the Director of Staff Development indicated that taking such photographs could be considered abuse. The facility's policies and procedures emphasize treating residents with dignity and respect, protecting them from abuse, and ensuring privacy and confidentiality. The policy on videotaping and photographing residents specifically states that any image that could be construed as humiliating or demeaning is considered abuse. Despite these policies, the photograph of the resident was taken and shown to family members, highlighting a significant breach of the resident's rights and dignity.
Failure to Notify Responsible Party and Physician After Resident Fall
Penalty
Summary
The facility failed to notify the responsible party and physician for a resident who experienced an unwitnessed fall, resulting in bleeding and an injury to the lip. This incident delayed prompt medical monitoring and treatment, leaving the family unaware of the situation. The resident, who was admitted with Alzheimer's Disease, major depressive disorder, lack of coordination, muscle weakness, and anxiety disorder, was not capable of making their own decisions. The resident's family member was designated as the responsible party. The incident was documented in the resident's progress notes, indicating that the fall occurred during the night, but the physician and responsible party were not notified until the following day. Interviews with facility staff, including CNAs and licensed nurses, revealed that the standard procedure was to notify the doctor and responsible party immediately after a fall. However, in this case, the notification was delayed, and the facility's fall protocol was not followed promptly. The Director of Nursing confirmed that there was no documentation of the fall or notification to the doctor and responsible party on the day of the incident. The facility's policy requires prompt notification of changes in a resident's condition, but this was not adhered to in this case. The lack of timely notification and documentation highlights a deficiency in the facility's handling of the resident's fall and subsequent injury.
Failure to Monitor Neurological Changes After Unwitnessed Fall
Penalty
Summary
The facility failed to monitor a resident for neurological changes after an unwitnessed fall, which was not documented in the electronic health record (EHR). The resident, who had Alzheimer's Disease, major depressive disorder, lack of coordination, muscle weakness, and anxiety disorder, was found on the floor with dark red spots next to their face. Despite the facility's protocol requiring immediate neurological checks after a fall, there was no documentation of the fall, neurological assessment, or notifications to the physician or responsible party on the day of the incident. Interviews with various staff members, including licensed nurses, the unit manager, the assistant director of nursing, and the director of nursing, revealed that the expected procedure was to start neurological checks immediately after a fall. However, the checks were only initiated the day after the fall. The director of nursing confirmed the lack of documentation and acknowledged that the nurse on duty at the time of the fall did not follow the protocol. The facility's policy on managing falls emphasized the importance of identifying interventions to prevent falls and minimize complications, which was not adhered to in this case.
Failure to Inform Resident's Representative of Skin Discoloration
Penalty
Summary
The facility failed to inform the representative or Responsible Party (RP) of a resident about changes in the resident's skin condition. Specifically, the facility did not notify the RP about the skin discoloration observed on the resident's forearms. The resident, who was admitted with Alzheimer's disease and Bipolar II disorder, had old purplish discoloration on her bilateral forearms, which was noted during a body skin assessment. However, this change was not communicated to the RP until the resident's daughter brought it to the facility's attention. The Director of Nursing (DON) acknowledged that the discoloration was not reported before the resident's daughter mentioned it. The facility's policy requires prompt notification of the resident, their attending physician, and representative of any changes in the resident's medical or mental condition. The DON stated that the expectation was for the Certified Nursing Assistant to report any skin changes immediately, as this was considered a change in condition.
Lack of Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to ensure the safety of two residents, resulting in a verbal and physical altercation between them. Resident 1, who has Alzheimer's disease and Bipolar II disorder, and Resident 2, who has unspecified dementia with anxiety, were involved in the incident in the backyard of the facility. The altercation led to Resident 1 sustaining a scratch on the cheek and Resident 2 having a skin tear on the left hand. At the time of the incident, there was no staff assigned to supervise the residents in the backyard, as confirmed by the Director of Nursing and a Certified Nursing Assistant (CNA). The CNA stated that he was on a break in his car when the incident occurred and acknowledged that the altercation could have been resolved sooner or prevented if a staff member had been present. The facility's policy on resident supervision, which emphasizes the importance of supervision based on individual resident needs, was not adhered to in this case. Additionally, it was noted that Resident 1 required constant supervision due to episodes of self-harm, further highlighting the lack of appropriate supervision during the incident.
Failure to Follow Infection Control Standards for Indwelling Catheter
Penalty
Summary
The facility failed to follow infection control standards for a resident with an indwelling catheter. The resident's catheter bag was observed lying on the floor under the bed, contrary to the facility's policy which mandates that catheter bags should be kept off the floor and attached to the bed frame. This observation was confirmed by both the resident and Licensed Nurse 2, who acknowledged that the catheter bag should not be in contact with the floor. The Infection Preventionist also confirmed that the catheter bag should be hung on the side of the bed without dragging on the floor to prevent the spread of germs. The resident was admitted to the facility with diagnoses including obstructive and reflux uropathy. The resident's care plan and order summary report indicated that the catheter tubing should be secured to prevent movement and urethral traction, and that there should be no dependent looping of the catheter tubing. Despite these directives, the catheter bag was found on the floor, which was acknowledged by the Director of Nursing and the facility Administrator as a violation of the facility's infection control policy.
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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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