Norwalk Skilled Nursing & Wellness Centre, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, California.
- Location
- 11510 Imperial Highway, Norwalk, California 90650
- CMS Provider Number
- 555668
- Inspections on file
- 36
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Norwalk Skilled Nursing & Wellness Centre, Llc during CMS and state inspections, most recent first.
A resident with acute kidney failure and severe cognitive impairment was not administered IV fluids at the rate ordered by the physician. Instead of receiving 0.45% Normal Saline at 100 mL/hour, the resident initially received the fluids at 50 mL/hour, contrary to the physician's order. This error was identified through observation and confirmed by nursing staff, in violation of the facility's medication administration policy.
The facility did not allow a resident or the resident's legal representative to access or purchase copies of all the resident's records, as required.
The facility failed to document the administration of acetaminophen for a resident with impaired cognition, did not maintain accurate accountability records for tramadol for another resident with severe cognitive impairment, and did not ensure a resident with Parkinson’s and diabetes received lactulose as ordered for constipation. These actions resulted in incomplete medication records and discrepancies between physician orders, pharmacy labels, and facility documentation.
Surveyors found that the facility did not keep medication error rates below 5 percent, as required. The report notes that the error rate was above the acceptable limit, but does not specify the medications or residents involved.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
Surveyors found that dietary staff did not label prepared juices and opened containers with the required dates, as observed in both the kitchen and a resident's refrigerator. The Dietary Supervisor confirmed that labeling is required by facility policy to ensure food safety, but multiple items were found without proper dating.
Two residents received psychotropic medications without valid, up-to-date informed consent, as required by facility policy. In one case, consent was outdated despite new medications being started, and in another, consent forms were incomplete and missing necessary signatures. Staff interviews and record reviews confirmed these deficiencies.
A resident with multiple chronic conditions did not receive quarterly or as-needed IDT meetings, resulting in the resident and her responsible party being unaware of her care plan and experiencing worry due to not receiving mammogram results for several months. The facility's failure to follow its policy on care planning meetings led to a lack of communication and documentation regarding the resident's care.
Facility staff did not provide advance notice or obtain consent from a resident or the resident's family before making multiple room changes, despite the resident's significant cognitive and physical impairments. Interviews and record reviews confirmed that required notifications were not given or documented, contrary to facility policy.
A resident with severe cognitive impairment and diagnoses of depression and vascular dementia was given haloperidol on a PRN basis for anxiety and agitation, despite lacking a specific diagnosis or documented justification for antipsychotic use. Staff and policy review confirmed the medication was not indicated, violating facility protocols regarding antipsychotic administration.
A resident with a history of cellulitis, sepsis, and contractures had an order for oxygen therapy and received oxygen on several occasions, but this was not documented in the MDS assessment. The MDS Coordinator confirmed the omission was a miscoding error, and the DON acknowledged that such inaccuracies could affect the delivery of appropriate care.
A resident with severe cognitive impairment and multiple dependencies was prescribed haloperidol for anxiety and agitation, but staff failed to develop a person-centered care plan addressing the use of this antipsychotic medication. Despite facility policy requiring comprehensive care planning and regular reassessment for psychoactive medications, the care plan did not include necessary details for monitoring or managing the medication.
A resident with a history of smoking and new oxygen therapy was not provided with an updated care plan to address the risks associated with both conditions. Staff confirmed the care plan lacked interventions for oxygen use, despite facility policy requiring care plans to be reviewed and revised based on assessed needs.
A resident with Parkinson's disease and diabetes, requiring moderate assistance with toileting hygiene, was left wet with urine for several hours despite staff awareness of the need. The CNA reported being occupied with another resident, resulting in delayed care until later in the morning. Facility policy requires individualized assistance to maintain hygiene and dignity.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in care that was not individualized or consistent with regulatory requirements.
The facility did not keep an area free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors. Staff did not implement sufficient monitoring or protective measures to address environmental risks.
A urinary catheter drainage bag for a resident with multiple complex medical conditions was observed touching the floor, contrary to facility policy and infection control standards. Nursing staff and the DON acknowledged that the bag should not be on the floor, and records indicated the resident was at high risk for UTI.
A resident received a feeding tube without documented medical necessity or agreement, and did not receive appropriate care for the feeding tube as required.
A resident did not receive safe and appropriate respiratory care when it was needed, as required by their condition.
A resident with ESRD on hemodialysis did not have fluid intake properly monitored, as a filled water pitcher was left at the bedside despite strict fluid restriction orders. Additionally, nursing staff failed to complete and document required post-dialysis assessments after the resident returned from outpatient dialysis treatments, in violation of facility policy and professional standards.
A nurse was found to be missing required competency validation for administering medication via a gastrostomy tube, as well as lacking documentation for other initial competencies such as hand hygiene and medication administration. The Director of Staff Development and Director of Nursing confirmed the absence of these records and orientation details, resulting in the facility's inability to verify the nurse's competency for safe medication administration.
A nurse failed to perform hand hygiene before and after donning gloves and gown during medication administration via gastrostomy tube for a resident with multiple medical conditions, despite facility protocols requiring this practice. Additionally, a peripheral IV catheter for another resident was not labeled or dated as required by facility policy, which was confirmed by both nursing staff and the DON.
A resident with severe cognitive impairment and a history of schizoaffective disorder, identified as at risk for elopement, was left unsupervised in a dining room. The receptionist, whose desk did not provide a direct view of the front door, was unable to monitor exits effectively, and the front door alarm was not activated. As a result, the resident left the facility undetected and was later found by a member of the public miles away.
A resident in a long-term care facility was injured during a transfer using a mechanical lift when a CNA attempted the transfer alone, contrary to policy requiring two-person assistance. The sling used was worn and not inspected for damage, leading to it ripping and the resident falling, resulting in head and arm injuries. The resident had a history of morbid obesity, dementia, and chronic kidney disease, and was dependent on staff for mobility.
A resident with multiple health conditions fell and sustained a head injury due to a CNA's improper use of a mechanical lift without assistance. The CNA had received only verbal training without sufficient return demonstrations. Facility policy required two staff members for such transfers, but this was not followed, highlighting inadequate training and adherence to procedures.
The facility failed to maintain and calibrate two mechanical lifts, leading to inaccurate weight readings that could result in using incorrect slings for resident transfers. During a demonstration, discrepancies were found between the weights shown by the mechanical lifts and a standing scale. The Maintenance Supervisor acknowledged annual calibration but noted that discrepancies were not feasible to address for every resident. The Administrator highlighted the risk of injury if incorrect slings were used, especially for residents with conditions like morbid obesity and dementia.
A resident with cognitive impairment and mobility dependence was injured when a CNA attempted a solo transfer using a mechanical lift, contrary to the care plan requiring two-person assistance. The sling failed, causing the resident to fall and sustain a head injury. Facility policy and staff interviews confirmed the need for two-person assistance during such transfers.
A facility failed to document a resident's debit and credit cards on the Personal Effects Inventory form and did not inform the resident of the risks of keeping them at her bedside. The resident was not offered a secure place for her cards, and interviews revealed that staff did not discuss safekeeping options. The facility's policy requires secure handling of residents' property, but this was not adhered to in this case.
A resident with depression and a history of suicidal ideation exhibited significant behavioral changes, including crying spells and accusations of poisoning, which were not properly assessed or monitored by the facility staff. The care plan was not followed, and the resident's primary care physician was not notified of these changes. The resident was later found deceased, having committed suicide, highlighting critical deficiencies in the facility's care and communication processes.
A resident with depression exhibited distress and delusions, but the LVN did not notify the physician or conduct a change of condition assessment. Despite the care plan's requirement to monitor and report changes, the LVN assessed the behavior as a misunderstanding. This inaction led to the resident's suicide, highlighting a failure to adhere to facility policies requiring prompt physician notification.
A resident with depression and a history of suicidal ideation was not properly monitored or assessed by nursing staff, despite exhibiting signs of distress and delusional thoughts. The care plan interventions, including monitoring and notifying the physician of changes in behavior, were not followed. This failure resulted in the resident's death by suicide, highlighting a significant deficiency in care plan implementation and communication among staff.
A resident with a history of depression and on antidepressant medication was observed in distress, accusing a CNA of poisoning him. Despite these signs, staff failed to intervene appropriately, resulting in a lack of care plan interventions. The resident later committed suicide. Interviews revealed failures in reporting, assessing, and monitoring the resident's condition, as well as a lack of timely assessments by the Social Service Director.
A facility's QAPI program failed to address a resident's behavioral health needs, leading to the resident's suicide. The resident, with a history of depression, was not adequately assessed or monitored, and significant changes in behavior were not communicated to the physician. The Social Services Director did not complete timely assessments, and nursing staff failed to conduct a Change of Condition assessment or notify the physician. The QAPI program did not focus on behavioral and psychosocial needs, contributing to the resident's unmet mental health needs.
The facility did not complete competency and skill set reviews for four out of five sampled staff members as per policy. CNA1 and CNA2 were last evaluated in 2022, CNA3 had no review since hire, and CNA4's last evaluation was in 2011. The DSD confirmed these lapses, emphasizing the importance of annual reviews for identifying staff strengths and weaknesses. Interviews with staff highlighted the need for regular evaluations to maintain quality care.
A resident was administered Seroquel without a proper diagnosis of paranoid schizophrenia. The resident, with existing diagnoses of dementia and other conditions, was incorrectly diagnosed at a hospital and continued on the medication upon returning to the facility. The DON acknowledged the error, and the MDSC confirmed the absence of a schizophrenia diagnosis in the resident's records.
A long-term care facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for two residents. An RN incorrectly documented Methadone administration, leading to an extra dose in inventory, while LVNs failed to document Norco administration in the MAR. These errors risked medication mismanagement and potential adverse effects.
A resident in an LTC facility experienced significant medication errors involving Methadone administration. The resident did not receive a prescribed dose on one occasion, and on another, received an extra dose due to a lack of clarity in the physician's order regarding Methadone clinic visits. These errors were identified through staff interviews and record reviews.
The facility failed to properly date, seal, refrigerate, and discard food items before expiration, affecting 91 residents. Observations revealed unlabeled and expired items in dry storage, the refrigerator, and the freezer. The Dietary Manager acknowledged the responsibility of dietary staff to ensure compliance with food storage policies.
The facility did not ensure all staff received the required five hours of annual dementia training, as confirmed by the DSD and DON. The facility's policy required two hours of training upon hire and five hours annually, excluding the initial two hours. This discrepancy was identified during a survey, indicating non-compliance with the policy, potentially leading to neglect or inadequate care for residents with dementia.
The facility failed to accommodate the needs of several residents by not adjusting side rails and ensuring call lights were within reach. A resident with paraplegia was unable to adjust her position due to high side rails, and multiple residents had call lights placed out of reach, increasing their risk of falls and injury. Staff interviews confirmed the importance of accessible call lights, which was not adhered to, leading to a deficiency.
The facility failed to implement care plan interventions for two residents, leading to potential delays in necessary care. A resident was observed smoking unsupervised in a non-designated area, contrary to the care plan. Another resident did not receive timely pain management due to a delay in developing a baseline care plan. Staff interviews confirmed these lapses, highlighting non-adherence to facility policies on care planning and smoking safety.
The facility failed to manage pain effectively for two residents. One resident did not receive appropriate medication for moderate pain, affecting her sleep, while another experienced unnecessary pain due to delayed administration of prescribed medication. The facility did not follow its pain management policy, resulting in these deficiencies.
A resident with osteomyelitis did not receive antibiotics as prescribed due to delays in pharmacy delivery and improper documentation. The facility failed to administer Cefepime and Daptomycin at the scheduled times, with several doses given hours late. Staff acknowledged the issue, and the facility's policies on medication administration and documentation were not followed, potentially impacting the resident's recovery.
A facility failed to change a resident's feeding tube formula, tubing, syringe, and water flush bags within 24 hours, as required by policy. During an observation, these components were found to be dated over 24 hours old. Interviews with staff revealed a lack of adherence to the policy, with an LVN unsure of the requirements and not having read the G-tube care policy. The RNS and DON confirmed the necessity of changing these components every 24 hours to prevent risks such as foodborne illness and G-tube clogging.
A facility failed to ensure a physician responded to a pharmacist's recommendation to monitor a resident's valproic acid levels related to divalproex sodium use. Despite the recommendation, no physician response or laboratory monitoring was documented. The resident had been admitted with psychosis and fluctuating decision-making capacity. The facility's policy required action on pharmacist recommendations, which was not followed, resulting in the deficiency.
A facility failed to monitor valproic acid levels for a resident prescribed divalproex sodium, despite a pharmacist's recommendation. The resident, with diagnoses including psychosis, was at risk due to the lack of laboratory tests to ensure safe medication levels. The facility's policy required regular monitoring, which was not followed.
An expired fluticasone/salmeterol inhaler was not removed from a medication cart, affecting a resident. The inhaler, opened on 5/4/24, should have been discarded by 6/4/24 per manufacturer's instructions. The facility's policy requires outdated medications to be removed immediately, but this was not followed, risking the resident's health.
A facility failed to assess a resident's mental capacity and provide necessary information before signing an arbitration agreement. The resident, diagnosed with dementia and cerebral vascular disease, lacked decision-making capacity. A family member signed the agreement without understanding it, believing it was part of the admission packet. The Admission Coordinator did not ensure the agreement was explained in a language the family member understood, violating facility policy.
A LTC facility failed to supervise a resident with dementia, who left the premises unsupervised and was found miles away, and did not provide timely assistance to another resident, who had to crawl to the bathroom. The facility's policies on resident safety and call system communication were not followed, leading to significant safety risks.
Two residents experienced unmet psychosocial needs due to the facility's failure to provide necessary psychological assessments and follow-up. One resident with dementia left the facility unnoticed and was found confused and minimally clothed miles away, while another resident, dependent on assistance, crawled to the bathroom after waiting an hour for help. The facility's policy required social service assessments, but these were not conducted, leading to unaddressed emotional needs.
Failure to Administer IV Fluids as Ordered
Penalty
Summary
Facility staff failed to administer intravenous fluids (IVF) as ordered by the physician for a resident who was admitted with a left tibia fracture and acute kidney failure. The resident's physician had ordered 0.45% Normal Saline to be administered at a rate of 100 mL/hour for 24 hours for hydration. However, observations revealed that the IVF was initially being administered at a rate of 50 mL/hour instead of the prescribed 100 mL/hour. This discrepancy was identified during an observation and confirmed through interviews and record review with nursing staff. The resident was noted to have severe cognitive impairment and required significant assistance with daily activities. The error in IVF administration was acknowledged by both the RN and the DON, who confirmed that the fluids were not being given at the correct rate as per the physician's order. The facility's medication administration policy required medications and treatments to be administered as prescribed to ensure compliance with dose guidelines, which was not followed in this instance.
Failure to Provide Resident Access to Records
Penalty
Summary
The facility failed to ensure that each resident or the resident's legal representative was able to access or purchase copies of all the resident's records. This deficiency was identified based on the facility's lack of compliance with requirements regarding the provision of records to residents or their legal representatives as requested.
Medication Documentation and Administration Deficiencies
Penalty
Summary
The facility failed to properly document the administration of acetaminophen for a resident who was admitted with pneumonia and sepsis and had moderately impaired cognition. On a specific date, the resident experienced a fever and was given acetaminophen as needed, which successfully reduced the fever. However, the administration of this medication was not recorded in the Medication Administration Record (MAR), as confirmed by the nurse who stated they forgot to document it. The Director of Nursing acknowledged that this lack of documentation could lead to duplicate administration and potential adverse reactions. There were also discrepancies in the accountability records for controlled medication, specifically tramadol, for another resident with severe cognitive impairment and multiple contractures. The facility's records, including the Individual Narcotic Record and prescription labels, did not match the physician's order for tramadol dosing. The narcotic records were handwritten and contained incorrect information regarding the dosage and administration times, which did not align with the pharmacy label or the physician's order. The Director of Nursing confirmed that the information on the narcotic count sheet should match exactly with the pharmacy label and that manual transcription increases the risk of medication errors. Additionally, the facility did not ensure that a resident with Parkinson’s disease, diabetes, and other conditions received lactulose as ordered for constipation. The resident reported not having a bowel movement for more than a week, and documentation confirmed a gap of several days without a bowel movement. The nurse acknowledged that the resident should have been offered lactulose during this period, as per the physician's order. The Director of Nursing stated that medications should be administered as ordered, and the facility's policy required medication administration according to orders.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5 percent. This deficiency was identified through surveyor observation and review, indicating that the rate of medication errors exceeded the acceptable threshold. The report does not provide specific details about the residents involved, the types of medications, or the circumstances of the errors, but it establishes that the facility did not maintain compliance with the required medication error rate standard.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Label and Date Prepared Juices and Opened Containers
Penalty
Summary
Surveyors observed that the facility failed to store food and beverages in a sanitary manner, specifically by not labeling prepared juices and opened containers with the required dates. During an initial kitchen visit, multiple glasses of cranberry juice, apple juice, milk, and orange juice were found in the walk-in refrigerator without a prepared-on date. Additionally, a large container of juice in a resident's refrigerator was found without an opened-on date. These observations were made in the presence of the Dietary Supervisor (DS). In an interview, the DS confirmed that it is the dietary staff's responsibility to label all foods and drinks with prepared-on and opened-on dates, as per facility policy. The DS stated that juices are to be discarded after 72 hours to prevent them from becoming hazardous. A review of the facility's policy and procedure on food storage and handling, revised on 2/9/2024, indicated that all food items must be labeled and dated. The failure to follow these procedures was identified for food prepared and served to 81 residents.
Failure to Obtain and Maintain Valid Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and maintain valid informed consent for the administration of psychotropic medications for two of three sampled residents. For one resident with dementia and bipolar disorder, the most recent informed consent for psychotropic medication was dated nearly a year prior, despite facility policy requiring renewal every six months. This resident was determined to be incapable of making healthcare decisions, yet new psychotropic medications were initiated without updated consent documentation. The Director of Nursing confirmed that consents should be current and acknowledged the lapse. For another resident with major depressive disorder and anxiety disorder, informed consent forms for prescribed psychotropic medications were found to be incomplete and invalid, lacking required dates and physician signatures. The responsible RN confirmed the deficiencies in the consent documentation. Facility policy specifies that informed consent must be obtained by the healthcare provider prior to the first dose and renewed every six months, but this was not followed in these cases.
Failure to Hold Timely IDT Meetings and Communicate Care Plan Updates
Penalty
Summary
The facility failed to conduct Interdisciplinary Team (IDT) meetings quarterly and as needed for one of three sampled residents. Specifically, a resident with diagnoses including diabetes, arthritis, and kidney failure, who had fluctuating capacity to make decisions but was assessed as cognitively intact, did not have an IDT meeting for over three months. The facility's policy requires quarterly IDT meetings and documentation of care planning conferences, but the last documented meeting for this resident was more than three months prior to the survey. As a result of the missed IDT meetings, the resident and her responsible party were not informed about the plan of care and were unaware of the results of a diagnostic bilateral mammogram that had been performed several months earlier. Both the resident and her responsible party expressed concern and worry due to the lack of communication regarding the mammogram results. The Social Services Director confirmed that the mammogram results were not present in the resident's medical record and acknowledged that the absence of a recent IDT meeting contributed to the lack of updates provided to the resident and her responsible party.
Failure to Notify Resident and Family of Room Changes
Penalty
Summary
Facility staff failed to provide advance notice or information regarding room changes for a resident with diagnoses including encephalopathy, Alzheimer's disease, and muscle weakness, who was dependent on staff for all activities of daily living. The resident's medical records showed multiple room changes on specific dates, but there was no documentation that the resident or his family were notified prior to these moves. Interviews with the resident's family member confirmed that they were not informed about the room changes, and facility staff, including the Social Services Director and Director of Nursing, acknowledged that notification and consent are required for such changes, even when moving a resident within the same room. Review of facility policy indicated that residents and their representatives must be given timely advance notice before any room or roommate change. Despite this policy, the lack of documentation and communication regarding the room changes for this resident was confirmed by both staff and family interviews. The deficiency was identified through interviews, record reviews, and policy examination, all of which demonstrated that the required notifications were not provided or documented as per facility protocol.
Unjustified PRN Antipsychotic Use Without Proper Diagnosis
Penalty
Summary
A deficiency was identified when a resident was administered haloperidol, an antipsychotic medication, on an as-needed (prn) basis for anxiety manifested by agitation, without a specific diagnosis or documented justification for its use. The resident's medical record indicated diagnoses of depression and vascular dementia, with severe cognitive impairment and total dependence on staff for daily activities. The physician's order for haloperidol did not include a qualifying mental health diagnosis, and staff interviews confirmed there was no appropriate indication for antipsychotic use as required by facility policy. Further review revealed that the facility's policy prohibits the use of antipsychotic medications on a prn basis and restricts their use to specific mental health conditions or certain physical behavior problems. Both the RN and DON acknowledged that the order for haloperidol did not meet these criteria, and the medication should not have been administered without a proper diagnosis or indication. The lack of adherence to policy and regulatory requirements resulted in the potential for unnecessary medication use for the resident.
Failure to Accurately Document Oxygen Use in MDS Assessment
Penalty
Summary
The facility failed to accurately document a resident's Minimum Data Set (MDS) assessment, specifically omitting the resident's use of oxygen therapy. The resident, who had a history of cellulitis, sepsis, and contractures, was noted in the physician order summary to have an order for oxygen as needed at 2 liters per minute. Medical records showed that the resident received oxygen on multiple dates within the MDS assessment reference period. During an interview and record review, the MDS Coordinator confirmed that the MDS submitted did not reflect the resident's oxygen use, acknowledging this as a miscoding error. The Director of Nursing also stated that inaccuracies in the MDS could result in the resident not receiving appropriate services or treatment. Facility policy requires that resident assessments accurately depict and identify resident-specific issues and objectives.
Failure to Develop Person-Centered Care Plan for Antipsychotic Medication Use
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was prescribed the antipsychotic medication haloperidol. The resident had diagnoses including depression and vascular dementia, with severe cognitive impairment and total dependence on staff for all activities of daily living. The resident was unable to make medical decisions, as documented in the physician's progress note. Despite the initiation of haloperidol for anxiety manifested by agitation, there was no care plan in place addressing the use of this antipsychotic medication. During interviews and record reviews, it was confirmed by both a registered nurse and the Director of Nursing that a care plan specific to the use of haloperidol was not developed for the resident. Facility policy required person-centered, comprehensive, and interdisciplinary care planning, including updates to the care plan with new problems or changes in behavior. The policy also required regular reassessment of psychoactive medication effectiveness. These requirements were not met in this case, as the care plan did not address the antipsychotic medication use.
Failure to Update Smoking Care Plan for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to update the care plan for a resident who was a smoker and had recently started using oxygen therapy. The resident, who had diagnoses including acute respiratory failure and congestive heart failure, was assessed as having moderately impaired cognition and required varying levels of assistance with daily activities. Despite documentation indicating the resident was a smoker and had a new order for oxygen via nasal cannula, the care plan did not include interventions to address the resident's oxygen use in relation to smoking. During observations, the resident was seen in the designated smoking area with a nasal cannula hanging on his chest. Interviews with nursing staff confirmed that the care plan had not been revised to reflect the new oxygen therapy, and the Director of Nursing acknowledged that smoking care plans should be updated and individualized to address such changes. The facility's policy required periodic review and revision of care plans based on residents' assessed needs, but this was not followed in this case.
Failure to Provide Timely Assistance with Toileting Hygiene
Penalty
Summary
A deficiency occurred when a resident with diagnoses including weakness, Parkinson's disease, and type 2 diabetes mellitus did not receive timely assistance with toileting hygiene. The resident's Minimum Data Set indicated intact cognitive skills and a need for moderate assistance with toileting hygiene. On the morning of the incident, the resident reported being wet with urine since 5 a.m. and stated that staff were aware of her need for assistance. Observation confirmed the resident was still in bed in her nightgown at 9:45 a.m. and had not yet been assisted. A Certified Nurse Assistant (CNA) acknowledged awareness of the resident's need for changing but stated she was busy with another resident after arriving at 6:30 a.m. The CNA was later observed assisting the resident with toileting and personal hygiene at 10:00 a.m. The Director of Nursing confirmed that all residents should be assisted with toileting hygiene and that failure to do so could have negative outcomes. Facility policies reviewed indicated a requirement to provide services that meet residents' individual needs and promote hygiene, comfort, self-esteem, and dignity.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Catheter Drainage Bag Found Touching Floor
Penalty
Summary
A deficiency was identified when a urinary catheter drainage bag for one resident was observed touching the floor during a survey. The resident in question had multiple significant medical diagnoses, including multiple sclerosis, bladder cancer, and an infection with an antibiotic-resistant organism. The resident required varying levels of assistance with activities of daily living and was assessed as high risk for urinary tract infection. Physician orders were in place for regular catheter and catheter bag changes, and facility policy required that drainage bags be kept off the floor. During the survey, a Licensed Vocational Nurse acknowledged that the urine bag was touching the floor and recognized this as a potential infection control issue. A Registered Nurse confirmed the resident's high risk for UTI and stated that staff should ensure the urine bag, including any dignity bag, does not touch the floor. The Director of Nursing also stated that the urine bag should be kept off the floor for infection control. Review of facility policies for both CNAs and charge nurses indicated that keeping drainage bags off the floor is a required infection control practice.
Inappropriate Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the intervention. Additionally, appropriate care and services related to the feeding tube were not provided as required. These actions resulted in a deficiency related to the use and management of feeding tubes.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Monitor Fluid Intake and Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide dialysis care and services according to professional standards for a resident with end stage renal disease who was dependent on hemodialysis. The resident had physician orders for a strict fluid restriction and scheduled dialysis treatments at an outpatient center. Despite these orders, the resident was observed with a filled water pitcher at the bedside, and staff confirmed that the pitcher was accessible, which was contrary to the requirement to monitor and control fluid intake for dialysis patients. Additionally, the facility did not complete or document post-dialysis assessments for the resident after returning from dialysis on multiple occasions. Review of records and interviews with nursing staff and the DON confirmed that these assessments were not performed, even though facility policy required a licensed nurse to evaluate residents after dialysis. The lack of monitoring fluid intake and failure to assess the resident post-dialysis constituted a deviation from professional standards and facility policy.
Missing Competency Validation for Medication Administration via Enteral Feeding Tube
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) was competent in administering medication via a gastrostomy tube (GT) in accordance with the facility's policy and procedure. During interviews and record reviews, it was found that the required competency validation form for medication administration with enteral formulas was missing from the LVN's employment file. The Director of Staff Development (DSD) and the Director of Nursing (DON) both confirmed that there was no documentation of this competency validation, and the DSD acknowledged that some review dates were also missing from other initial competency validations, such as hand hygiene, medication administration, and head-to-toe assessment. Additionally, there was no documentation indicating which nursing station the LVN was oriented to, which is necessary for understanding the specific diagnoses and residents under their care. The facility's policies require that staff receive training and competency validation for tasks such as medication administration via enteral feeding tubes, hand hygiene, and the use of personal protective equipment. However, the lack of documentation in the LVN's file indicated that these requirements were not met or properly recorded. The DSD admitted to forgetting to document review dates on some competencies, and the DON had not reviewed the LVN's file to confirm completion of the necessary validations. This lack of documentation and oversight resulted in the facility's inability to verify that the LVN possessed the required competencies to safely administer medications via a gastrostomy tube.
Failure to Perform Hand Hygiene and Label IV Catheter
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to perform proper hand hygiene during medication administration for a resident with multiple complex medical conditions, including dysphagia, diabetes mellitus type II, epilepsy, hypertension, blindness, and gastrostomy status. The LVN prepared and administered several medications via gastrostomy tube without performing hand hygiene before donning gloves and gown, and again failed to perform hand hygiene after changing gloves during the process. The LVN later acknowledged forgetting to sanitize her hands, despite being aware of the facility's protocols requiring hand hygiene before and after resident contact, and before donning and after doffing personal protective equipment (PPE), especially for residents on Enhanced Barrier Precautions. The facility's Infection Preventionist Nurse confirmed that staff are required to perform hand hygiene before any high-contact activity, such as medication administration via gastrostomy tube, and before and after using PPE. Facility policy also specifies that wearing gloves does not replace the need for hand hygiene, and that hand hygiene must be performed before donning and after doffing PPE, as well as upon entering and exiting resident rooms. The LVN's failure to follow these protocols was observed during a medication pass and confirmed in subsequent interviews. Additionally, a Registered Nurse (RN) failed to label and date a peripheral intravenous (IV) catheter for another resident. The RN and Director of Nursing both stated that IV sites must be labeled with the date, time, and nurse's initials at the time of insertion to track when the IV needs to be replaced. Facility policy requires this labeling to prevent infection at the IV site. The omission was observed and confirmed through interviews and review of facility policy.
Resident Elopement Due to Inadequate Supervision and Environmental Safeguards
Penalty
Summary
A resident with a diagnosis of schizoaffective disorder and severely impaired cognition was assessed as being at risk for elopement, as indicated by his Minimum Data Set and Elopement Evaluation. The resident's care plan identified him as at risk for wandering or elopement, with a goal to prevent him from leaving the facility unattended, but did not specify what triggers staff should monitor for. On the day of the incident, the resident was last seen in the dining room at 6:15 p.m. by a registered nurse, who then left him alone while the receptionist was at the front desk. The receptionist's desk did not provide a direct line of sight to the front door, and the front door alarm was not activated before 8 p.m., allowing the resident to leave the facility undetected. The resident was discovered missing at approximately 7 p.m., and was later found by a member of the public about 14 miles from the facility. Interviews with staff confirmed that the receptionist could not adequately monitor the front door from her position, and that the front desk should not be left unattended. The facility's policy required documentation of elopement risk and individualized interventions, but the care plan lacked specific details on triggers for wandering or elopement. The combination of inadequate supervision, lack of clear monitoring procedures, and insufficient environmental safeguards contributed to the resident's elopement.
Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer using a mechanical lift, resulting in the resident falling and sustaining injuries. The incident involved a Certified Nursing Assistant (CNA) who attempted to transfer the resident alone, contrary to the facility's policy and the mechanical lift manufacturer's guidelines, which require two-person assistance. The CNA used a mechanical lift sling with worn-out straps, which were not inspected for damage prior to use, leading to the sling ripping during the transfer. The resident involved had a history of morbid obesity, dementia, and chronic kidney disease, and was dependent on staff for mobility and self-care activities. The resident's care plan indicated the need for extensive assistance with transfers, requiring two persons and the use of a mechanical lift. Despite this, the CNA proceeded with the transfer alone, and the sling, which was not checked for wear and tear, failed, causing the resident to fall and sustain a head injury and other physical trauma. Interviews with staff revealed that the facility had not replaced the slings in a long time, and the CNA assumed that the laundry staff checked the slings for damage. The Director of Nursing and other staff acknowledged that the incident could have been prevented if the transfer had been conducted with two-person assistance and if the sling had been inspected for damage. The facility's policy and the manufacturer's manual both emphasize the importance of using two assistants for transfers and inspecting slings for damage after laundering.
Inadequate Training on Mechanical Lift Use Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was competent in using a mechanical lift to transfer a resident, resulting in a fall and injury. The incident involved a resident with multiple diagnoses, including morbid obesity, dementia, and chronic kidney disease, who was dependent on staff for mobility and required extensive assistance for transfers. The resident's care plan specified the need for a mechanical lift and assistance from two staff members for transfers. However, CNA 1 attempted to transfer the resident alone, leading to the resident falling from the sling and sustaining a head injury. Interviews and record reviews revealed that CNA 1 had received only general verbal education on using the mechanical lift, with infrequent return demonstrations. The Director of Staff Development confirmed that the last in-service training was lecture-based without return demonstrations. The Director of Nursing and other staff members emphasized the necessity of having two staff members assist with mechanical lift transfers, highlighting that CNA 1 did not follow the facility's policy and procedure by not calling for help. Further observations demonstrated that other staff members, including Restorative Nursing Assistants, also lacked proper training, as they incorrectly used the mechanical lift during a demonstration. The facility's policy required staff to be educated on proper transfer procedures and the use of assistive devices, but the lack of comprehensive training and return demonstrations contributed to the deficiency. The incident underscores the need for effective training and adherence to established procedures to ensure resident safety during transfers.
Failure to Maintain and Calibrate Mechanical Lifts
Penalty
Summary
The facility failed to maintain and calibrate two out of five mechanical lifts used for transferring residents, which could potentially lead to injury if the lifts provided inaccurate weight readings. During an observation and interview, the Maintenance Supervisor (MS), Restorative Nursing Assistants (RNA) 1 and 2, and the Director of Nursing (DON) demonstrated the use of mechanical lift 1. The lift was calibrated using a 25-pound weight, and the MS was weighed, showing a discrepancy between the mechanical lift and a standing scale. A similar process was followed for mechanical lift 2, which also showed a different weight for the MS. The MS acknowledged that the lifts were calibrated annually, with the last calibration in January 2024, and stated that discrepancies would be addressed by contacting the manufacturer, although this was not feasible for every resident. The Administrator (ADM) emphasized the importance of accurate weight measurements to ensure the correct sling is used for resident transfers, as using the wrong sling could result in injury. A review of the admission record for a resident with morbid obesity, dementia, and chronic kidney disease highlighted the potential risk of using inaccurate weight measurements. The manufacturer's user manual indicated that proper calibration required specific weights, which were not used during the facility's calibration process, contributing to the inaccuracy of the mechanical lifts.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to the comprehensive care plan for a resident requiring a two-person assist with a mechanical lift, resulting in an incident where the resident slid out of the lift's sling and sustained a head injury. The resident, who was admitted with diagnoses including morbid obesity, dementia, and chronic kidney disease, was assessed as having moderate cognitive impairment and was dependent on staff for self-care activities and mobility. Despite the care plan indicating the need for two-person assistance during transfers, a Certified Nursing Assistant (CNA) attempted to transfer the resident alone, leading to the sling's failure and the resident's fall. Interviews with facility staff, including the CNA involved, a Registered Nurse Supervisor, and the Director of Staff Development, confirmed that the resident was considered a total assist and required two staff members for transfers using the mechanical lift. The facility's policy also mandated that at least two people be present during such transfers. However, the CNA proceeded with the transfer alone, and the sling's hook latch ripped, causing the resident to fall. This incident highlights a breach in following established protocols and care plans, resulting in harm to the resident.
Failure to Document and Secure Resident's Personal Valuables
Penalty
Summary
The facility failed to ensure that a resident's debit and credit cards were properly documented on their Personal Effects Inventory form. The resident was not informed of the risks associated with keeping these cards at her bedside, nor was she offered a secure place to store them. This oversight was identified during a review of the resident's records, which showed that while the cards were listed on an initial inventory form, they were not documented on a subsequent Personal Effects Inventory form. Additionally, there was no evidence in the clinical records that the resident had been educated about the potential risks of keeping her cards unsecured. Interviews conducted with the resident and facility staff revealed that the inventory of the resident's belongings was conducted by two nurses upon her readmission, but no discussion about the risks or safekeeping options for her debit and credit cards took place. The Social Service Director acknowledged the importance of completing an inventory of belongings to prevent loss or misappropriation, and the facility's policy emphasized the need for secure handling of residents' property. However, these procedures were not followed in this instance, leading to the deficiency.
Failure to Monitor and Assess Resident Leads to Tragic Outcome
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with depression and a history of suicidal ideation. The resident exhibited significant changes in behavior, including crying spells, accusations of poisoning, and expressions of fear and anxiety. Despite these clear indicators of a change in condition, the facility staff did not initiate continuous assessment or close monitoring of the resident's behavior, mood, cognition, hallucinations, delusions, or suicidal ideation. The staff also failed to notify the resident's primary care physician of these changes, which was a critical oversight given the resident's mental health history. The resident's care plan, which included monitoring for changes in behavior and mood, was not followed. The Licensed Vocational Nurse (LVN) did not complete a change of condition assessment when the resident exhibited paranoid behavior and verbalized fears of being poisoned. The Social Services Director (SSD) also did not review the resident's history of suicidal ideation or complete necessary assessments, such as the Patient Health Questionnaire (PHQ-9), within the required timeframe. These lapses in care and communication contributed to the resident's deteriorating mental state. Ultimately, the resident was found deceased in the bathroom, having committed suicide. The facility's failure to adhere to its policies and procedures for resident safety, including the lack of a comprehensive assessment and monitoring plan, directly contributed to this tragic outcome. The staff's inaction and failure to communicate significant changes in the resident's condition to the appropriate medical personnel were critical deficiencies that led to the resident's death.
Removal Plan
- The DON provided 1:1 education to LVN 1, CNA 1, Registered Nurse Supervisor, LVNs, and CNAs on the Change of Condition (COC) process, with emphasis on assessment and close monitoring of residents with changes in behavior, mood, cognition, hallucinations, delusions, and suicidal thoughts, disruptive vocalizations, and difficulty sleeping.
- Ensured a COC assessment is completed for residents having a change in behavior, including paranoid behavior, verbalization of hurting self, hallucinations, delusions, disruptive vocalizations, yelling, and difficulty sleeping.
- Staff were educated to monitor, document, and report as necessary any change in resident's behavior, mood, cognition, hallucinations, delusions, and suicidal thoughts, and to notify the physician of the COC.
- Provided education on non-pharmacological interventions for residents with depression, including removing stressors, offering food and beverages, increasing therapeutic activities, psychosocial support, encouraging family involvement, and other interventions to ensure a safe environment.
- Educated staff on informing the physician and responsible party when a resident has a COC in behavior, mood, delusions, hallucinations, and suicidal thoughts, and on recognizing residents who are depressed and have a history of suicidal ideation.
- Provided education on behavior management and suicide prevention.
- The Administrator provided 1:1 in-service education to the Social Services Director (SSD) regarding completion of assessments, including PHQ-9, following the Resident Assessment Instrument (RAI) Manual guidelines.
- The DON/designee conducted an audit of current residents with diagnoses of serious mental illness to determine residents who have had a change in behavior, mood, cognition, hallucinations, delusions, or current/history of suicidal ideations or suicide attempt, ensuring assessment, close monitoring, COC completion, care plan initiation, physician notification, and SSD assessments are completed.
- SSD conducted an audit of current residents with diagnoses of serious mental illness, identified residents with changes in mood, ensured assessment by licensed nurse, COC completion, physician notification, and completed PHQ-9 assessments for all identified residents with depression.
- The DON/Designees conducted interviews of current interviewable residents to identify any potential changes in behavior or mood.
- The DON/Designee provided in-service education to staff on Behavior Management/Suicide Management.
- The DON/Designee initiated in-service education to department heads and staff regarding policies and procedures for Behavior/Psychoactive Medication Management, Change of Condition Notification, Behavior - Threats to Harm Self, and Comprehensive Care Planning.
- The Regional Social Service Consultant provided in-service education to the Social Service Designee on the Policy and Procedure titled Social Service Assessment and Social Service Program, emphasizing the importance of completing required Social Service Assessments, including the PHQ-9 per regulatory guidelines.
- The Administrator and DON will present the results of the Admission/Readmission, and Change in Condition Audits, and Resident Interviews to the Quality Assurance and Performance Improvement Committee for review and recommendations until substantial compliance is achieved.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that licensed nurses notified the physician when a resident with a diagnosis of depression experienced a significant change in condition. The resident, who had a history of depression, cerebral infarction with right-sided hemiplegia, and failure to thrive, exhibited signs of distress, including sobbing and expressing delusions that someone was trying to poison him. Despite these clear indicators of a change in condition, the licensed vocational nurse (LVN) did not notify the resident's physician or initiate a change of condition (COC) assessment. The resident's care plan included monitoring for changes in behavior and mood and reporting these to the physician, but this was not done. The LVN assessed the resident as alert and oriented and believed the resident's behavior was a misunderstanding rather than a change in condition. Consequently, the LVN did not take further action, such as notifying the physician or providing one-on-one monitoring, which could have potentially prevented the resident's subsequent suicide. Interviews with facility staff, including a psychiatric nurse practitioner and a registered nurse supervisor, indicated that the resident's behavior should have prompted immediate notification of the physician and closer monitoring. The facility's policies required prompt notification of the physician and the resident's representative in the event of a significant change in condition, which was not adhered to in this case. This oversight resulted in the tragic outcome of the resident's death by suicide.
Failure to Implement Care Plan Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that licensed nurses implemented the care plan interventions for a resident who was prescribed Lexapro for depression and anxiety. The care plan required monitoring, documenting, and reporting changes in the resident's behavior, mood, and cognition, including any signs of hallucinations, delusions, social isolation, suicidal thoughts, and withdrawal. On a specific date, the resident exhibited crying spells, shaking hands, and expressed fear that someone was trying to poison him, but these symptoms were not adequately addressed or documented by the nursing staff. The resident, who had a history of depression and suicidal ideation, was found deceased in the bathroom with a phone charging cord around his neck. Prior to this incident, the resident had shown signs of distress, including crying and expressing delusional thoughts about being poisoned. Despite these clear indicators of a change in condition, the licensed nurses did not follow the facility's policy to notify the attending physician or implement one-on-one monitoring to ensure the resident's safety. Interviews with staff revealed that there was a lack of communication and documentation regarding the resident's behavioral changes. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) did not perform a change of condition assessment or notify the physician, which could have led to preventive measures being taken. The Director of Nursing acknowledged that the care plan was not followed, and the necessary interventions were not implemented, contributing to the resident's tragic outcome.
Failure to Address Behavioral Health Needs Leads to Resident's Suicide
Penalty
Summary
The facility failed to ensure that staff members, including the Social Service Director, Registered Nurses, Licensed Vocational Nurses, and Certified Nursing Assistants, possessed the necessary competencies to care for residents with mental and psychosocial disorders. This deficiency was highlighted by the case of a resident who was observed sobbing and accusing a CNA of poisoning his water. Despite these signs of distress, the staff did not intervene appropriately, resulting in a lack of care plan interventions to address the resident's symptoms of depression. The resident, who had a history of depression and was on antidepressant medication, did not receive the necessary care and services to address his emotional and psychosocial needs. The resident's condition deteriorated, and he was found to have committed suicide by hanging himself in the bathroom. Interviews with staff revealed that there was a failure to report and assess the resident's change in behavior adequately. The CNA and LVN involved did not notify the resident's physician or implement one-to-one monitoring, despite the resident exhibiting delusional thoughts and anxiety. The LVN admitted to not conducting a Change of Condition (COC) assessment, which could have led to better monitoring and intervention. The Social Service Director also failed to review the resident's previous records and did not complete necessary assessments in a timely manner. The Director of Nursing acknowledged that the staff should have reviewed the resident's past medical history and care plan interventions. The facility's policies and procedures emphasized the importance of staff competency and resident safety, but these were not effectively implemented in this case, leading to the tragic outcome.
Failure to Address Behavioral Health Needs Leads to Resident's Death
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) program failed to identify and address critical resident care issues, particularly concerning the behavioral health care and services for a resident with a history of depression and suicidal thoughts. The resident, who had been admitted with a diagnosis of depression, was not adequately assessed or monitored, and the primary care physician was not notified of significant changes in the resident's behavior. This lack of action resulted in the resident not receiving necessary care and services, ultimately leading to the resident's suicide. Interviews and record reviews revealed that the Social Services Director (SSD) did not review the resident's previous admission documents and failed to complete a timely assessment using the Patient Health Questionnaire (PHQ-9). The SSD admitted to only seeing the resident once and not conducting frequent checks on the resident's behavior and emotional condition. Additionally, the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) failed to conduct a Change of Condition (COC) assessment or notify the resident's physician when the resident exhibited signs of anxiety, fear, and delusions about being poisoned. The facility's QAPI program was found to be lacking in addressing the behavioral and psychosocial needs of residents with depression and changes in mood and behavior. The QAPI Committee Minutes did not reflect any focus on these areas, despite the facility's policy and procedure indicating that the program should monitor and evaluate residents' care comprehensively. The failure to implement appropriate plans of action and evaluate necessary measures contributed to the resident's unmet mental and emotional health needs, culminating in the tragic outcome.
Failure to Conduct Timely Staff Competency Reviews
Penalty
Summary
The facility failed to ensure that competency and skill set reviews were completed for four out of five sampled staff employees according to the facility's policy and procedure. Specifically, the Employee Performance Reviews for Certified Nursing Assistants (CNAs) were either outdated or not conducted at all. CNA1 and CNA2 were last evaluated on March 29, 2022, while CNA3 had no performance review since being hired five months prior. CNA4's last evaluation was dated October 21, 2011, and was unsigned. The Director of Staff Development (DSD) confirmed these findings and acknowledged the importance of annual performance reviews to identify staff strengths and weaknesses, which are crucial for maintaining quality care. Interviews with staff, including CNA4, the RN Supervisor, and the Administrator, highlighted the significance of regular performance evaluations. CNA4 expressed the need for evaluations to improve her skills, while the RN Supervisor and Administrator emphasized that these reviews help identify areas for improvement and guide training efforts. The facility's policy, revised on March 17, 2022, mandates competency assessments upon hire, during the 90-day employment period, annually, or when new procedures are introduced. The lack of adherence to this policy potentially jeopardizes resident care by not ensuring staff competency.
Resident Administered Seroquel Without Proper Diagnosis
Penalty
Summary
The facility failed to ensure that a resident did not receive Seroquel, a psychotropic medication, without a proper diagnosis and indication for its use. The resident, who was admitted and readmitted to the facility with diagnoses including dementia, mania, metabolic encephalopathy, and hypertension, was administered Seroquel despite not having a diagnosis of paranoid schizophrenia. The Minimum Data Set (MDS) for the resident indicated no delusions or hallucinations, and the resident required various levels of assistance with daily activities. During an interview, the Director of Nursing (DON) acknowledged that the resident was incorrectly diagnosed with paranoid schizophrenia at a General Acute Care Hospital and continued on Seroquel upon returning to the facility. The DON admitted that the diagnosis was incorrect and should have been questioned with the resident's physician. The Minimum Data Set Coordinator (MDSC) confirmed that the resident's MDS did not include a schizophrenia diagnosis and noted that paranoid schizophrenia is typically diagnosed earlier in life. The facility's policy indicated that schizophrenia should be diagnosed by a qualified practitioner using evidence-based criteria.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to several medication administration errors. For one resident, a Registered Nurse (RN) incorrectly documented the administration of Methadone on a specific date, although the medication was not given. This error resulted in an extra dose remaining in the inventory, which could have led to withdrawal symptoms for the resident. Additionally, the physician's order for Methadone did not specify that the medication should not be administered on Mondays when the resident visits a methadone clinic, leading to the resident receiving an extra dose on one occasion. Furthermore, the facility did not ensure that Licensed Vocational Nurses (LVNs) documented the administration of Norco in the Medication Administration Record (MAR) for two residents. This lack of documentation created a risk of medication mismanagement, as subsequent nurses would not have accurate records of when the medication was administered. The failure to document these administrations was confirmed through interviews and record reviews with the nursing staff and the Quality Assurance nurse. The facility's policy and procedure for medication administration, which emphasizes the importance of accurate documentation, was not followed. The Director of Nursing (DON) acknowledged the risk of medication errors due to the lack of documentation, which could result in residents being under or over-medicated. The report highlights the need for adherence to established protocols to ensure the safety and well-being of residents.
Medication Administration Errors with Methadone
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Methadone. The resident, who was admitted with diagnoses including osteomyelitis of the vertebra and post-laminectomy syndrome, had a physician's order for Methadone Hydrochloride 55 milligrams once daily for opioid withdrawal. However, on one occasion, the resident did not receive the prescribed dose, as the nurse accidentally charted the administration without actually dispensing the medication. This oversight placed the resident at risk for drug withdrawals. Additionally, the facility did not properly manage the resident's Methadone administration schedule in relation to the resident's visits to a Methadone clinic. The physician's order did not specify that the medication should be withheld on Mondays when the resident attended the clinic and received a dose there. As a result, the resident received an extra dose of Methadone on a Monday, both at the facility and at the clinic, which could have led to adverse drug reactions. Interviews with the nursing staff and a review of the resident's records revealed these deficiencies. The Quality Assurance nurse acknowledged that the physician's order should have specified to hold the medication on Mondays, and the Director of Nursing confirmed the potential risks associated with the missed and double doses. The facility's policy on medication administration emphasized the importance of adhering to prescribed dosages and schedules, which was not followed in this case.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that food items were properly dated, sealed, refrigerated, and discarded before their expiration dates, affecting 91 out of 93 residents. During an observation and interview with the Dietary Manager (DM), it was found that several food items in the dry storage room were not labeled with receiving, opening, or used by dates. These items included lemon juice, sesame oil, Italian dressing, penne pasta, orzo pasta, marshmallows, and soy sauce, some of which were expired or not refrigerated as per manufacturer's recommendations. The DM acknowledged that it was the responsibility of all dietary staff to ensure food items were labeled, stored, and discarded appropriately. Further observations in the kitchen revealed additional issues with food storage. An opened liquid coffee creamer in the refrigerator and hash browns in the freezer were not properly dated. The facility's policies and procedures for food storage, including guidelines for dry goods, refrigerated, and freezer storage, were not followed. These policies outlined specific requirements for labeling, dating, and storing food items to ensure their safety and suitability for consumption.
Deficiency in Dementia Training for Facility Staff
Penalty
Summary
The facility failed to ensure that all staff received the required five hours of annual dementia training, which is crucial for providing comprehensive care to residents with dementia. During an interview and record review, the Director of Staff Development (DSD) confirmed that staff were supposed to receive two hours of dementia training upon hire and six hours annually. However, the facility's policy, revised in October 2017, stated that staff should complete two hours of dementia-specific training within the first 40 hours of employment and a minimum of five hours annually, excluding the initial two hours. This discrepancy in training hours was identified during a survey, indicating that the facility did not adhere to its policy, potentially leading to neglect or inadequate care for residents with dementia. The Director of Nursing (DON) emphasized the importance of dementia training to prevent nurse burnout and to educate staff on caring for residents at risk of being started on unnecessary medications. The lack of adherence to the training policy was documented, with attendance at in-service training required to be maintained in each employee's personal file. This failure to provide adequate training had the potential to result in residents with dementia being neglected and not receiving resident-centered, comprehensive care.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The nursing staff at the facility failed to provide reasonable accommodation to meet the needs of five residents, as observed during a survey. Resident 442, who has paraplegia and requires significant assistance for daily activities, was unable to adjust her position comfortably due to the side rails being placed too high. Despite her requests for adjustment, the maintenance supervisor forgot to document and follow up on her complaint, which was acknowledged by the Director of Nursing as a failure to accommodate the resident's needs. Additionally, the facility failed to ensure that the call lights were within reach for Residents 442, 19, 32, and 192. Resident 19, who has dementia and requires dependent assistance, had a call light wrapped around the side rail, making it difficult to reach. Similarly, Resident 441, who has a history of falls and requires assistance for daily activities, could not reach her call light, leading her to feel neglected. Observations also revealed that Residents 32 and 192, both with severe cognitive impairments, had call lights placed out of reach, increasing their risk of falls and injury. Interviews with staff, including CNAs and the Director of Nursing, confirmed that call lights should be within reach to prevent falls and ensure timely assistance. The facility's policy on communication and call systems mandates that call cords be placed within residents' reach, but this was not adhered to, resulting in a deficiency in accommodating the residents' needs and preferences.
Failure to Implement Care Plans for Smoking and Pain Management
Penalty
Summary
The facility failed to implement care plan interventions for two residents, leading to potential delays in necessary care and services. Resident 293, who was admitted with conditions including osteomyelitis, type 2 diabetes, and peripheral vascular disease, was observed smoking in a non-designated area without supervision, contrary to the care plan that required supervision during smoking. Despite being informed of the designated smoking area and the facility's policy of storing smoking paraphernalia, Resident 293 chose to smoke independently and keep his smoking items, which was not in line with the facility's standard practice. Resident 193, admitted with diagnoses such as type 2 diabetes, dysphagia, and epilepsy, did not receive timely pain management. Although there were physician orders for various pain medications, the baseline care plan addressing pain and discomfort was not developed until several days after admission. This delay resulted in Resident 193 not receiving pain medication until a few days post-admission, despite complaints of severe pain. The facility's policy required a baseline care plan to be generated within 48 hours of admission to prevent delays in care. Interviews with facility staff, including the Activities Director and MDS Coordinator, confirmed the lapses in implementing the care plans for both residents. The facility's policies on care planning and smoking safety were not adhered to, leading to the deficiencies noted in the report. The failure to supervise Resident 293 during smoking and the delay in developing a care plan for Resident 193's pain management were significant oversights in the facility's care provision.
Deficient Pain Management for Two Residents
Penalty
Summary
The facility failed to ensure effective pain management for two residents, Resident 441 and Resident 193. For Resident 441, the facility did not obtain a physician order for pain medication to address moderate pain levels. Resident 441, who had a history of a left hip fracture and surgery, reported experiencing pain at a level of six out of ten, which affected her sleep. Despite this, the facility only had orders for mild and severe pain medications, and the moderate pain was not adequately addressed. The Registered Nurse Supervisor acknowledged that the Licensed Vocational Nurse should have documented the refusal of the severe pain medication and the actual pain level experienced by the resident. In the case of Resident 193, the facility failed to administer pain medication in a timely manner as ordered by the physician. Resident 193, who had diagnoses including type 2 diabetes, dysphagia, and epilepsy, was prescribed morphine sulfate for severe pain. However, the medication was not administered until several hours after the resident complained of pain, as the medication had not yet arrived and the emergency kit was not utilized. This delay resulted in the resident experiencing unnecessary pain. The facility's policy and procedure on pain management required that pain assessments be completed upon admission and when there is a new onset or change in pain. It also required that pain medication be administered as ordered and documented on the Medication Administration Record. The Director of Nursing emphasized the importance of administering pain medication promptly to prevent worsening pain. However, these procedures were not followed, leading to deficiencies in pain management for both residents.
Failure to Administer Antibiotics as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received treatment in accordance with the physician's order, specifically regarding the administration of antibiotics for osteomyelitis. The resident was admitted with an IV line and had orders for Cefepime and Daptomycin to be administered at specific times. However, the Daptomycin was not available upon admission, and there were delays in its administration due to pharmacy delivery issues. The resident's IV line also came out, necessitating a PICC line, which further delayed the administration of the medication. The report highlights several instances where the scheduled administration times for Cefepime were not adhered to, with medications being given several hours later than prescribed. The facility's staff, including RNS 2 and the DON, acknowledged that the antibiotics were not administered at the appropriate times, which could disrupt the therapeutic range of the medication. The facility's policy requires that initial antibiotic doses be given within four hours from the time the physician's order is obtained, but this was not followed. Interviews with the facility's staff, including the DON and a pharmacist, revealed that the delays in medication administration were not documented properly, and there was a lack of communication with the physician regarding missed doses. The facility's policies on medication administration and documentation were not adhered to, contributing to the deficiency. The failure to administer antibiotics on time and document the administration accurately could potentially impact the resident's recovery and increase the risk of infection.
Failure to Change Feeding Tube Components Within 24 Hours
Penalty
Summary
The facility failed to ensure that feeding tube formula, tubing, administration syringe, and water flush bags were changed within 24 hours for a resident with a gastrostomy tube (G-tube). This oversight was identified during an observation where the resident was receiving tube feeding via a pump, and the feeding formula, syringe, tubing, and water flush bag were found to be dated more than 24 hours prior. The facility's policy and procedure require these items to be changed every 24 hours to prevent clogging of the G-tube and foodborne illness. Interviews with staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse Supervisor (RNS), and the Director of Nursing (DON), revealed a lack of adherence to the facility's policy. The LVN was unsure about the specific requirements for changing the feeding system components and had not read the policy and procedure for G-tube care. Both the RNS and DON confirmed that the feeding system components should be changed every 24 hours, as per the facility's policy, to protect residents from potential risks such as foodborne illness and G-tube clogging.
Failure to Monitor Valproic Acid Levels for Resident on Divalproex Sodium
Penalty
Summary
The facility failed to ensure that a physician responded to a consultant pharmacist's recommendation to monitor a resident's valproic acid levels. This recommendation was made on June 4, 2024, concerning the use of divalproex sodium, a medication prescribed to the resident for poor impulse control. Despite the consultant pharmacist's suggestion, there was no documented response from the physician, nor was there any laboratory monitoring of the valproic acid levels conducted for the resident. The resident in question had been admitted with diagnoses including psychosis and had fluctuating capacity to understand and make decisions. The facility's Director of Nursing acknowledged the failure to monitor the valproic acid levels, which could have resulted in the medication being ineffective or toxic. The facility's policy required that recommendations from the consultant pharmacist be acted upon and documented, with the physician either accepting or rejecting the suggestion by the next visit. However, this protocol was not followed, leading to the deficiency.
Failure to Monitor Valproic Acid Levels for Resident on Divalproex Sodium
Penalty
Summary
The facility failed to monitor valproic acid levels for a resident who was prescribed divalproex sodium, a medication used to treat seizures and manage poor impulse control. Despite a recommendation from the consultant pharmacist to monitor these levels, there was no documented response from the physician, and no laboratory tests were ordered or conducted to ensure the medication was at a safe and effective level. This oversight was identified during a review of the resident's clinical records and confirmed in an interview with the Director of Nursing. The resident, who had been admitted with diagnoses including psychosis and fluctuating capacity to understand and make decisions, was prescribed divalproex sodium to manage agitation and aggression. The facility's policy required serum drug levels to be monitored 7-10 days after initiation or dosage change and then every six months, but this was not adhered to. The failure to monitor the valproic acid levels increased the risk of the medication being ineffective or toxic, potentially leading to medical complications.
Expired Medication Not Removed from Cart
Penalty
Summary
The facility failed to discard and replace an expired fluticasone/salmeterol inhaler, which is used to treat breathing problems, for Resident 22. During an observation and interview with an LVN, it was found that the inhaler was opened on 5/4/24 and should have been discarded by 6/4/24 according to the manufacturer's instructions. However, the inhaler remained in the medication cart beyond its expiration date, increasing the risk of the resident receiving ineffective medication. The facility's policy on the storage of medications, dated April 2008, requires that medications and biologicals be stored safely and properly, following the manufacturer's recommendations. Outdated, contaminated, or deteriorated medications are to be immediately removed from stock and disposed of according to procedures. The failure to adhere to these guidelines resulted in the expired inhaler remaining in the medication cart, potentially compromising the health of Resident 22.
Failure to Assess Capacity and Explain Arbitration Agreement
Penalty
Summary
The facility failed to assess the mental capacity of Resident 85 and provide necessary information to the resident and their responsible parties before signing an arbitration agreement. Resident 85, who was diagnosed with conditions including dementia and cerebral vascular disease, was found to lack the capacity to understand and make decisions. Despite this, the arbitration agreement was signed by a family member who later stated they did not remember signing it and did not understand the content, as it was written in English. The family member believed they were signing the admission packet and was not informed about the option to rescind the agreement within 30 days. The Admission Coordinator, responsible for the arbitration process, acknowledged the importance of ensuring that the resident and their representative understand the agreement. However, the facility's policy requires that the arbitration agreement be explained in a manner and language that the resident understands, which was not adhered to in this case. The failure to provide adequate explanation and assess the resident's decision-making capacity led to the deficiency identified in the report.
Inadequate Supervision and Assistance in LTC Facility
Penalty
Summary
The facility failed to adequately supervise Resident 1, who was admitted with diagnoses including diabetes mellitus, osteoporosis, hypertension, and dementia. Despite being ambulatory and having periods of disorientation, Resident 1 was left unsupervised in the dining room, where she was last seen at 3 a.m. on 5/21/2024. The resident was later found approximately 7 miles away from the facility, sitting under a tree in her personal clothes and socks, having left the facility without staff knowledge. Interviews with staff revealed that the alarm system did not alert them to her departure, and there was a lack of consistent supervision, which was necessary given her cognitive impairments and medical conditions. The facility also failed to provide timely assistance to Resident 6, who was admitted with asthma, diabetes mellitus, and morbid obesity. Resident 6, who required a two-person assist for activities of daily living, was left waiting for assistance to use the toilet after activating the call light. Unable to wait any longer, she crawled to the bathroom, risking injury. Interviews with staff indicated that Resident 6 was patient but had to resort to crawling due to the lack of timely assistance, highlighting a failure in the facility's response to call lights and resident needs. The facility's policies on resident safety and communication through the call system were not adhered to, as evidenced by the incidents involving Residents 1 and 6. The policy required staff to perform resident checks every two hours or more frequently as needed, and to promptly respond to call lights. These deficiencies in supervision and timely assistance posed significant risks to the residents' safety and well-being, as acknowledged by the facility's staff and administration.
Failure to Provide Psychological Assessments and Follow-Up
Penalty
Summary
The facility failed to provide necessary psychological assessments and follow-up for two residents, leading to unmet psychosocial needs. Resident 1, who had a history of dementia, left the facility unnoticed and was found by staff approximately 7 miles away, sitting under a tree with minimal clothing and no shoes. Despite being alert, Resident 1 was confused and refused to return to the facility. Interviews with staff revealed that no psychosocial assessment or support was documented for Resident 1, despite the potential trauma of the situation. Resident 6, who was dependent on assistance for daily activities, crawled to the bathroom after waiting for an hour for help that never arrived. This resident, who had conditions including asthma and morbid obesity, expressed feelings of fear and shame during the incident. The Social Services Director confirmed that no psychosocial assessment or follow-up was conducted for Resident 6, despite the resident filing a grievance about the lack of assistance and the undignified experience. The facility's policy required social service assessments to address residents' psychosocial needs, but these were not conducted for the two residents involved. The Social Service Director acknowledged the oversight and the importance of addressing residents' emotional needs. The Administrator also recognized the unpleasant experiences of the residents and the role of the Social Service Director in ensuring that residents' concerns and grievances are addressed.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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