Novato Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Novato, California.
- Location
- 1565 Hill Road, Novato, California 94947
- CMS Provider Number
- 555844
- Inspections on file
- 57
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 48
Citation history
Health deficiencies cited at Novato Healthcare Center during CMS and state inspections, most recent first.
A resident with paralysis, joint contractures, and lower extremity stiffness was discharged from OT with a recommendation for referral to the Restorative Nursing Program (RNP) for passive ROM to all extremities and use of hand splints and a palm protector. The OT documented the need for RNP three times per week and reported giving the referral to the DOR, but no RNP order was obtained, and no RNP services or tasks were documented in the EMR. The DOR and DON described differing expectations about who initiates and confirms RNP orders, and LNs stated that an order should exist for RNP but did not. Review of the facility’s RNP policy showed it assigned Nursing responsibility for the RNP plan of care but did not define the process for converting Rehab referrals into RNP orders or clarify roles between Rehab and Nursing, resulting in the resident not receiving the recommended restorative services.
Two residents experienced physical and emotional abuse from other residents, including being struck with a pillow and hit in the face with a bottle, despite documented behavioral risks and care plans. Staff witnessed the incidents, and both cases resulted in physical harm and emotional distress, with the facility's policies requiring protection from such abuse.
A resident with a history of wandering and falls, who required close supervision and a wandering device, exited the facility unnoticed. Staff failed to consistently monitor and document the resident's wandering device, did not follow required procedures for elopement response, and did not immediately alert leadership or make a facility-wide announcement. The resident was found outside the facility and returned without injury.
A CNA did not immediately report a fall incident involving a resident with Alzheimer's Dementia, leading to incomplete information being given to an LN. As a result, a change of condition assessment was not promptly performed, causing a two-day delay in diagnosing and treating a left arm fracture. Facility policies requiring immediate reporting and assessment after accidents were not followed.
A resident with severe memory impairment and a history of aggressive behaviors struck another resident, causing pain and swelling to the left eyebrow. The incident followed previous documented episodes of hitting, kicking, and scratching by the same resident. Staff were not present at the time of the assault, and the injured resident reported ongoing pain and blurry vision.
The facility did not report an allegation of verbal abuse between two residents to the appropriate authorities within the required two-hour timeframe. Nursing staff and CNAs witnessed the incident, and although it was documented and discussed by the IDT, the written report was not submitted until the following day, contrary to facility policy.
A resident with Type 1 diabetes received a double dose of insulin lispro, along with an additional sliding scale dose, due to a transcription error that left duplicate orders active. Two nurses administered separate scheduled doses within a short interval, and an extra sliding scale dose was also given. This resulted in the resident experiencing a hypoglycemic episode and becoming unresponsive, with staff confirming the error was due to failure to discontinue the previous insulin order.
A resident with heart failure and chronic kidney disease was not assisted in obtaining timely dental care after a local oral surgery clinic determined that full mouth extractions should be performed in a hospital. Despite care plan requirements and multiple contacts with dental providers, there was no documentation of a formal hospital referral, and the facility did not document extenuating circumstances for the delay.
A resident with Type 1 diabetes received a double dose of insulin lispro from two nurses within a short time frame, along with an additional sliding scale dose, resulting in a hypoglycemic episode. Despite facility policy requiring prompt notification, the resident was not informed of the medication error or the cause of her condition change.
A resident with vascular dementia and intact cognitive skills struck another resident with moderately impaired cognition after a dispute involving spilled hot chocolate. The assaulted resident, who also had anxiety and depression, reported distress following the incident. Both residents confirmed the altercation, and the DON noted the need for improved assessment and care planning to prevent such events.
The facility did not report an allegation of abuse between two residents to the Department of Public Health within the required two-hour timeframe. Although staff stated they attempted to fax a report and leave a voicemail, there was no confirmation these were received, and the official report was not submitted until four days after the incident, contrary to facility policy.
A resident with a recent spinal infection and complex medical history did not receive a prescribed IV antibiotic as ordered after admission. Staff were aware of the medication order and pharmacy delay but did not notify the physician about the missed doses, and documentation confirmed the medication was not administered as scheduled.
A resident's MAR was inaccurately documented to show that a prescribed antibiotic dose was not given due to hospitalization, even though the resident was still present in the facility at the time the medication was due. The DON confirmed the error and acknowledged that the entry did not meet facility policy for accurate medical record documentation.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These failures resulted in a deficiency related to resident care.
A working call system was not available in each resident's bathroom and bathing area, as required. This deficiency was observed during the survey and no further resident-specific details were provided.
A licensed nurse failed to document the administration of multiple scheduled medications for four residents in the EMAR during an evening shift, despite administering the medications after accessing the system with assistance from another nurse. Staff interviews confirmed that credential sharing was not allowed and facility policy required timely documentation of all medication administration.
Multiple residents with diabetes and other conditions experienced repeated delays and omissions in scheduled medication administration due to insufficient nursing staff. Both regular and registry nurses struggled to manage medication passes, with residents reporting late doses and feeling unwell as a result. Staff interviews confirmed frequent short staffing, high turnover, and lack of key leadership, leading to inconsistent care and unmet resident needs.
Six residents experienced significant medication errors involving insulin, including late administration, missed doses, and incorrect dosages. Residents with diabetes, some with cognitive impairment or chronic kidney disease, did not receive their medications as ordered, and documentation was often incomplete or inaccurate. Staff interviews confirmed that insulin was frequently given outside prescribed timeframes, and facility policies regarding medication timing and documentation were not consistently followed.
The facility did not ensure that registry nurses received proper orientation or training before independently caring for residents, resulting in repeated delays in medication administration, including insulin, for a resident with diabetes. Staff and residents reported that registry nurses often lacked access to the EMR system at the start of their shifts, leading to late medication passes and inconsistent care, especially during periods of high staff turnover and management vacancies.
Two residents with complex medical and psychological needs did not have their individual preferences and required accommodations documented in their care plans or electronic records. One resident, who is legally blind, did not have her blindness or related needs reflected in her care plan or EMR dashboard, requiring her to repeatedly inform unfamiliar staff. Another resident's preferences regarding medication administration times and avoidance of early morning blood glucose checks were not recorded in his care plan, despite staff awareness. This lack of documentation led to inconsistent communication and unmet personalized care needs.
The facility did not update its abuse reporting policy to reflect current federal and state guidelines, and staff interviews revealed inconsistent and sometimes incorrect understanding of abuse reporting procedures and time frames. This failure could result in delayed or improper reporting of abuse allegations.
Five residents did not have their baseline care plans completed within 48 hours of admission, and there was no documentation that copies were provided to them or their representatives. Required signatures were missing, and the Infection Preventionist confirmed these omissions during review.
The facility did not enforce its smoking policy, resulting in residents smoking without required supervision, not using protective smoking blankets, keeping their own cigarettes despite care plans prohibiting it, and disregarding the established smoking schedule. Staff confirmed these practices were not in line with facility policy and care plans, and that no specific staff were assigned to supervise smoking times.
A resident dependent on staff for ADLs, including bathing, was not provided showers as scheduled according to facility policy. Staff interviews and record reviews confirmed the resident, who had dementia and dysphagia and was enrolled in hospice, did not consistently receive showers three times a week, despite no care plan exceptions.
A resident with dementia and dysphagia, dependent on staff for feeding, experienced a significant unintentional weight loss over one month. Despite facility policy requiring physician notification for such changes, staff did not inform the physician or document the change, and there was no care plan indicating otherwise, even though the resident was on hospice.
A resident was repeatedly pinched by an LPN in a teasing manner, despite asking for the behavior to stop and reporting it to multiple staff members. Another resident also reported similar unwanted pinching. Staff were aware of the LPN's immature conduct but did not intervene, leaving the affected resident feeling disrespected and her dignity violated.
A resident with contractures in both hands was found with unexplained bruising, swelling, and a spiral fracture of the right humerus. The facility did not submit the results of its investigation into the injury of unknown source to the Department within the required five working days, as confirmed by staff interviews and policy review.
A resident with a history of aggression and moderate cognitive impairment struck another resident on the head with a hard plastic coffee cup, causing a laceration that required hospital evaluation. Despite prior similar incidents and staff awareness of the aggressor's behaviors, monitoring was inadequate to prevent the assault, resulting in physical harm.
A resident with quadriplegia and bipolar disorder did not receive timely PT, OT, and ST evaluations as ordered by a physician. Despite the requirement for therapy evaluations to be completed within 24 to 72 hours, documentation showed significant delays, with some evaluations not performed at all and no evidence of physician notification or valid waivers. Staff interviews confirmed the lack of compliance and absence of a rehabilitation services policy.
Two residents experienced a lack of dignity and respect from a staff member. One resident had her cheek pinched roughly without consent, while another resident's preferred name pronunciation was repeatedly ignored by the same staff member. The DON and Administrator acknowledged the issues, highlighting the need for staff to respect resident preferences.
During a power outage, the facility failed to ensure that LNs administered medications to five residents, as there was no documented evidence of medication administration. The residents had various medical conditions, including dementia, hypertension, and schizophrenia. The DON confirmed that the e-MAR system was down, and paper e-MARs were not available. Despite the facility's policy for eMAR Backup, no paper images were provided, and LNs were not trained on administering medications without computer access.
The facility failed to have a contingency plan for medication administration during a power outage, affecting five residents. The generator activated, but paper e-MARs were unavailable, and medication administration was undocumented. Staff were unsure of protocols, and the facility's assessment lacked necessary emergency preparedness details.
A resident with borderline personality disorder and no cognitive impairment was verbally abused by a physician who addressed him inappropriately despite the resident's preference for his legal first name. The incident was confirmed by staff and reported to the Administrator, violating the facility's policy against abuse.
A resident with a history of insomnia and borderline personality disorder was verbally abused by a physician who did not respect the resident's request to be addressed by his legal first name. The incident was reported to the DON and Administrator, but the facility failed to notify the CDPH or conduct an investigation, contrary to its policies.
The facility did not investigate an allegation of verbal abuse between a resident and a physician, as required by its policy and state regulations. The DON and Administrator, who is also the Abuse Coordinator, both confirmed the report of the allegation but failed to conduct an investigation or report it to regulatory agencies. The facility's policy requires immediate action, including ensuring resident safety, interviewing relevant individuals, suspending accused employees, and reporting to CDPH within five days, none of which were followed.
A resident was unsafely discharged from an LTC facility without a glucometer, leading to refusal of insulin administration due to inability to monitor blood sugar levels. Additionally, the resident was discharged to an unlicensed Board and Care home, contrary to facility requirements. The facility's discharge policy lacked guidance on essential medical equipment and licensed facility requirements.
A resident with Type 2 Diabetes Mellitus did not receive his prescribed early-morning insulin on most days for over a year due to a nurse's decision not to administer it. The nurse did not document the omission or inform the DON, and the issue was only identified when the resident reported it. The facility's medical records department failed to detect the error despite being responsible for auditing records.
A resident with a known risk of elopement left the facility undetected due to inadequate implementation of preventative measures. Despite wearing a wander guard and being identified as high risk, the facility failed to consistently document and conduct required checks. Staff unfamiliar with the resident's history were not adequately informed, leading to the resident's elopement and subsequent involvement with the police.
Failure to Initiate Restorative Nursing Program After Therapy Referral
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate restorative nursing services to maintain or improve range of motion (ROM) for a resident who had significant mobility impairments. The resident was admitted with paralysis from the neck down, contractures of the left hand, and stiffness of the left hip, both knees, and both ankles. An Occupational Therapy (OT) discharge summary documented that the resident should be referred to the Restorative Nursing Program (RNP) for passive ROM to both arms and legs three times per week, and for application and removal of a right-hand splint and a left-hand palm protector by a restorative nursing assistant. Review of the resident’s medical record showed no documentation of any RNP activities, and the Medical Records Assistant confirmed there was no order for the recommended RNP or evidence that RNP services had been initiated. Interviews with facility staff confirmed that the RNP referral and order process was not completed. The Director of Rehabilitation acknowledged that the RNP referral/order for the resident was not completed and described a new process in which she would initiate the RNP order and the Director of Nursing (DON) would confirm and obtain the physician’s order. The DON stated she expected the Rehabilitation Department to write the RNP order, and Nursing to confirm the order, create the plan of care, and add RNP tasks into the electronic medical record. Licensed nurses interviewed stated that there should be an order in place if a resident is to be on RNP, but one was not present. Review of the facility’s Restorative Nursing Program policy showed that it assigned responsibility to Nursing for initiating and updating the RNP plan of care but did not specify how an RNP order is generated from a Rehabilitation referral or clearly define the roles of Rehabilitation and Nursing in initiating RNP services, contributing to the failure to implement the ordered restorative care for this resident.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical Harm
Penalty
Summary
The facility failed to protect two residents from physical and emotional abuse by other residents. In the first incident, a resident with severe cognitive impairment and a history of aggressive behavior struck another resident, who was wheelchair-bound and totally dependent on staff, with a pillow multiple times. This occurred after the aggressor believed the other resident was interfering with his belongings. Staff, including a licensed nurse and a CNA, witnessed the incident and confirmed that the resident being struck attempted to protect himself. The administrator substantiated the occurrence as resident-to-resident abuse. In the second incident, a resident with no cognitive impairment but a history of behavioral issues and fabricating stories engaged in a physical altercation with her roommate, who was also physically dependent due to medical conditions. The altercation began after a dispute over personal items and the use of a television. During the incident, a full bottle of nutritional supplement was thrown, resulting in a bruise to the dependent resident's lower lip. Both residents provided conflicting accounts, but staff observations and interviews indicated a pattern of negative interactions and previous behavioral concerns. The administrator substantiated this event as resident-to-resident abuse as well. The facility's own policies define abuse as the willful infliction of injury and require the protection of residents from all forms of abuse and neglect. Despite documented behavioral risks and care plans addressing these issues, the facility did not prevent these incidents, resulting in physical harm and emotional distress to the affected residents. The findings were based on interviews, record reviews, and direct observations by staff and surveyors.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A resident with a history of aphasia, muscle weakness, unsteadiness, falls, and prior elopement was admitted to the facility and assessed as being at risk for wandering and elopement. The resident's care plan included interventions such as engaging the resident in purposeful activity, placing a wandering device and checking its presence every shift, monitoring the resident's whereabouts every 15 minutes, and identifying de-escalation behaviors. However, documentation revealed that staff did not consistently monitor or document the presence and functionality of the resident's wandering device as required. On the day of the incident, the resident was observed by the receptionist walking out the front doors, which triggered an alarm. The receptionist turned off the alarm, checked on the resident, and saw the resident walking toward a lounge area. When the resident's CNA arrived, the receptionist returned to her duties. The CNA attempted to persuade the resident to return inside, but the resident refused. The CNA then informed the nurse and resumed his work. Subsequently, the nurse and another staff member searched for the resident, who was eventually found walking down the street approximately 0.8 miles from the facility. The resident was returned to the facility without injury. Interviews and record reviews indicated that staff were unaware the resident had eloped until after the fact, and the required facility-wide announcement and immediate notification of the DON or Administrator were not made. The facility's policy required staff to accompany or follow a resident who exits the facility and to alert other staff and organize a search if a resident is missing. These procedures were not followed, and documentation of monitoring the wandering device was lacking.
Failure to Report Fall Results in Delayed Fracture Diagnosis and Treatment
Penalty
Summary
Certified Nursing Assistant 1 (CNA 1) failed to immediately report a fall incident involving a resident with Alzheimer's Dementia, who had moderately impaired decision-making abilities and memory problems. During an episode in the shower room, the resident began to fall, grabbed a metal bar, and lowered himself to the floor, resulting in yelling, kicking, and swinging his arms. CNA 1 and another staff member observed a skin tear and scratch on the resident's left arm after the incident and informed the Licensed Nurse (LN 1) only of the injuries, not the fall itself. LN 1, believing the wounds to be superficial and unaware of the fall, did not conduct a change of condition assessment at that time, as required by facility policy. This lack of immediate and complete communication led to a two-day delay in diagnosing a left arm fracture, as the resident continued to display pain and swelling before an X-ray was ordered and the fracture was identified. The facility's policies required prompt reporting of incidents and changes in condition, as well as immediate assessment and notification of the physician and family in the event of an accident. The failure to follow these protocols resulted in a delay in appropriate treatment and pain management for the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with fully intact cognition and a history of pressure ulcers and heart failure was struck in the face by another resident diagnosed with Alzheimer's disease and severe memory impairment. The incident occurred after the resident with Alzheimer's complained about television noise, prompting the first resident to turn off the TV. When staff left the room, the resident with Alzheimer's returned, grabbed the other resident's arm, and punched him in the left eye area. The injured resident reported pain and blurry vision, and a licensed nurse documented mild redness and swelling to the left eyebrow. Prior to this incident, the resident with Alzheimer's had documented behavioral issues, including hitting, kicking, and scratching others on multiple occasions. The facility's policy defined physical abuse as hitting and required identification and intervention in situations where abuse is more likely to occur. Despite these documented behaviors, the facility failed to prevent the assault, resulting in injury to the resident.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse between two residents within the required two-hour timeframe. Documentation showed that a verbal altercation occurred between the residents, and the incident was witnessed by nursing staff and certified nurse assistants. The event was documented in the facility's SBAR Communication Forms and discussed by the Interdisciplinary Team the following day. However, the written report of suspected dependent adult/elder abuse was not submitted to the California Department of Public Health until the day after the incident occurred. Interviews with the Administrator, DON, and ADON confirmed that the report was not sent within the mandated timeframe, as required by the facility's Abuse Prevention and Management policy. The policy specifies that all allegations of abuse must be reported to CDPH Licensing and Certification within two hours. The delay in reporting was acknowledged by facility leadership during interviews.
Double Insulin Dose Leads to Hypoglycemic Episode
Penalty
Summary
A significant medication error occurred when a resident with Type 1 diabetes received a double dose of insulin lispro, along with an additional sliding scale dose, resulting in a total of 27 units of fast-acting insulin administered within a short period. The error was caused by a transcription mistake during the entry of new insulin orders into the computer system, where the previous insulin order was not discontinued. As a result, two licensed nurses administered separate doses of 12 units each, and one nurse also gave an additional 3 units based on a sliding scale order. This led to the resident receiving two scheduled doses only 1 hour and 24 minutes apart, in addition to the sliding scale dose. Following the administration of these insulin doses, the resident experienced a hypoglycemic episode, becoming unresponsive with a blood sugar reading of 43 mg/dl, which was significantly lower than her average blood glucose level. Staff interviews confirmed that the resident was not acting normally and was found to be shaking and unresponsive. The facility's documentation and interviews with the Director of Nursing and other staff acknowledged the medication error, attributing it to a failure to discontinue the prior insulin order, resulting in duplicate administration.
Failure to Arrange Timely Hospital Referral for Dental Extractions
Penalty
Summary
The facility failed to assist a resident in obtaining timely dental care after receiving a letter from a local oral surgery clinic indicating that the resident required referral to a hospital for full mouth extractions. The resident, who had diagnoses including heart failure and chronic kidney disease, was identified as having oral/dental problems related to poor oral hygiene and likely cavities. The care plan specified that licensed nurses or a social worker were responsible for coordinating dental care and transportation as needed. Despite a referral to a local oral surgery clinic and subsequent consultation, the clinic determined that the procedure should be performed in a hospital setting. However, there was no documentation that a formal referral to the hospital was ever made. Record reviews and interviews revealed that the social services staff contacted Denti-Cal and learned that both Denti-Cal and the local oral surgery clinic, as well as the hospital, declined services. The social services director stated that it became the nurse's responsibility to find a location for the procedure, but no progress note or documentation was found to confirm that a hospital referral was completed. The administrator also confirmed the absence of documentation for a formal hospital referral. The facility's policy required social services to arrange necessary dental appointments and document any extenuating circumstances for delays, but this was not done in this case.
Failure to Notify Resident of Significant Medication Error
Penalty
Summary
The facility failed to notify a resident of a significant medication error involving the administration of a double dose of insulin lispro, which resulted in a hypoglycemic episode. The resident, who has Type 1 diabetes and is her own healthcare decision maker, was scheduled to receive 12 units of insulin lispro at two separate times in the morning. However, two licensed nurses administered the doses only 1 hour and 24 minutes apart, and an additional sliding scale dose was also given, totaling 27 units of fast-acting insulin. This led to the resident experiencing a dangerously low blood sugar level of 43 mg/dl, as documented in the medical record and confirmed by staff interviews. Despite the occurrence of this medication error and the resulting change in the resident's condition, the facility did not inform the resident about the error. Interviews revealed that the resident was not told about the double dosing incident and expressed a desire to have been notified. The facility's own policies require prompt notification of residents and their representatives regarding significant changes in condition or medication errors, but this was not followed in this case. Staff interviews further confirmed that the resident was not made aware of the medication error at the time it occurred.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident physical abuse when one resident struck another on the back of the head. Resident 1, who had diagnoses including end stage renal disease and vascular dementia but was assessed as having intact cognitive skills for daily decision making, hit Resident 2 after Resident 2 spilled hot chocolate on her. Resident 2, who had peripheral vascular disease, dementia with moderately impaired cognitive skills, anxiety disorder, and depression, reported feeling distressed as a result of the altercation. Resident 1 admitted to hitting Resident 2 and stated it was in response to being called names. The incident was reported by Resident 2 to staff, and both residents confirmed the details during interviews. The Director of Nursing acknowledged recent changes in facility leadership and management, and emphasized the importance of improved resident assessment and care planning to prevent such altercations. A review of the facility's abuse prevention policy indicated that the facility is responsible for identifying, correcting, and intervening in situations where abuse is more likely to occur.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving two residents was reported to the Department of Public Health within the required two-hour timeframe. Documentation shows that a verbal altercation occurred between the two residents, with one making verbal threats toward the other. Although staff members stated they attempted to report the incident by faxing a SOC 341 form and leaving a voicemail, there was no confirmation or evidence that these reports were successfully received by the Department. The written investigation summary and five-day follow-up report were not received by the Department until four days after the incident. Interviews with the administrator and licensed nurses confirmed that facility policy required reporting allegations of abuse to the Department within two hours. However, there was no fax confirmation or voicemail log to verify that the initial report was made as required. The administrator acknowledged that, even if a phone call had been made at the time stated by staff, it would not have met the two-hour reporting requirement. The facility's policy specifically mandated that a written SOC 341 report be sent to the Department within two hours of the incident.
Failure to Administer Prescribed Antibiotic and Notify Physician
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received a prescribed antibiotic, Ceflozane Sulfate Tazobactram Sodium (CSTS), as ordered by the physician following admission from the hospital. The resident, who had a complicated medical history including a recent spinal infection and abscess treated for lumbosacral-spine-osteomyelitis, was admitted with orders for CSTS to be administered intravenously every eight hours until a specified date. Despite these orders, the medication was not acquired or administered as scheduled, with the medication administration record showing missed doses on the day of admission and the following morning and afternoon. Interviews and record reviews confirmed that staff were aware of the medication order and the delay in pharmacy delivery, but there was no documentation that the physician was notified about the inability to administer the antibiotic as prescribed. The Director of Nursing confirmed that it was expected for the physician to be notified in such situations, and the facility's policy required medications to be administered as ordered to ensure compliance with dosing guidelines. The lack of timely acquisition and administration of the antibiotic, as well as the failure to notify the physician, led to the identified deficiency.
Inaccurate MAR Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for one resident when the Medication Administration Record (MAR) incorrectly indicated that a prescribed dose of Ceflozane Sulfate Tazobactram Sodium (CSTS) was not administered because the resident was hospitalized. A review of the resident's transfer form showed that the resident was not transferred to the hospital until 7:15 p.m., but the MAR entry at 4:00 p.m. on the same day stated the medication was withheld due to hospitalization. The Director of Nursing (DON) confirmed that the resident was still present in the facility at the time the medication should have been administered and that the MAR entry was inaccurate. Facility policy titled 'Completion and Correction' requires that all entries in the medical record be complete, legible, and accurate. The DON acknowledged that the MAR entry did not meet these standards, as it did not accurately reflect the resident's status or the administration of the prescribed medication. This resulted in an inaccurate medical record for the resident.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Nonfunctional Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance while in these areas, was not available or functional at the time of the survey. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Document Medication Administration in EMAR
Penalty
Summary
The facility failed to ensure accurate and complete medical records for four residents when medication administration during the evening shift was missing from their Electronic Medication Administration Record (EMAR). Specifically, a licensed nurse did not document the administration of multiple scheduled medications, including anticonvulsants, cholesterol-lowering agents, laxatives, pain medications, antianxiety medications, antidepressants, sleep aids, and muscle relaxants for residents with conditions such as seizure disorder, hyperlipidemia, constipation, diabetes, anxiety, depression, neuropathy, and pain. The absence of documentation was identified during a review of the EMARs, which showed that the nurse did not sign for the administration of these medications on the specified date. Interviews with staff revealed that the nurse responsible for medication administration experienced issues accessing the EMAR due to a password problem, but was still able to view the medication list and administer medications with assistance from another nurse. However, the nurse did not document the administration in the EMAR at the time. Additional staff interviews indicated that sharing credentials to access the EMAR was not permitted, and facility policy required licensed nurses to chart each medication administered, including the time and their initials, on the MAR.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed and Missed Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of multiple residents, resulting in the late or missed administration of scheduled medications, particularly insulin for residents with diabetes. Medication Administration Records (MARs) for several residents showed repeated instances where insulin and other medications were administered late or not at all over the course of two months. For example, one resident with diabetes and moderate cognitive impairment had insulin doses administered late or missed on numerous occasions, while another resident with diabetes and no cognitive impairment experienced similar delays and omissions in insulin administration. Interviews with residents and staff confirmed the ongoing issue of short staffing, with both regular and registry (temporary) nurses struggling to manage medication administration and resident care. Residents reported receiving medications late, sometimes after meals instead of before as prescribed, and described feeling unwell as a result. Staff interviews revealed that the facility was often operating with only one nurse per station, and that the absence of key leadership positions such as the Director of Nursing and Director of Staff Development exacerbated the problem. Staff also noted that registry nurses were frequently unfamiliar with residents' routines, leading to inconsistent care and further delays. Facility documentation and staff statements indicated that the facility was aware of the need to match staffing levels and competencies to resident needs, including those with complex conditions such as diabetes. However, the ongoing reliance on registry staff, frequent staff turnover, and lack of adequate supervision resulted in the facility's inability to consistently administer medications as scheduled. This failure decreased the facility's potential to safely meet residents' needs and promote their physical well-being, as evidenced by the direct impact on residents' medication schedules and reported well-being.
Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that six out of seven sampled residents were free from significant medication errors, specifically related to the administration of insulin and other diabetes medications. Multiple residents with diabetes mellitus, some with additional conditions such as chronic kidney disease or cognitive impairment, did not receive their prescribed insulin regimens as ordered by their physicians. The errors included late administration, omission of doses, and administration of incorrect dosages. For example, one resident received insulin glargine when it should have been held due to a low blood glucose level, and there was no documentation that the physician was notified. In several instances, the medication administration records (MARs) were incomplete or lacked explanations for missed or late doses, and progress notes did not document reasons for deviations or physician notifications. Residents reported receiving their insulin and other medications late, sometimes after meals when they were ordered to be given before or with meals. Some residents expressed feeling unwell as a result, describing symptoms such as feeling "crappy," tired, dizzy, or sick. Staff interviews confirmed that insulin was often administered outside the prescribed timeframes, and that documentation practices were inconsistent, with some nurses recording administration times that did not reflect when the medication was actually given. The Assistant Director of Nursing acknowledged that medication auditing had only recently begun and that prior auditing practices were unclear. The facility's policies required medications to be administered as prescribed, with specific timing for medications ordered with meals, and for documentation to occur at the time of administration. However, these policies were not consistently followed. Staff interviews further confirmed that late or missed insulin administration could result in significant health risks for residents, and that the practice of documenting medications at times other than when they were actually given could lead to medication errors. The facility's failure to administer medications as ordered and to document appropriately resulted in significant medication errors for multiple residents.
Deficient Training and Orientation for Registry Nursing Staff
Penalty
Summary
The facility failed to ensure that registry staff, who are nurses working on a contracted or as-needed basis, were effectively trained prior to independently providing care to residents. Multiple interviews and record reviews revealed that registry staff often did not receive orientation or training specific to the facility or their assigned residents. One nurse confirmed it was her first day at the facility and she had not been oriented or trained, only instructed to read and sign documents before starting her shift. Additionally, registry staff frequently lacked timely access to the facility's electronic medical record (EMR) system, resulting in delays in medication administration. A resident with diabetes and moderate bilateral non-proliferative diabetic retinopathy reported not receiving medications, including insulin, on time, particularly when registry staff were assigned. Medication administration records showed repeated late administration of insulin over several weeks. The resident described feeling unwell due to these delays and noted that care was inconsistent and slower when registry staff were present, especially on weekends and at night. Other staff interviews corroborated that registry nurses often did not have EMR access at the start of their shifts, leading to further delays in resident care. The facility had experienced significant staff turnover, including the absence of a Director of Nursing and a Director of Staff Development, which contributed to increased reliance on registry staff. The process for providing EMR access to registry staff was inefficient, particularly when staff were scheduled at the last minute. The facility's own assessment tool indicated the need to ensure all direct care staff, including contracted staff, have documented education, training, and competencies, but this was not consistently implemented. Residents and staff expressed concerns about the lack of consistent care and the negative impact on resident well-being.
Failure to Develop and Update Person-Centered Care Plans Reflecting Resident Preferences
Penalty
Summary
The facility failed to develop and update person-centered care plans for two residents, resulting in unmet needs and preferences. One resident, admitted with diabetes mellitus and legal blindness, had care plans that did not include specific interventions or accommodations for her blindness, such as explaining the location of personal belongings or her lunch tray. Despite being able to communicate her needs, there was no documentation of her blindness on her electronic medical record dashboard, and no posted communication in her room to alert staff. The resident reported having to remind staff of her blindness, especially when registry staff unfamiliar with her routine were assigned to her care. Multiple staff interviews confirmed a lack of consistent communication and orientation for temporary staff, which contributed to the oversight of the resident's needs. Another resident, admitted with diabetes mellitus, major depressive disorder, anxiety disorder, and personality disorder, expressed a preference not to be woken early for blood glucose checks and had specific times he preferred for medication administration. However, these preferences were not documented in his care plan or progress notes. Staff acknowledged the resident's preferences and noted that he would post notes on his door when he did not want to be disturbed, but there was no formal record of these preferences in his care documentation. The facility's policy required that any accommodations or adaptive devices provided to assist residents with communication needs be reflected in the resident's plan of care and updated as appropriate. However, the care plans for both residents lacked documentation of their individual needs and preferences, reducing the facility's ability to provide consistently communicated, personalized care.
Failure to Update and Implement Current Abuse Reporting Policies
Penalty
Summary
The facility failed to establish and implement an appropriate abuse policy and procedure, as evidenced by an outdated policy titled 'Reporting Abuse' that did not reflect current reporting guidelines. The policy, last revised in 2014, contained instructions that were inconsistent with the requirements outlined in All Facilities Letter 21-26, which mandates specific time frames and reporting entities for incidents involving abuse, neglect, exploitation, or mistreatment. The policy did not clearly align with the updated federal and state requirements for reporting abuse, particularly regarding the time frames and the parties to whom reports must be made. Interviews with staff revealed a lack of understanding and inconsistent knowledge regarding the correct procedures and time frames for reporting abuse allegations. Unlicensed and licensed staff, as well as the Infection Preventionist, provided varying and sometimes incorrect information about whom to notify and when, with some staff stating reports should only be made to certain agencies or within incorrect time frames. This demonstrated that staff were not adequately trained or informed about the current abuse reporting requirements, which could result in delayed or improper reporting of abuse allegations.
Failure to Complete and Distribute Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete baseline care plans (BCPs) within 48 hours of admission for five sampled residents. Record reviews showed that the BCPs for these residents were not finalized within the required timeframe, and the signature sections for both the residents and their representatives were left blank. Additionally, there was no documentation indicating that copies of the BCPs had been provided to the residents or their representatives as required by facility policy. During an interview and concurrent record review, the Infection Preventionist confirmed that the BCPs for the five residents were not completed within 48 hours of admission and that no evidence existed showing that copies had been distributed to the appropriate parties. The facility's policy, revised in November 2018, specifies that a baseline care plan must be completed within 48 hours of admission and a summary provided to the resident and/or their representative.
Failure to Enforce Smoking Policy and Safety Measures
Penalty
Summary
The facility failed to implement and enforce its smoking policy in a safe and consistent manner for all sampled residents who smoke. Observations revealed that one resident, who had no cognitive impairment but suffered from nicotine dependence, lack of coordination, and muscle weakness, was not provided with or wearing a smoking apron/blanket while smoking. The smoking blanket and fire extinguisher were kept in a locked glass case, and the resident did not know how to access them. Staff confirmed that residents were not being offered the protective blanket, despite the resident's care plan requiring its use. Another resident with moderately impaired cognition and a history of tremors and schizophrenia was observed smoking without staff supervision, contrary to the care plan that required supervision. Multiple staff interviews confirmed that residents often smoked without staff present, and there was no designated staff or department responsible for supervising residents during smoking times. Staff acknowledged that the facility's smoking policy was not being strictly enforced, and that supervision was important for resident safety. Additionally, a resident with moderately impaired cognition and COPD was found to be keeping his own cigarettes, despite his care plan and smoking assessment not permitting this. Staff and the infection preventionist confirmed that this practice was a safety risk and not in accordance with the resident's care plan. Furthermore, several residents reported and were observed smoking outside of the facility's established smoking schedule, with staff confirming that the schedule was not being enforced and residents smoked whenever they wanted. The facility's policy required the use of fire-retardant blankets, supervision, and adherence to a smoking schedule, but these measures were not operationalized as required.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A resident with dementia and dysphagia, who was dependent on staff for activities of daily living (ADLs) including bathing and personal hygiene, was not provided showers as scheduled. Facility policy required showers three times a week, and the resident's care plan did not indicate any exception to this schedule. Observations revealed the resident's hair appeared oily and greasy, and interviews with staff confirmed the expectation for regular showers, even for residents enrolled in hospice care. Record reviews showed inconsistencies in documentation, with point of care records indicating only one shower provided over a month, while weekly skin evaluation forms listed several shower dates. Staff interviews and policy review confirmed that showers were to be provided unless contraindicated, and the resident was still expected to receive them. The failure to provide scheduled showers was acknowledged by both the licensed nurse and the infection preventionist.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for one resident who experienced unintentional weight loss. The resident, who had diagnoses including dementia and dysphagia, was dependent on staff for feeding assistance and was not on a physician-prescribed weight loss regimen. Documentation showed the resident lost 5.2 pounds, or 5.18% of body weight, over a one-month period. Despite this significant weight loss, there was no evidence in the medical record that the physician had been notified, as required by facility policy and standard practice. Interviews with licensed nursing staff and the infection preventionist confirmed that a weight loss of 5 pounds in a month, especially for a resident weighing under 100 pounds, constitutes a significant change of condition that should be reported to the physician. The staff acknowledged that this notification did not occur, and there was no care plan indicating that weight monitoring or reporting should be discontinued, even though the resident was on hospice services. The facility's policy also required physician notification for such weight variances, but this was not followed in this case.
Failure to Protect Resident Dignity Due to Inappropriate Staff Behavior
Penalty
Summary
A deficiency occurred when a licensed nurse (LN C) repeatedly pinched a resident (Resident 2) in a teasing manner, despite the resident's clear and repeated requests for the behavior to stop. Resident 2 reported that the pinching was painful, disrespectful, and violated her dignity. She distinguished between necessary pinching during injections and the inappropriate, playful pinching by LN C, which occurred even when not administering care. Resident 2 stated she informed multiple staff members about the unwanted behavior, but her concerns were dismissed or minimized, with staff suggesting LN C was just being playful or not believing her reports. This lack of response from staff left Resident 2 feeling hurt, frustrated, and disrespected. Another resident (Resident 4) also reported being pinched by LN C, specifically on the cheeks, and indicated that she had communicated her discomfort to LN C. Staff interviews confirmed awareness of LN C's immature and playful behavior, including the pinching of residents. The Director of Staff Development acknowledged prior in-servicing of LN C for issues related to conduct and professionalism and was not surprised by the recurrence of such behavior. Facility policy reviewed indicated that patients have the right to be treated with consideration, respect, and full recognition of dignity and individuality, which was not upheld in this instance.
Failure to Timely Report Investigation Results for Injury of Unknown Source
Penalty
Summary
The facility failed to report the results of an investigation into an injury of unknown source for one resident within five working days, as required. The resident, who had a history of contractures in both hands, was found with bruising, purple skin discoloration, swelling, and limited mobility in the right arm. The resident was unable to explain the cause of the injury and was observed to be grimacing and crying. The resident was subsequently sent to the emergency room, where a closed displaced spiral fracture of the right humerus was diagnosed. Interviews with facility staff, including the Director of Staff Development, Infection Preventionist, and Assistant Director of Nursing, confirmed that the results of the investigation into the injury should have been submitted to the Department within five working days. However, the facility was unable to provide evidence that this report was made within the required timeframe. Review of the facility's policy also indicated that such reporting is required within five working days of the incident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with major depressive disorder and dementia was physically abused by another resident who had a documented history of aggressive behaviors, including previous incidents of hitting other residents and staff. The aggressor, who also had dementia, depression, and schizophrenia, had a BIMS score indicating moderate cognitive impairment and was known to display both physical and verbal behavioral symptoms toward others. Despite these known risks and previous similar incidents, the resident was able to strike another resident on the head with a hard plastic coffee cup, causing the cup to shatter and resulting in a laceration that required hospital evaluation and treatment. Multiple staff members, including CNAs and a nurse, witnessed the incident and confirmed that the attack was unprovoked and occurred while both residents were seated near the nurse's station. Staff reported that the aggressor had previously broken a coffee cup on another resident's head, and a CNA was assigned to monitor the resident due to these prior behaviors. However, the monitoring was insufficient to prevent the incident, and the aggressor was able to inflict harm before staff could intervene. The facility's own policy prohibits any form of resident abuse and requires systems for prevention, yet the repeated nature of the aggressor's behavior and the failure to prevent this latest incident demonstrate a breakdown in protective measures. The injured resident sustained a head wound with moderate bleeding and was sent to the emergency department for further evaluation, while the aggressor continued to display aggressive behavior even after the incident.
Failure to Provide Timely Rehabilitative Therapy Evaluations
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for a resident with quadriplegia and bipolar disorder. Despite a physician's order dated 11/29/23 for evaluations in physical therapy (PT), occupational therapy (OT), and speech therapy (ST), these evaluations were not completed within the required 24 to 72 hours. The resident reported that the facility refused to evaluate him for these therapies for several months, which was confirmed by the absence of documentation for timely PT, OT, and ST evaluations. The only OT evaluations on file were conducted months after the physician's order, and there was no documentation of an ST evaluation or a waiver to justify its absence. The facility was also unable to provide evidence that the physician was notified about the delay or reasons for not completing the evaluations as ordered. Interviews with facility staff revealed that the expectation was for therapy evaluations to be completed within 24 to 72 hours of a physician's order. The Director of Nursing and Director of Rehabilitation both acknowledged the lack of documentation and the absence of a facility policy on rehabilitation services. Additionally, a witness reported that a physical therapist dismissed the physician's order, stating it was unnecessary and that the resident would not benefit from therapy. This lack of action resulted in the resident not receiving the ordered rehabilitative services for an extended period.
Failure to Respect Resident Dignity and Preferences
Penalty
Summary
The facility failed to maintain the dignity of two residents, Resident 3 and Resident 6, as evidenced by inappropriate actions by Licensed Staff A. Resident 3 reported that Licensed Staff A pinched her cheek roughly without her consent, which made her feel angry and disrespected. Resident 3, who has a background in dental hygiene, expressed that she did not want Licensed Staff A to care for her anymore due to his inappropriate behavior. The Director of Nursing (DON) confirmed that Licensed Staff A was disciplined for this action. Resident 6 experienced a lack of respect for her preferred name pronunciation. Despite repeatedly correcting Licensed Staff A, he continued to use a Hispanic pronunciation instead of the Anglican pronunciation she preferred. This ongoing issue persisted for approximately a year, leaving Resident 6 feeling disrespected. The DON and the Administrator both acknowledged that it was unreasonable for Licensed Staff A to continue mispronouncing Resident 6's name after being corrected multiple times.
Medication Administration Failure During Power Outage
Penalty
Summary
The facility failed to ensure that Licensed Nurses administered medications to five residents during a power outage that occurred from December 14 to December 15, 2025. There was no documented evidence that the residents received their medications during this period, which decreased the facility's ability to ensure that residents received necessary medications. The residents involved had various medical conditions, including dementia, hypertension, major depressive disorder, Parkinsonism, hyperlipidemia, schizophrenia, Alzheimer's disease, COPD, bipolar disorder, type 2 diabetes, and malignant neoplasm of the larynx. During the power outage, the Director of Nursing (DON) confirmed that the facility's electronic Medication Administration Record (e-MAR) system was down, and paper e-MARs were not available to the nurses. The DON was not present at the facility during the outage but was available by phone. Despite the facility's policy indicating that paper images of the e-MAR should be used as a backup during such disruptions, no paper e-MARs were provided to the staff. Interviews with Licensed Nurses revealed that they were not provided with copies of the residents' MARs and were unsure of the protocol to follow during the power outage. The facility's policy and procedure for eMAR Backup, dated October 8, 2014, stated that paper images of the electronic Medication Administration Records should be printed and used to document medication administration when the e-MAR application is inaccessible. However, this procedure was not followed, and the Licensed Nurses were not trained on how to administer medications without computer access. The absence of the Administrator and DON during the power outage further contributed to the lack of guidance and support for the staff, resulting in the failure to document medication administration for the affected residents.
Lack of Contingency Plan for Medication Administration During Power Outage
Penalty
Summary
The facility failed to ensure a contingency plan was in place for the administration of resident medication during a power outage that occurred from December 14 to December 15, 2024. This failure affected five residents, as there was no documented evidence that their medications were administered during the outage. The Plant Operations Manager confirmed that the facility's generator activated, and emergency protocols were implemented, but the Director of Nursing (DON) verified that medication administration was not documented unless there was computer access. During interviews, it was revealed that paper e-MARs were unavailable to nurses during the power outage because the entire system was down. The DON stated that staff claimed to have administered medications, but there was no documentation to support this. The facility's e-MAR policy indicated that paper images of electronic Medication Administration Records should be available as a backup during such disruptions, but this was not part of the facility's assessment. Several Licensed Nurses (LNs) working during the outage confirmed that they were not provided with copies of the residents' MARs and were unsure of the protocol for medication administration without computer access. The facility's policy and procedure for the Facility Assessment Tool required a documented assessment of resources necessary for resident care during emergencies, including medication management and emergency preparedness, but the assessment lacked descriptions of downtime procedures and other critical elements.
Verbal Abuse by Physician
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a physician. The incident involved a resident with a medical history of insomnia and borderline personality disorder, who was admitted to the facility on an unspecified date. The resident, who had no cognitive impairment as indicated by a BIMS score of 14 out of 15, was his own responsible party. During a visit to assess and treat a wound on the resident's right foot, Physician A addressed the resident by a nickname, despite the resident's preference to be called by his legal first name. When the resident expressed his preference, Physician A responded inappropriately by asking, "Aren't you a shit?" This interaction left the resident feeling upset and angry. The incident was confirmed by Licensed Staff B, who was present during the interaction, and later reported it to the facility's Administrator. The facility's policy on abuse and mistreatment, revised in March 2018, clearly states that the facility does not condone any form of resident abuse or mistreatment. However, the physician's actions violated this policy, resulting in the resident feeling verbally abused. The report does not mention any corrective actions or follow-up measures taken by the facility to address this deficiency.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse in accordance with State law and its own policies and procedures. This incident involved a resident who had been admitted with a medical history of insomnia and borderline personality disorder. The resident, who was cognitively intact and his own responsible party, became upset when a physician addressed him by a nickname and then by his surname, despite his request to be called by his legal first name. The physician responded inappropriately, which was reported by a licensed staff member to the Director of Nursing (DON) and the Administrator. Despite the report, the facility did not notify the California Department of Public Health (CDPH) or conduct an investigation into the verbal abuse allegation. The facility's policy required the Administrator to notify CDPH, the Ombudsman, and Law Enforcement within two hours of such an incident, and to send a written report within the same timeframe. The failure to follow these procedures prevented the CDPH from investigating the allegation and potentially placed the resident and others at risk for further abuse.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving Resident 1 and Physician A, as per the facility's policy and state requirements. The Director of Nursing (DON) confirmed that the allegation was reported to her by Licensed Staff B, but no investigation was conducted. Similarly, the Administrator, who is also the facility's Abuse Coordinator, acknowledged that the allegation was reported to him, yet no investigation or report to regulatory agencies was made. The facility's policy, revised in March 2018, mandates immediate action, including ensuring a safe environment for the resident, interviewing relevant individuals, suspending accused employees, and providing a written report to the California Department of Public Health (CDPH) within five working days. These steps were not followed, leading to a deficiency in handling the abuse allegation.
Unsafe Discharge of Insulin-Dependent Resident
Penalty
Summary
The facility failed to ensure the safe discharge of a resident who was insulin-dependent, as they were discharged without a glucometer or information on obtaining one. This oversight led to the resident refusing to administer insulin for several days, as they could not monitor their blood sugar levels. The Director of Nursing confirmed that it was the facility's responsibility to provide a glucometer if needed by a resident upon discharge. The discharging nurse admitted to verbally reminding the resident to purchase a glucometer but did not provide one or document this information due to being busy. Additionally, the resident was discharged to a Board and Care home that was not licensed by the California Department of Social Services, which was a requirement of the facility. The Social Services Director was unaware of how to verify the licensing status of such facilities and relied on a placement agent's incorrect information. The Director of Nursing stated that discharges to Board and Care homes required the homes to be licensed. The facility's policy on the discharge and transfer of residents did not address the provision of essential medical equipment or the requirement to discharge residents to licensed facilities. This lack of documentation and oversight contributed to the unsafe discharge of the resident, potentially jeopardizing their health and well-being.
Failure to Administer Prescribed Insulin
Penalty
Summary
The facility failed to ensure that a resident received his prescribed early-morning insulin, resulting in significant medication errors over a period of more than a year. The resident, who had Type 2 Diabetes Mellitus and required insulin for blood glucose control, was not administered his morning insulin on most days. This oversight was not identified by the facility until the resident himself reported the issue to the administration. The deficiency occurred because a licensed nurse, responsible for administering the insulin during the night shift, chose not to do so. The nurse believed that administering the insulin between 6 a.m. and 7 a.m. was too early and did not want to wake the resident. Despite checking the resident's blood glucose levels, the nurse failed to document the omission or inform the Director of Nursing (DON) about the deviation from the physician's orders. The facility's medical records department was responsible for auditing medical records to ensure completeness and accuracy. However, the Director of Medical Records did not recall any specific issues with the resident's medication administration records (MARs). The facility's policies required documentation of any held or refused medications, but this was not followed in the case of the resident's insulin administration.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to implement interventions to reduce the risk of elopement for a resident who left the facility undetected and was found by the local Police Department. The resident, who had a wander guard bracelet, was identified as an elopement risk upon admission with a score indicating a high risk. However, the section of the evaluation detailing preventative measures was left unmarked. The resident's care plan initially included interventions such as wearing a wander guard and conducting 15-minute checks, but these were not consistently documented or followed. On multiple occasions, the resident attempted to leave the facility, including an incident where the resident was seen leaving through the front door and was coaxed back by staff. Despite these attempts, the facility did not adequately document or implement the necessary interventions. The resident was hospitalized after a loss of consciousness and upon return, continued to exhibit behaviors indicating a risk of elopement. The facility's staff, including registry staff who were not familiar with the resident's history, failed to monitor the resident effectively, leading to another elopement incident. Interviews with staff revealed that the wander guard was not regularly checked or documented, and the 15-minute checks were not consistently recorded. The Assistant Director of Nursing acknowledged the lack of documentation and monitoring, particularly during the resident's readmission and subsequent elopement. The facility's policy on wandering and elopement required documentation and re-evaluation of the resident's risk, which was not adhered to, contributing to the deficiency.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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