Ocean Ridge Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 3850 E. Esther St., Long Beach, California 90804
- CMS Provider Number
- 056378
- Inspections on file
- 54
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Ocean Ridge Post Acute during CMS and state inspections, most recent first.
A resident with dementia, polyosteoarthritis, muscle weakness, and moderate cognitive impairment, who was dependent on staff for all ADLs and had bilateral upper and lower extremity impairments, developed swelling and ecchymosis of the left arm that was reported by a CNA to an LVN. An X-ray later showed a displaced fracture of the left humeral neck, and the resident was transferred to a hospital. The LVN acknowledged not notifying the DON of this change in condition. The DON and administrator stated that such an unexplained fracture constitutes an injury of unknown origin and an unusual occurrence that, under facility policy, must be reported promptly to the DON, administrator, CDPH, the ombudsman, and other agencies within specified time frames. Review of the abuse and unusual occurrence P&Ps confirmed these reporting requirements, but the incident was not reported as required, resulting in a deficiency.
The facility failed to maintain the quality and freshness of stored produce, impacting the nutritional status of 83 residents. Observations revealed that strawberries, grapes, limes, and lettuce were not stored properly, appearing mushy, discolored, and wilted. The Dietary Supervisor and Registered Dietician confirmed that these items did not meet quality standards, and the facility's policy on food storage and monitoring was not adhered to.
The facility failed to store food properly, risking foodborne illnesses for 83 residents. Observations revealed unlabeled and undated food items, including burritos, donuts, and produce, with improperly sealed bacon. The dietary supervisor and registered dietician acknowledged these issues, emphasizing the need for labeling and proper storage to prevent spoilage. The facility's policy required all foods to be covered, labeled, and dated, which was not adhered to.
The facility failed to ensure dumpsters were not overfilled and left with lids open, as observed with the Dietary Supervisor. The left dumpster was overfilled, preventing proper closure, and the right dumpster lid was left open. The maintenance supervisor confirmed the need for lids to be closed to prevent foul smells and pest attraction. Facility policy requires dumpsters to be kept closed and food waste stored to prevent vermin access.
The facility failed to accurately complete Level 1 PASRR screenings for several residents, including those with schizophrenia and bipolar disorder, leading to potential delays in necessary care and services. The admissions staff did not verify the accuracy of the screenings, resulting in missed Level 2 evaluations and improper placement of residents.
A LTC facility failed to follow infection control practices for three residents. A resident's Foley catheter bag was found touching the floor, contrary to policy. Another resident's nasal cannula, after falling on the floor, was not replaced but cleaned improperly. Additionally, a CNA did not wear an isolation gown while caring for a resident on Enhanced Barrier Precautions. These actions were against the facility's infection control policies, as confirmed by the DON and other staff.
A resident with hypertension and renal dialysis dependence received amlodipine against physician orders, which specified holding the medication on dialysis days and when certain blood pressure and heart rate parameters were not met. The DON confirmed the medication was administered incorrectly, constituting a significant medication error.
A resident with muscle weakness and dementia was unable to access her call light, which was found on the floor or tangled behind the bed frame during observations. This failure to ensure accessibility, despite her high fall risk, was confirmed by staff interviews and contradicted the facility's policy requiring call lights to be within easy reach.
A resident with a gastrostomy tube experienced progressive weight loss due to the facility's failure to adjust the enteral feeding rate from 65 ml/hr to 70 ml/hr as ordered by the physician. Despite the RD's recommendation and the physician's order, observations showed the feeding rate remained unchanged, leading to unmet nutritional goals.
The facility failed to provide proper respiratory care for four residents by not adhering to physician orders for oxygen administration and monitoring. One resident received higher oxygen levels than prescribed, while another's oxygen saturation was not consistently monitored, risking unrecognized respiratory distress.
A facility failed to manage severe pain for a resident by not notifying the physician of pain levels, not following medication parameters, and not updating care plans. The resident, with a history of chronic pain, received inappropriate medication for severe pain. Another resident's pain was not accurately assessed per the physician's order, as staff documented an 'X' instead of a numeric value on the MAR. The DON confirmed the importance of following the pain assessment policy to ensure proper pain management.
The facility failed to administer medications as per physician orders and maintain accurate documentation, affecting multiple residents. Issues included improper administration of Advair Diskus and aspirin, late administration of hydralazine, and discrepancies in controlled medication records. Additionally, a resident was transferred to a hospital due to the unavailability of methadone.
A facility failed to act on a consultant pharmacist's recommendations to reduce the doses of quetiapine and sertraline for a resident with schizoaffective disorder and major depressive disorder. The Psychiatry NP disagreed with the recommendations without providing a clinical rationale, contrary to facility policy. The resident continued to receive the same medication doses, and the facility did not follow up with the medical director as required.
A resident receiving apixaban for DVT prophylaxis was not monitored for side effects, despite being at high risk for bleeding. The resident, with multiple health conditions and moderate cognitive impairment, was not monitored from the start date of the medication. Facility staff confirmed the lack of monitoring, which was against the facility's policy requiring continual monitoring for side effects.
A facility failed to obtain informed consent before administering temazepam, a controlled medication, to a resident with multiple diagnoses, including bipolar disorder and anxiety. Despite the resident's capacity to understand and make decisions, the facility did not secure consent for the medication's dosage and frequency. Interviews with staff confirmed the oversight, acknowledging the need for informed consent due to changes in medication administration.
The facility failed to maintain a medication error rate below 5%, resulting in a 17.86% error rate. Errors included incorrect administration of ClearLax and Advair Diskus, failure to instruct a resident to chew aspirin, and late administration of hydralazine. These errors were due to non-compliance with physician orders and facility policies.
The facility failed to report changes in the conditions of two residents, leading to deficiencies in care. One resident consistently refused RNA services for PROM exercises, but the facility did not notify the physician or initiate a timely COC evaluation. Another resident experienced critically high blood sugar levels, but the facility failed to notify the physician promptly. These lapses in following protocols resulted in inadequate care for the residents.
The facility failed to accurately document the medical diagnoses and pain frequency for two residents in their MDS assessments. One resident's bipolar disorder was not reflected in the MDS, despite being treated for it, while another resident's frequent pain was documented as occasional, affecting their pain management. These inaccuracies were confirmed by the DON and MDSC, highlighting a failure to adhere to documentation standards.
A facility failed to properly label and store medications, affecting several residents. A resident's lorazepam was found without an open date, making it impossible to determine its expiration. In a medication cart, another resident's latanoprost was expired, and both latanoprost and fluticasone-salmeterol inhalers lacked open dates. An Advair Diskus for a third resident was also improperly labeled. These deficiencies were acknowledged by staff, highlighting risks of administering expired or ineffective medications.
The facility failed to create and implement person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with nausea had no care plan for Zofran use, another on temazepam lacked a plan to monitor its effectiveness, and a third resident required assistance with fingernail care but had no care plan in place. The absence of these care plans hindered individualized care and monitoring.
The facility failed to update care plans for two residents, leading to inadequate care. One resident consistently refused RNA services for left leg ROM limitations, but the care plan was not revised. Another resident experienced severe pain without appropriate medication adjustments. The facility did not follow its policies for care plan updates and pain management, resulting in deficiencies in care.
A resident was found with long fingernails and black material underneath, indicating a failure in personal hygiene care. The resident expressed concerns about previous nail cutting experiences and stated that staff had not offered to clean or cut her nails. Interviews with staff revealed a lack of documentation and adherence to facility policy regarding nail care, resulting in unmet care needs.
A facility failed to follow a dietician's recommendation to obtain a physician's order for mid-arm circumference measurements for a resident who refused to be weighed. The resident, with severe cognitive impairment and poor oral intake, was at risk of malnourishment. The order was delayed for several months, and staff were unaware of the measurement's importance, contrary to the facility's nutritional assessment policy.
A resident with left leg ROM limitations and high risk for contracture development repeatedly refused RNA services for ROM exercises over nearly a year. Despite these refusals, the facility did not implement necessary evaluations or modify the RNA program to ensure appropriate care, leading to a potential decline in the resident's ROM and physical functioning.
A facility failed to assess the need for continued use of an indwelling urinary catheter for a resident admitted with fractures. Despite being cognitively intact and requiring assistance with toileting, the resident had a Foley catheter due to urinary retention, which is not a valid reason for long-term use. The facility did not document clinical indications or assess the ongoing need for the catheter, increasing the risk of infection.
A resident with left leg ROM limitations and at high risk for contracture development repeatedly refused RNA services for left leg exercises over a year. Despite documented refusals, the facility failed to ensure the resident received skilled therapy services to maintain joint ROM and functional abilities. The Rehabilitation Department was not informed of the refusals until six months later, and no timely interventions or PT consultations were initiated.
A resident with muscle wasting and COPD had incomplete physician orders for splint application, lacking details on the responsible staff and wear time. The resident reported that splints were not applied as expected, and observations confirmed improper limb positioning. Interviews with the DOR and DON highlighted the risk of unqualified staff applying splints due to unclear orders, contrary to facility policy requiring clear documentation and assessment by therapy.
A facility failed to implement its Infection Prevention and Control Program for a resident on enhanced barrier precautions. A CNA did not wear an isolation gown during high-contact care, failed to provide proper perineal care, and improperly discarded contaminated items, risking cross-contamination. The facility's policies required gowns and proper handling of soiled items to prevent infection spread.
A resident with severe cognitive impairment received Levaquin for UTI prophylaxis without meeting the McGeer criteria for infection surveillance. The order was made by an NP without consulting the physician, who had advised waiting for culture results. The resident received the antibiotic twice before lab results showed resistance, contrary to the facility's antibiotic stewardship policy.
A resident in an LTC facility was found to have a firearm in their belongings after their death, despite the facility's policy prohibiting weapons. The resident, who had mental health and substance dependence issues, was admitted with the capacity to make medical decisions but required supervision for daily activities. The firearm was discovered during postmortem care, revealing a lapse in the facility's procedures for checking residents' belongings.
A facility failed to create an individualized care plan for a resident with suicidal ideations and an OOP order. Despite the resident's diagnoses of major depressive disorder and opioid dependence, the care plan lacked specific interventions for suicidal ideations and guidance for staff when the resident returned from OOP. Interviews with staff revealed that the care plan should have included monitoring for suicidal ideation and mood changes, as well as increased supervision, in accordance with the facility's policy for comprehensive, person-centered care plans.
A resident with opioid dependence and suicidal ideations was allowed to leave the facility unsupervised, leading to the discovery of unauthorized medications and a gun in their possession. The facility failed to assess the resident upon return, compromising safety and supervision protocols.
A resident with major depressive disorder and opioid dependence was found with multiple medication bottles at their bedside, leading to a potential overdose and death. The facility's policy required medications to be stored securely, but this was not followed, as revealed during postmortem care. Staff interviews confirmed the risk of overdose due to improper storage.
A resident in an LTC facility did not receive timely care due to staff failing to respond promptly to call lights. The resident, who required significant assistance for daily activities, was left in soiled briefs for an extended period. CNAs involved admitted to not noticing the call light and delaying care due to assignment confusion. The resident felt ignored and worthless, and the facility's policies on timely care were not followed.
The facility failed to ensure a resident's medical record was complete and accurate by not documenting an assessment after an alleged drug use incident and not entering the correct date and time for a weekly assessment. This resulted in an inaccurate depiction of the resident's care and health status.
Failure to Report Injury of Unknown Origin as Required by Abuse and Unusual Occurrence Policies
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse reporting and prevention policies by not reporting an injury of unknown origin for one resident to required external agencies. The resident had diagnoses including polyosteoarthritis, dementia, and muscle weakness, and an H&P documented that the resident did not have capacity to understand and make decisions. An MDS assessment showed moderate cognitive impairment, dependence on staff for all ADLs, need for assistance with rolling, and impairments in both upper and lower extremities. A change in condition note documented swelling and ecchymosis of the resident’s left arm, and a subsequent X-ray identified a displaced fracture at the surgical neck of the left humerus, with the resident later transferred to a general acute care hospital for treatment. Staff interviews revealed that a CNA notified an LVN about discoloration of the resident’s left arm, and the LVN observed discoloration in the upper and lower parts of the arm. The LVN acknowledged that, in the event of a change in condition, she should have notified the DON but did not do so. The DON stated that an unusual occurrence includes suspected abuse such as an injury of unknown origin, and that the facility’s protocol required the LVN to report such events to the DON, the administrator, CDPH, the ombudsman, and, if needed, law enforcement and APS within specified time frames. The DON stated that serious injuries such as accidents and fractures are unusual occurrences that must be reported to appropriate officials and CDPH within two hours, and that when the LVN learned of the fracture, she should have informed the DON. The administrator stated that an unusual occurrence is an event that cannot be explained or have its root cause identified, and that for unusual occurrences and abuse allegations, the facility is to report the incident and notify the ombudsman, police, and CDPH within two hours, followed by an investigation within five days. The administrator stated they did not know how the resident’s left arm was broken, that this was an injury of unknown origin, and that it would have been reportable. Review of the facility’s written policies confirmed that all reports of resident abuse, including injuries of unknown origin, must be reported immediately to the administrator and to state licensing/certification and other required agencies within defined time frames, and that unusual occurrences affecting health, safety, or welfare must be reported by telephone within 24 hours and in writing within 48 hours. Despite these policies, the injury of unknown origin and resulting fracture were not reported as required, leading to the cited deficiency.
Deficiency in Produce Quality and Freshness
Penalty
Summary
The facility failed to ensure the quality and freshness of fruits and vegetables stored in the refrigerator, which had the potential to impact the nutritional status and quality of life of 83 out of 88 residents. During an observation, it was noted that strawberries, grapes, limes, and lettuce were stored in a manner that did not maintain their quality. The strawberries and grapes appeared mushy and dark in color, the limes had brown spots, and the lettuce was wilted. The Dietary Supervisor acknowledged that these items did not meet the quality and freshness standards and needed to be discarded. Interviews with the Dietary Supervisor and Registered Dietician revealed that the facility's staff were expected to check the produce for firmness, color, and absence of bruising or discoloration to ensure they were not old or spoiling. The Registered Dietician emphasized that poor appearance of produce could lead to decreased intake by residents. The facility's policy indicated that food should be stored to minimize nutrient loss and maintain safety, with regular monitoring and rotation to ensure freshness. However, these practices were not followed, leading to the deficiency.
Deficient Food Storage Practices in Facility
Penalty
Summary
The facility failed to store food in a sanitary manner, which could lead to the growth of microorganisms and potential foodborne illnesses for 83 out of 88 residents. During an observation and interview, it was found that the facility's refrigerator contained three bean burritos, a box of donuts, and a package of bacon that were not labeled or dated. Additionally, the bacon was not properly sealed and was open to air. Another refrigerator contained a cut onion and two bell peppers that were also not labeled or dated. The dietary supervisor acknowledged these issues, noting that the donuts should have been dated with the date received and thawed, and that the cook had forgotten to label and date the leftover produce. The registered dietician confirmed that all food stored in the kitchen needed to have a delivery date, date opened, and/or a use-by date to prevent serving spoiled or poor-quality food to residents. The dietician emphasized the importance of properly sealing and covering food to prevent oxidation and faster spoilage. The facility's policy and procedure on food receiving, labeling, and storage, dated November 2022, indicated that all foods stored in the refrigerator or freezer were to be covered, labeled, and dated with a use-by date. These practices were not followed, placing residents at risk for developing foodborne illnesses.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two out of two facility dumpsters were not overfilled and left with the lid open. During an observation and interview with the Dietary Supervisor in the facility parking lot, it was noted that the left dumpster was overfilled, preventing the lid from shutting properly, and the right dumpster lid was left open. The Dietary Supervisor indicated that facility staff might have forgotten to close the lid when disposing of trash. In a subsequent interview, the maintenance supervisor confirmed that the dumpster lids needed to be completely closed to prevent foul smells and the attraction of pests such as flies. A review of the facility's policy and procedure titled Food-Related Garbage and Rubbish Disposal indicated that outside dumpsters provided by garbage pick-up services should be kept closed, and garbage containing food waste should be stored in a manner that is inaccessible to vermin. This deficient practice had the potential to harbor and feed pests, including rodents and flies.
Inaccurate PASRR Screenings Lead to Potential Delays in Care
Penalty
Summary
The facility failed to ensure accurate completion of the Level 1 Preadmission Screening and Resident Review (PASRR) for five out of nine sampled residents, which is a federal requirement to prevent inappropriate placement in nursing homes. This deficiency was identified through interviews and record reviews, revealing that the PASRR screenings for Residents 6, 24, 17, 28, and 79 were inaccurately marked as negative for serious mental illness, despite their diagnoses of conditions such as schizophrenia and bipolar disorder. This oversight had the potential to delay necessary care and services for these residents. Resident 24 was admitted with diagnoses of schizophrenia and anxiety, yet their PASRR Level 1 screening was marked negative, indicating no need for a Level 2 screening. Similarly, Resident 6, diagnosed with bipolar disorder and schizophrenia, also had a negative PASRR Level 1 screening. The Director of Nursing (DON) acknowledged that the admissions staff, who were not nurses, only ensured the completion of the PASRR without verifying its accuracy. This led to missed opportunities for appropriate psychiatric evaluations and treatments. Resident 17's PASRR Level 1 screening was positive for serious mental illness, but a Level 2 evaluation was not conducted due to a duplicate PASRR on file. The facility failed to resubmit a new Level 1 screening, potentially resulting in improper placement. Residents 28 and 79, both with serious mental illness diagnoses, also had incorrect PASRR Level 1 screenings, which did not trigger the necessary Level 2 evaluations. The facility's policy required accurate PASRR completion prior to admission, but this was not adhered to, impacting the residents' access to appropriate mental health services.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices in three separate instances involving three residents. In the first instance, a resident with a Foley catheter had their drainage bag touching the floor, which was observed during a room visit. Both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that this was against the facility's policy and increased the risk of infection. The facility's policy clearly stated that the catheter drainage bag should be kept off the floor to prevent infections. In the second instance, a resident's nasal cannula fell on the floor and was not replaced as required. Instead, a Certified Nurse Assistant (CNA) attempted to clean it with hand sanitizer, which was not an appropriate method of sanitization. The LVN and DON confirmed that the nasal cannula should have been replaced immediately to prevent potential contamination and infection, as per the facility's policy. The third instance involved a resident on Enhanced Barrier Precautions (EBP) due to a tracheostomy stoma and Candida auris infection. A CNA provided direct care to this resident without wearing an isolation gown, which was required to prevent the spread of multi-drug-resistant organisms. The Infection Preventionist Nurse and the DON emphasized the importance of following infection control protocols, including the use of personal protective equipment, to reduce the transmission of infections.
Failure to Prevent Significant Medication Error
Penalty
Summary
The facility failed to prevent a significant medication error for a resident who was receiving medication for high blood pressure. The resident, who had been admitted with diagnoses of hypertension and dependence on renal dialysis, had specific physician orders for the administration of amlodipine, a medication to treat high blood pressure. The orders specified that the medication should be held if the resident's systolic blood pressure was below 110 or heart rate was less than 60, and also on dialysis days (Monday, Wednesday, and Friday) to prevent hypotension during dialysis. Despite these orders, the resident received amlodipine on several occasions when it should have been withheld. The Director of Nursing (DON) confirmed that the resident received the medication on dialysis days and when the blood pressure and heart rate were below the specified parameters. This was not in accordance with the physician's orders, constituting a medication error. The facility's policy indicated that medications were to be administered according to the prescriber's written orders, which was not followed in this case.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 73, had access to her call light, which is essential for requesting assistance from nursing staff. Resident 73 was admitted with diagnoses of muscle weakness, dementia, and major depressive disorder, and was assessed as a high risk for falls due to general weakness. Her care plan included the intervention of keeping her call light within reach to prevent falls. However, during multiple observations, the call light was found out of her reach, either on the floor or tangled behind the bed frame, which prevented her from calling for help when she felt unwell. Staff interviews confirmed the importance of having the call light within reach, as it is the primary means for residents to communicate their need for assistance. The Director of Nursing acknowledged the potential safety risks if residents cannot access their call lights. The facility's policy also stipulated that call lights should be within easy reach when residents are in bed, highlighting a failure to adhere to established procedures, thereby placing Resident 73 at risk for accidents.
Failure to Adjust Enteral Feeding Rate as Ordered
Penalty
Summary
The facility failed to follow physician's orders for enteral feeding for a resident with a traumatic brain injury, aphasia, and a gastrostomy tube. The resident was experiencing slow progressive weight loss, and the registered dietician recommended increasing the tube feeding rate from 65 ml/hr to 70 ml/hr. The physician's order to increase the feeding rate was placed on January 16, 2025. However, observations on January 21 and January 23, 2025, revealed that the tube feeding was still running at the previous rate of 65 ml/hr, contrary to the updated physician's order. Interviews with the LVN and the RD confirmed that the feeding rate had not been adjusted as per the physician's order, which was necessary to address the resident's weight loss. The Director of Nursing also acknowledged that the feeding rate was not set to the correct rate, which meant the resident was not meeting their nutritional goals. The facility's policy and procedure for enteral tube feeding required checking the rate of administration against the order, which was not adhered to in this case.
Failure to Provide Proper Respiratory Care and Monitoring
Penalty
Summary
The facility failed to provide proper respiratory care for four residents by not adhering to physician orders for oxygen administration and monitoring. Resident 69, who was admitted with respiratory failure and COPD, was observed receiving oxygen at 4L/min and 4.25L/min instead of the prescribed 2L/min. Similarly, Resident 496, admitted with COPD and shortness of breath, was found to be receiving oxygen at levels between 3L/min and 4L/min, contrary to the physician's order of 2L/min. Resident 492, diagnosed with leukemia and requiring continuous oxygen for shortness of breath, was also observed receiving oxygen at 3.5L/min instead of the ordered 2L/min. Additionally, the facility failed to adequately monitor oxygen saturation for Resident 53, who was on continuous high-concentration oxygen due to chronic respiratory failure and COPD. The resident's medical records indicated that oxygen saturation should be checked every shift, yet there were numerous instances where this was not documented. The lack of monitoring could lead to unrecognized changes in the resident's condition, such as respiratory distress due to insufficient oxygen levels. Interviews with the Director of Nursing and Licensed Vocational Nurse confirmed these deficiencies, acknowledging that the residents did not receive the prescribed level of care. The facility's policies on oxygen administration and documentation were not followed, resulting in a failure to provide appropriate respiratory care and monitoring for the affected residents.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to manage severe pain appropriately for Resident 79, who experienced pain levels of 7-10 out of 10. The staff did not notify the physician of these severe pain levels from August 2024 to January 2025, nor did they follow the physician's ordered pain medication parameters. Resident 79's pain was not accurately documented in the Minimum Data Set (MDS), and care plans were not updated to address the continued pain. Additionally, the location of the pain was not consistently documented, which contributed to a delay in obtaining appropriate consults and providing a suitable pain management regimen. Resident 79, who had a history of nontraumatic subdural hemorrhage, type 2 diabetes mellitus, and chronic pain from a left hip replacement, was admitted to the facility in August 2024. Despite the resident's complaints of severe pain, the facility administered Tramadol for moderate pain and Acetaminophen for mild pain, without contacting the physician for a more appropriate medication. The Licensed Vocational Nurse (LVN) acknowledged that there was no documentation indicating that the physician was contacted about the severe pain levels, and the Director of Nursing (DON) confirmed that medications should be administered within the ordered pain scale parameters. For Resident 32, the facility failed to accurately assess pain per the physician's order. Resident 32, who had severe cognitive impairment and a history of traumatic brain injury, was to be monitored for pain using a numeric scale every shift. However, the Medication Administration Report (MAR) showed that an 'X' was documented instead of a numeric value, which was not in accordance with the physician's order. The DON stated that the numeric pain scale was appropriate for Resident 32 and emphasized the importance of monitoring pain to ensure proper management. The facility's policy on pain assessment and management was not followed, leading to a potential for Resident 32 to experience unnecessary pain.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and manufacturer specifications, affecting multiple residents. For instance, a resident was not instructed to rinse their mouth after using Advair Diskus, increasing the risk of oral thrush. Another resident was observed swallowing an aspirin chewable tablet instead of chewing it, as required. Additionally, the facility did not ensure that polyethylene glycol was dissolved in the correct amount of water, as per physician orders, for two residents, potentially leading to gastrointestinal issues. The facility also failed to administer medications within the scheduled time frame. A resident's hydralazine, prescribed for hypertension, was administered almost two hours late, contrary to the facility's policy of administering medications within 60 minutes of the scheduled time. This delay occurred despite the nurse's awareness of running late and the potential risks associated with late administration, such as high blood pressure and stroke. Furthermore, the facility did not maintain accurate documentation of controlled medications. Discrepancies were found between the medication count sheets and the actual medication cards for several residents, indicating a failure to document the administration of controlled substances immediately. This lack of documentation could lead to medication errors, misuse, overdose, and drug diversion. Additionally, a resident did not receive their scheduled methadone dose due to the facility's failure to reorder the medication in a timely manner, resulting in the resident being transferred to a hospital for uncontrolled pain.
Failure to Act on Pharmacist's Recommendations for Medication Adjustment
Penalty
Summary
The facility failed to act on two recommendations from the consultant pharmacist regarding the medication regimen of a resident, identified as Resident 41. The consultant pharmacist had recommended reducing the doses of quetiapine and sertraline for Resident 41, but the recommendations were not acted upon. The Psychiatry Nurse Practitioner (NP) disagreed with the pharmacist's recommendations without providing a clinical rationale, which is against the facility's policy that requires a clinical explanation for any disagreement with pharmacist recommendations. Resident 41 was admitted with diagnoses including schizoaffective disorder and major depressive disorder. The resident's Minimum Data Set (MDS) indicated intact cognition and varying levels of assistance required for Activities of Daily Living (ADLs). Despite the consultant pharmacist's recommendations, the resident continued to receive the same doses of quetiapine and sertraline as documented in the Medication Administration Record (MAR) over several months. The NP stated that the resident felt stable with the current medication regimen and had not experienced episodes of delusions or significant mood changes, which was the reason for not adjusting the medication. The facility's policy on Medication Regimen Review requires that any disagreement with the pharmacist's recommendations be documented with a clinical rationale. The Director of Nursing (DON) emphasized the importance of providing a clinical rationale due to the potential side effects of psychotropic medications. However, in this case, the NP did not provide such a rationale, and the facility did not follow up with the medical director as required by their policy, leading to a deficiency in medication management for Resident 41.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen for side effects, specifically for a resident receiving an anticoagulant medication, apixaban, which was prescribed for deep vein thrombosis prophylaxis. The resident, who had multiple diagnoses including chronic respiratory failure, COPD, hypertension, and hyperlipidemia, was at high risk for bleeding due to the anticoagulant. Despite this risk, there was no monitoring for side effects from the start date of the medication on 12/19/24. This lack of monitoring was confirmed during interviews with facility staff, who acknowledged that residents on anticoagulants should be monitored every shift for signs of bleeding, such as skin discoloration, gum bleeding, and dark stools. The resident, who had moderate cognitive impairment and required varying levels of assistance for daily activities, was not monitored for side effects from 12/20/25 to 1/13/25. This oversight was identified during a review of the Medication Administration Record (MAR) and confirmed by both a Licensed Vocational Nurse and the Director of Nursing. The facility's policy on medication administration emphasized the importance of continual monitoring for side effects, particularly after the administration of new medications. However, this policy was not followed, leading to a potential delay in necessary care and services for the resident.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering a controlled medication, temazepam, to a resident identified as Resident 17. This resident was admitted with multiple diagnoses, including bipolar disorder, major depressive disorder, anxiety disorder, and hemiplegia following a cerebral infarction. Despite having the capacity to understand and make decisions, as indicated in the resident's history and physical, the facility did not secure informed consent for the administration of temazepam, a psychotropic medication prescribed for insomnia. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and varying levels of assistance required for daily activities. The Order Summary Report showed that temazepam was ordered and administered daily from January 10 to January 23, 2025, without any missing doses. However, a review of the resident's informed consent documentation revealed no consent for the medication at the prescribed dosage and frequency. During an interview, the resident acknowledged taking a sleeping pill but was unaware of its name, indicating a lack of informed consent. Interviews with the MDS Coordinator and the Director of Nursing confirmed the absence of informed consent for the temazepam medication. The facility's policy required informed consent for psychotropic medications, which was not obtained in this case. The MDS Coordinator and the Director of Nursing acknowledged the oversight, noting that the change in frequency and dosage necessitated a new informed consent, which was not secured, potentially leaving the resident uninformed about the medication's side effects.
Medication Administration Errors Exceeding 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration, resulting in a 17.86% error rate. This deficiency was observed in the administration of medications to four residents. For one resident, the nurse did not ensure the resident finished the full dose of ClearLax solution and failed to instruct the resident to rinse their mouth after using Advair Diskus, contrary to the manufacturer's instructions. Additionally, the nurse used an incorrect amount of water to dissolve the ClearLax, which was not in accordance with the physician's order. Another resident was administered an aspirin tablet that was supposed to be chewed, but the nurse failed to instruct the resident to do so, leading to the resident swallowing the tablet whole. The physician's order for this medication was also unclear, as it indicated an oral capsule instead of a chewable tablet. This discrepancy was not clarified, contributing to the medication error. For a third resident, the nurse dissolved ClearLax in an incorrect amount of water, not following the physician's order. The fourth resident received hydralazine two hours late, beyond the facility's policy of administering medications within one hour of the scheduled time. This delay in administration was not in accordance with the facility's policy and could potentially affect the resident's blood pressure management. The Director of Nursing acknowledged these errors and the need for clarification of physician orders to prevent such medication errors.
Failure to Report Changes in Resident Conditions
Penalty
Summary
The facility failed to report changes in the condition of two residents, leading to deficiencies in care. Resident 32, who was admitted with diagnoses including left hemiplegia and traumatic brain injury, consistently refused Restorative Nursing Aide (RNA) services for passive range of motion (PROM) exercises from February 2024 to January 2025. Despite these refusals being documented, the facility did not notify the resident's physician or initiate a change of condition (COC) evaluation in a timely manner. The first COC was only initiated in August 2024, six months after the refusals began, and no further COCs were initiated despite continued refusals. This lack of timely notification and intervention put Resident 32 at risk for a decline in mobility and the development of contractures. Resident 58, who was admitted with diabetes mellitus, experienced multiple instances where blood sugar levels exceeded 400 mg/dL, a critical level for diabetic patients. On three occasions in November and December 2024, the facility failed to notify the physician when Resident 58's blood sugar levels were critically high. Additionally, a blood test result showing a critically high Hemoglobin A1C level of 9.7% was not reported to the physician until eight days after the results were available. This delay in notification could have led to adverse health outcomes for Resident 58, as timely intervention is crucial in managing diabetes effectively. The facility's policy and procedure require immediate notification of the physician when there is a significant change in a resident's condition, such as refusal of treatment or critically high blood sugar levels. However, in both cases, the facility did not adhere to these protocols, resulting in a failure to provide appropriate and timely care to the residents. The Director of Nursing and other staff members acknowledged the lapses in following the facility's procedures, which contributed to the deficiencies identified in the care of Residents 32 and 58.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to accurately document the medical diagnosis of two residents in their Minimum Data Set (MDS) assessments, which are crucial for ensuring appropriate care. Resident 21 was admitted with diagnoses of Parkinson's disease and anxiety disorder, but was later assessed to have bipolar affective disorder, for which they were receiving Depakote. However, the MDS did not reflect this diagnosis, as confirmed by the Director of Nursing (DON) during an interview. The DON acknowledged the importance of accurate MDS coding to ensure residents receive the correct care and treatment. Resident 79's MDS inaccurately documented their pain frequency as occasional, despite records showing they experienced pain almost constantly and required daily Tramadol for relief. The MDS Coordinator (MDSC) confirmed that the MDS should have reflected the resident's frequent pain to ensure proper care and treatment. An interview with Resident 79 revealed that their pain was not adequately managed with the current medication regimen, and they had requested stronger pain medication without receiving it. The facility's MDS Nurse Job Description and the policy on Charting and Documentation emphasize the need for accurate and complete documentation. However, the discrepancies in the MDS assessments for Residents 21 and 79 indicate a failure to adhere to these standards, potentially impacting the residents' care plans and treatment outcomes.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to potential risks for residents. In the Station 1 Medication Room, a bottle of lorazepam oral concentrate for Resident 81 was found without an open date label, contrary to the manufacturer's requirements. The absence of an open date made it impossible to determine the expiration date, which could result in the administration of expired medication. This oversight was acknowledged by both RN 1 and the Director of Nursing (DON), who confirmed that the medication could potentially harm the resident if it was expired or ineffective. In the Station 1 Medication Cart 1, several medications were either expired, improperly stored, or lacked necessary labeling. For Resident 84, an unopened bottle of latanoprost ophthalmic solution was found without an open date, and an opened bottle was past its expiration date. Additionally, a fluticasone-salmeterol inhalation device for Resident 84 and an Advair Diskus inhalation device for Resident 35 were found without open dates. LVN 1 admitted to the oversight and acknowledged the potential risks of administering these medications without proper labeling and storage. The facility's policy and procedure for medication storage, dated May 2022, requires medications to be stored according to manufacturer's recommendations, with open dates clearly labeled to determine expiration. The failure to adhere to these guidelines resulted in the potential for residents to receive expired or ineffective medications, posing risks to their health and safety. The DON confirmed the importance of proper storage and labeling to ensure the therapeutic effectiveness and safety of medications administered to residents.
Failure to Implement Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to create and implement person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident 73, who was admitted with diagnoses including muscle weakness, dementia, and major depressive disorder, had an order for Zofran to manage nausea. However, there was no care plan in place to address the use of this medication, despite the resident frequently experiencing nausea. The Director of Nursing acknowledged the absence of a care plan, emphasizing its importance for continuity of care and individualized interventions. Resident 17, diagnosed with bipolar disorder, major depressive disorder, anxiety disorder, and hemiplegia, was prescribed temazepam for insomnia. Despite receiving the medication consistently, there was no care plan to monitor its effectiveness or to outline goals and interventions if the medication was ineffective. The MDS Coordinator confirmed the lack of a care plan, which hindered the facility's ability to monitor the medication's impact on the resident's sleep. Resident 28, with diagnoses including schizophrenia, COPD, CHF, and diabetes mellitus, required assistance with self-care and grooming, particularly concerning fingernail care. The resident expressed concerns about previous nail trimming experiences and had not been offered assistance with nail care. The absence of a care plan for grooming and self-care was noted by a Licensed Vocational Nurse, who stated that even if the resident refused care, a plan should have been in place to document the offer and explore alternative interventions. The Director of Nursing highlighted the necessity of care plans for ensuring resident-centered care and guiding staff in providing appropriate services.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for two residents, leading to deficiencies in their care. Resident 32, who was identified as having left leg range of motion (ROM) limitations and was at high risk for contracture development, consistently refused Restorative Nursing Aide (RNA) services from August 2024 to January 2025. Despite these refusals, the care plan was not updated since August 2024, and the interventions listed were ineffective. The Minimum Data Set Nurse Coordinator (MDSC) and the Director of Nursing (DON) confirmed that the care plan should have been revised to include effective interventions to maintain the resident's ROM, mobility, and activities of daily living (ADLs). Resident 79 experienced severe pain that required increased use of as-needed (PRN) pain medications from August 2024 to January 2025. The resident complained of pain levels of 7/10 and 8/10, but there was no PRN medication ordered for severe pain, and the nursing staff did not contact the physician to clarify and order an appropriate medication. The care plan for pain management was not revised during this period, and the facility's policy indicated that pain management interventions should be consistent with the resident's goals for treatment and should be revised as necessary. The facility's policies and procedures for care plans and pain management were not followed, leading to inadequate care for both residents. The care plans were not updated quarterly or as needed, and the interventions were not adjusted to meet the residents' changing conditions. This failure to update and revise care plans resulted in a lack of appropriate care and services for the residents, as confirmed by the MDSC and the DON.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to maintain good grooming and personal hygiene for a resident, identified as Resident 28, who was observed to have long fingernails with black material underneath. This deficiency was noted during an observation and interview with the resident, who expressed that the last time her fingernails were cut, it resulted in a cut to her skin, and she did not want that to happen again. The resident also mentioned that staff had not offered to clean or cut her fingernails, although she would like them to try again. Interviews with facility staff, including an LVN and the DON, revealed that CNAs are responsible for daily grooming and ADLs, including nail care. The DON acknowledged that there was no documentation of services being offered or refused by the resident, indicating that the services were not provided. The facility's policy on nail care emphasizes the importance of cleaning and trimming nails to prevent infections and requires documentation of any difficulties or refusals, which was not adhered to in this case.
Failure to Follow Dietician's Recommendations for Nutritional Assessment
Penalty
Summary
The facility failed to follow the dietician's recommendations and obtain a physician's order for mid-arm circumference measurements for a resident, which could delay care and identification of potential malnourishment. The resident, who was admitted with diagnoses including blindness, traumatic brain injury, and hemiplegia, refused to be weighed and had poor oral intake. The registered dietician recommended mid-arm circumference measurements in August 2024 as an alternative to assess the resident's nutritional status, but the order was not placed until January 2025. Interviews revealed that the licensed vocational nurse was unaware of what a mid-arm circumference measurement was, and the dietician expressed concern that her recommendations were not followed up promptly. The Director of Nursing confirmed that there was no indication the physician was informed of the dietician's recommendation until months later. The facility's policy on nutritional assessment emphasizes the importance of timely and multidisciplinary interventions, which were not adhered to in this case.
Failure to Address Resident's ROM Decline Due to RNA Refusals
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent a decline in range of motion (ROM) for a resident identified as having left leg ROM limitations and at high risk for contracture development. The resident, who had diagnoses including left hemiplegia and traumatic brain injury, repeatedly refused Restorative Nursing Aide (RNA) services for left leg ROM exercises from February 2024 to January 2025. Despite these refusals, the facility did not implement multiple Change of Condition (COC) evaluations, investigate the reasons for refusals, or modify the RNA program to ensure the resident received appropriate care. The resident's RNA Flowsheets consistently indicated refusals of RNA services, yet there was a lack of follow-up actions from the facility. The Director of Staff Development (DSD) confirmed that the resident refused or did not receive RNA services almost every day, five times a week, during the specified period. The facility's policy required that residents with limited ROM receive treatment and services to prevent further decline, but this was not adhered to in the case of this resident. Interviews with facility staff, including the Director of Rehabilitation (DOR) and the Director of Nursing (DON), revealed that the facility's RNA program was not reassessed or modified despite the resident's continuous refusals. The DOR stated that the Rehabilitation Department was unaware of the resident's multiple refusals until a COC evaluation was initiated in August 2024. The DON confirmed that the RNA program was not provided as ordered, and no follow-up assessments were conducted to check the effectiveness of any interventions. This lack of action contributed to the resident's potential decline in ROM and physical functioning.
Failure to Assess Continued Need for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to assess the need for the continued use of an indwelling urinary catheter for a resident, identified as Resident 22, who was admitted with a periprosthetic fracture and multiple rib fractures. The resident was cognitively intact and required assistance with toileting hygiene. Despite having an order for a Foley catheter due to urinary retention, there was no documentation supporting the necessity of the catheter for long-term use, as urinary retention is not an approved diagnosis for prolonged catheterization in a nursing home setting. Observations and interviews revealed that the resident still had the Foley catheter due to limited mobility, but the Director of Nursing confirmed that this was not a valid reason for continued catheter use. The facility's policy required documentation of clinical indications for catheter use and regular assessments for its necessity, which were not conducted. This oversight increased the risk of catheter-induced infections due to unnecessary prolonged use.
Failure to Provide Necessary Physical Therapy Services
Penalty
Summary
The facility failed to provide necessary Physical Therapy (PT) services for a resident identified as having left leg range of motion (ROM) limitations and at high risk for contracture development. The resident repeatedly refused Restorative Nursing Aide (RNA) services for left leg ROM exercises from February 2024 to January 2025. Despite these refusals, the facility did not ensure the resident received skilled therapy services to maximize joint ROM and maintain functional abilities. The resident, who was initially admitted in 2019 and readmitted in 2023, had diagnoses including left hemiplegia and traumatic brain injury. A physician's order from August 2023 required RNA to assist the resident with passive range of motion (PROM) exercises to the left hip and ankle five times a week. However, the RNA documentation from February 2024 to January 2025 consistently showed that the resident refused these exercises. Despite the refusals being documented, the facility failed to initiate timely interventions or consult PT for re-assessment and modification of the RNA program. Interviews with facility staff revealed that the Rehabilitation Department was not informed of the resident's continuous refusals until August 2024, six months after the refusals began. The Director of Staff Development confirmed that a Change of Condition (COC) should have been initiated in February 2024, and PT should have been consulted. The facility's failure to address the resident's refusals and provide appropriate skilled therapy services resulted in the resident not receiving the necessary care to prevent a decline in ROM and functional abilities.
Incomplete Physician Orders for Splint Application
Penalty
Summary
The facility failed to ensure that a resident had complete and accurate physician's orders for the application of splints. The orders for the resident's bilateral knee extension splints, left elbow extension splint, and left resting hand splint did not specify the designated staff member responsible for applying the splints or the splint wear time. This omission led to confusion and incomplete documentation regarding the care and services provided to the resident. The resident, who was admitted with diagnoses including muscle wasting, atrophy, and chronic obstructive pulmonary disease, was cognitively intact and required assistance with various activities of daily living. The resident reported that staff had not applied the splints as expected, which was confirmed during an observation where the resident's limbs were not in the correct position. Interviews with the Director of Rehabilitation and the Director of Nursing revealed that the orders were unclear and could lead to unqualified staff applying the splints improperly, potentially causing harm. The facility's policy and procedure for orthotic application required that therapy assess the resident for appropriate splints and establish a wear schedule, which should be documented clearly in the physician's orders. However, the orders for the resident in question did not meet these requirements, leading to a lack of clarity and potential risk for the resident. The facility's documentation guidelines emphasized the need for complete and accurate records to facilitate communication among the interdisciplinary team, which was not achieved in this case.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program for a resident by not ensuring that a Certified Nursing Assistant (CNA) wore an isolation gown when providing high-contact care. The resident was on enhanced barrier precautions (EBP) to prevent the spread of multidrug-resistant organisms. Despite the presence of an EBP sign outside the resident's room, the CNA entered without a disposable gown and proceeded to change the resident's soiled incontinence brief without adhering to the required precautions. Additionally, the CNA did not provide proper perineal care to the resident. The CNA cleaned only the outside of the resident's perineal area and failed to clean the labia minora or urethra, which is essential to prevent urinary tract infections. The CNA also improperly discarded contaminated linens and incontinence briefs by opening the door with contaminated gloves to discard them in the hallway, further risking cross-contamination. The Director of Staff Development and the Director of Nursing confirmed the importance of following proper procedures, including wearing gowns in EBP rooms and correctly discarding soiled items to prevent infection spread. The facility's policies on Enhanced Barrier Precautions, Laundry, and Perineal Care were reviewed, indicating the need for gowns during high-contact care and proper handling of soiled laundry to prevent infection transmission.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol for a resident who did not meet the McGeer criteria for infection surveillance. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was ordered Levaquin for UTI prophylaxis despite not exhibiting clinical manifestations of an infection. The order was made by a Nurse Practitioner without clarifying with the physician, who had previously advised waiting for culture results before prescribing antibiotics. The resident's lab results showed a high white blood cell count, but not high enough to meet the criteria for antibiotic treatment. Despite this, the resident received Levaquin on two occasions before culture results indicated resistance to the prescribed antibiotic. The Infection Preventionist and Director of Nursing both stated that antibiotics should only be administered when minimum criteria are met to prevent antibiotic resistance, which was not the case here. The facility's policy on antibiotic stewardship emphasizes the importance of monitoring antibiotic use and ensuring that lab results and clinical situations are communicated to prescribers before starting or continuing antibiotic therapy. However, in this instance, the protocol was not followed, leading to the inappropriate administration of antibiotics to the resident.
Resident Found with Firearm in LTC Facility
Penalty
Summary
The facility failed to ensure the safety of its residents, staff, and visitors by allowing a resident to possess a firearm within the premises. The deficiency was identified when a gun was discovered in the belongings of a resident who had passed away. The resident, who had been admitted with diagnoses including major depressive disorder, opioid dependence, and suicidal ideations, was found to have a firearm in a bag beside the nightstand in their room. The facility's policy prohibits firearms and other weapons, yet there were no signs posted to indicate this prohibition. The resident's admission records and assessments indicated they had the mental capacity to make medical decisions and required supervision for activities of daily living. Despite this, the facility did not detect the presence of the firearm until after the resident's death. Interviews with staff revealed that the gun was found during postmortem care and was subsequently secured by the facility's administration. The incident highlighted a lapse in the facility's procedures for checking residents' belongings, as noted by the medical doctor, who emphasized the danger posed by the firearm to the resident and others in the facility.
Failure to Develop Individualized Care Plan for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to develop an individualized care plan for a resident who had an Out on Pass (OOP) order and a diagnosis of suicidal ideations. The resident was admitted with major depressive disorder, opioid dependence, and suicidal ideations, and had the mental capacity to make medical decisions. Despite these diagnoses, the care plan did not include specific interventions for the resident's suicidal ideations or a plan for when the resident returned from OOP. This lack of a personalized care plan resulted in staff not knowing what interventions to implement upon the resident's return from OOP. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), revealed that the care plan should have been individualized based on the resident's needs and diagnoses. The staff acknowledged that the care plan should have included monitoring for verbalization of suicidal ideation, mood changes, and increased supervision. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, which were not developed for this resident, potentially affecting the resident's well-being.
Failure to Supervise Resident and Prevent Hazards
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for a resident who was admitted with diagnoses of opioid dependence and suicidal ideations. The resident was allowed to leave the facility on multiple occasions without supervision, despite having a history of substance abuse and psychiatric issues. Upon returning from these outings, the resident was not assessed for items brought back into the facility, which is a critical oversight given the resident's condition and history. During the resident's stay, four bottles containing medications, including Ibuprofen and quetiapine, were found in the resident's bedside drawer. These medications were not accounted for, and there was no documentation of a self-administration assessment, which posed a significant risk of overdose. Additionally, a gun was discovered in the resident's bag, which was brought into the facility without detection, further compromising the safety of the resident and others in the facility. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policies regarding out-on-pass procedures and the assessment of residents upon their return. The Director of Nursing and other staff members acknowledged the dangers posed by the resident's unsupervised outings and the presence of unauthorized items in the facility. The facility's policy emphasized the importance of resident safety and supervision, yet these protocols were not effectively implemented, leading to a hazardous environment.
Resident's Death Linked to Improper Medication Storage
Penalty
Summary
The facility failed to ensure that medications were not kept at the bedside of a resident, which potentially led to a drug overdose resulting in the resident's death. The resident, who had been admitted with diagnoses including major depressive disorder, opioid dependence, and suicidal ideations, was found to have multiple bottles of medications in their bedside drawer after their death. These included both empty and filled bottles of ibuprofen and quetiapine, a medication used for schizophrenia, bipolar disorder, and depression. The resident had the mental capacity to understand and make medical decisions, as indicated in their records, but had episodes of confusion noted in their progress notes. Interviews with facility staff revealed that the medications were discovered during postmortem care, and the labels on the bottles were unreadable. The facility's Director of Nursing acknowledged that medications should be stored in a medication cart or room accessible only to licensed nurses, and that keeping medications at the bedside without a proper self-administration assessment posed a risk of overdose. The facility's policy on medication labeling and storage, dated 2001, required medications to be stored in secure locations, which was not adhered to in this case.
Failure to Provide Timely Care and Respond to Call Lights
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. The deficiency involved a resident who required dependent assistance from two or more staff for toileting hygiene and maximal assistance from one staff for other activities. On one occasion, a Certified Nurse Assistant (CNA) did not respond to the resident's call light in a timely manner, despite being in the room to attend to another resident. The CNA admitted to not noticing the call light and acknowledged that the resident might feel ignored due to the delay. Another incident involved a different CNA who delayed changing the resident's soiled adult briefs, resulting in the resident sitting in soiled briefs for an extended period. The CNA was unsure of her assignment and did not provide the requested care immediately. The resident expressed feeling ignored and worthless due to the lack of timely care, and the Director of Nursing emphasized the importance of responding to call lights promptly and providing necessary hygiene care. The resident's care plan indicated a risk for skin breakdown and a need for staff to anticipate and meet the resident's needs. The facility's policies and procedures required timely responses to call lights and appropriate care for residents unable to carry out activities of daily living independently. However, the facility failed to adhere to these standards, resulting in the resident's needs not being met in a timely manner.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that Resident 2's medical record was complete and accurate. Specifically, the facility did not document an assessment after an allegation of suspected drug use was made regarding Resident 2. Additionally, the facility failed to enter the correct date and time of a weekly assessment completed for Resident 2. This resulted in an inaccurate depiction of Resident 2's care and health status. Resident 2 had diagnoses including opioid dependence, blood clots, substance abuse, paraplegia, and one-sided weakness. The Minimum Data Set (MDS) indicated that Resident 2 had moderately impaired cognition and required various levels of assistance with daily activities. On 4/15/2024, kitchen staff observed Resident 2 allegedly injecting himself with a syringe. However, there was no documented evidence of a completed assessment following this incident. Progress notes indicated that Resident 2 left the facility on 4/16/2024, and a late entry on 4/19/2024 stated that a weekly summary assessment was completed but did not include the date and time. During interviews, both LVN 1 and the Director of Nursing (DON) confirmed that the assessment was not documented after the alleged drug use incident and that the late entry should have included the date and time of the assessment. The facility's policy required documentation of any notable changes in the resident's condition, including the date and time of procedures and treatments, which was not followed in this case.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with 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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