Osage Healthcare & Wellness Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Inglewood, California.
- Location
- 1001 South Osage Ave, Inglewood, California 90301
- CMS Provider Number
- 056143
- Inspections on file
- 23
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Osage Healthcare & Wellness Centre during CMS and state inspections, most recent first.
A resident with cognitive impairment, Parkinson’s disease, and dependence in several ADLs had an MDS assessment completed inaccurately when the MDS nurse failed to follow RAI Section B guidelines for assessing hearing and hearing aid use. Although the social services assessment documented bilateral hearing aids, the MDS was coded as having adequate hearing and no hearing aid, based only on the nurse not seeing the resident using a hearing aid during the look-back period and without fully reviewing the record or consulting other sources, contrary to facility policy and CMS RAI manual instructions.
A resident with severe cognitive impairment, multiple medical diagnoses, and total dependence on staff for several ADLs had a missing right hearing aid documented on a theft/loss report. Despite this identified problem, staff, including the RN, MDS nurse, and DON, acknowledged that no comprehensive, person-centered care plan was developed by the IDT to address the missing hearing aid, contrary to facility policy requiring measurable objectives and timeframes for all identified needs.
A resident with severe cognitive impairment, Parkinson’s disease, and documented bilateral hearing aids had one hearing aid reported missing and had stopped using the other. An ENT provider identified hearing loss and recommended an audiogram, and a physician ordered an audiology consult with follow-up treatment. However, the audiogram was not completed until 39 days after the ENT recommendation, despite facility policies requiring Social Services to arrange indicated audiology services and to support residents in maintaining their highest practicable well-being. The resident reported being upset at times when unable to hear staff.
A resident with cognitive impairment and multiple medical conditions was admitted with personal belongings, but the Personal Effects Inventory Form was not signed by the resident or representative, nor by staff, and no copy was provided to the representative. RN, SSD, and DON interviews confirmed that the form should be completed at admission, is part of the medical record, and should be signed and shared, yet the facility had not been following this practice. Review of facility policies showed that a signed inventory must be placed in the medical record and a copy given to the resident or representative, and that medical records must be complete and accurate, which did not occur in this case.
A resident with paraplegia and total dependence for transfers was moved from a wheelchair to bed by a single CNA using an improper technique, despite care plans and therapy assessments requiring a two-person assist. The resident experienced discomfort during the transfer, and the CNA could not explain how he determined the level of assistance needed or how he was informed of residents' care requirements.
A CNA did not receive a required annual skills competency assessment, as confirmed by a review of employee records and an interview with the DSD. The DSD stated the assessment was missed due to an oversight, despite facility policy requiring annual competency validation to ensure staff performance and resident safety.
A resident's sandwich was found undated and unlabeled, posing a risk of foodborne illness. The resident, with intact cognitive skills and requiring assistance for ADLs, noted the sandwich appeared old. Interviews with the Dietary Service Supervisor and Registered Dietitian highlighted a lack of adherence to food safety protocols, as the facility's policy requires all food items to be labeled and dated.
A resident's call light was not within reach, contrary to their care plan and facility policy, placing them at risk for accidents. Staff interviews confirmed the importance of call light accessibility for resident safety and communication.
A resident with major depressive disorder repeatedly refused trazodone, but the facility failed to notify the physician as required by policy. Despite the resident's cognitive impairment, the facility did not document the refusals or inform the physician, risking the resident's health.
A facility failed to accurately complete an MDS assessment for a resident receiving dialysis, resulting in incorrect data being sent to CMS. The MDS Nurse admitted an error in marking the dialysis treatment section, despite the resident undergoing dialysis three times weekly. The resident had diagnoses of ESRD and CHF, and the facility's policy stressed the need for accurate assessments to meet guidelines.
A resident on a prescribed pureed diet was not monitored for outside food brought by family, leading to potential choking risks. The facility lacked a care plan to track the frequency and type of food, as confirmed by the DON and RD.
A resident with COPD, DM, and GERD was at risk of aspiration, requiring a pureed diet and oxygen therapy. Despite a care conference identifying the need for aspiration precautions, the care plan was not updated. The DSD and DON confirmed the oversight, which violated the facility's care planning policy.
A facility failed to reposition a resident with a stage 4 pressure ulcer every two hours, as required. The resident, with severe cognitive impairment and multiple health issues, was observed lying in the same position over two days. Staff interviews revealed a lack of documentation and clarity regarding repositioning schedules, despite facility policy requiring such interventions.
A resident with long, thick toenails did not receive timely podiatry care despite requests and visible discomfort. The CNA was aware but did not report it, and the Social Service Director, responsible for referrals, was not informed. Facility policies required referral to a podiatrist for such conditions, but this was not adhered to.
A resident at high risk for falls had their bed positioned too high, contrary to their care plan, which required the bed to be in the lowest position to prevent injuries. A CNA and the Director of Staff Development confirmed the oversight, which violated the facility's fall management and safety policies.
A resident with severe cognitive impairment and total dependence on staff for toileting was not provided with a scheduled toileting plan, despite being a candidate for such a program. The facility's policy requires individualized toileting programs for incontinent residents, but no evidence of implementation was found in the resident's records.
A resident with End Stage Renal Disease did not receive recommended nutritional care due to a failure in communication between the facility's staff and the physician. The Registered Dietitian recommended a high-calorie supplement, Novasource, which was not communicated to the physician because the facility lacked the supplement. This oversight risked the resident's nutritional status and health, contrary to the facility's policy requiring collaboration among care providers.
A LTC facility failed to label and date medications for two residents, leading to potential harm. One resident's ophthalmic solutions lacked open dates, while another's expired inhalation solution was not removed. The LVN and DON acknowledged the importance of proper labeling to ensure medication efficacy.
A facility failed to date and label a nasal cannula for a resident with COPD, contrary to its policy requiring weekly changes and labeling. Observations and interviews with the DSD and DON confirmed the oversight, which placed the resident at risk for respiratory infection.
The facility failed to comply with regulations by accommodating five residents in two rooms, exceeding the maximum allowed capacity of four residents per room. Observations and a Client Accommodations Analysis confirmed the presence of five beds in each room, despite some beds being empty at the time. The Administrator requested a renewal for a variance to address this issue.
Inaccurate MDS Hearing and Hearing Aid Coding for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment for one resident by not properly assessing and coding the resident’s hearing status and use of hearing aids. The resident had diagnoses including a left femur fracture, Parkinson’s disease, and dysphagia, and was documented as lacking capacity to understand and make decisions. An MDS assessment dated 10/29/2025 showed the resident had severely impaired cognitive skills for daily decision making and was totally dependent on staff for oral hygiene, toileting hygiene, and lower body dressing. A Social Services Assessment dated 10/27/2025 documented that the resident had both right and left hearing aids. During an interview and concurrent record review, the MDS nurse acknowledged that Section B of the MDS, which covers hearing, speech, and vision, was completed inaccurately. The nurse stated that the hearing item (B0200) was coded as 0 (Adequate) instead of 1 (Minimal difficulty), and the hearing aid item (B0300) was coded as 0 (No) instead of 1 (Yes), despite the Social Services Assessment indicating the resident had hearing aids. The MDS nurse reported she did not see the resident using hearing aids at the time of the assessment and did not follow the RAI Section B guidelines, which require ensuring the resident is using their normal hearing appliance, reviewing the medical record, and consulting family and staff. The DON confirmed that MDS assessments must be completed accurately to meet resident needs and develop an appropriate plan of care, and facility policy and the CMS RAI User’s Manual both require accurate, guideline-based resident assessments.
Failure to Care Plan for Missing Hearing Aid
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing a resident’s missing right hearing aid. The resident had been admitted and later readmitted with diagnoses including a left femur fracture, Parkinson’s disease, and dysphagia. A History and Physical documented that the resident lacked capacity to understand and make decisions, and an MDS assessment showed severely impaired cognitive skills for daily decision-making, with total dependence on staff for oral hygiene, toileting hygiene, and lower body dressing. A Theft/Loss Report documented that the resident’s right hearing aid was missing. During a concurrent interview and record review, RN 1 confirmed that there was no comprehensive care plan addressing the missing right hearing aid and described the care plan as a communication tool among the IDT that should include a problem, goal, and interventions. The MDS nurse stated that care plan development is a consolidated team effort and that the IDT should develop a care plan to address any identified resident problems or concerns. The DON stated that the care plan serves as guidance on how to care properly for residents and emphasized the importance of developing a comprehensive care plan to provide appropriate care. The facility’s policy on Person-Centered Care Planning required development and implementation of a comprehensive person-centered care plan for each resident, with measurable objectives and timeframes to meet identified needs, but this was not done for the missing hearing aid.
Delay in Audiology Consultation After Loss of Hearing Aids
Penalty
Summary
The facility failed to ensure timely access to audiology services for a resident who had documented hearing impairment and missing hearing aids. The resident, who had diagnoses including a left femur fracture, Parkinson’s disease, and dysphagia, was cognitively severely impaired and totally dependent on staff for several activities of daily living. The resident’s social services assessment documented bilateral hearing aids, and a theft/loss report later showed the right hearing aid was missing. An ENT consultation subsequently documented that the resident had hearing loss and had stopped wearing hearing aids after losing the left one, and recommended an audiogram for further assessment. A physician telephone order was placed for an audiology consultation with follow-up treatment. Despite these findings and orders, the audiogram was not completed until 39 days after it was recommended by the ENT provider. The Social Service Director acknowledged responsibility for scheduling the audiogram and stated that the referral should have been made within seven days of the recommendation. The DON stated that the resident should have been referred to audiology as soon as the missing hearing aid was identified. The resident reported losing her hearing aids and stated she sometimes became upset when she could not hear well, especially when staff spoke to her. Facility policies on resident rights and care of hearing-impaired residents required that residents receive services to maintain their highest practicable well-being and that Social Services refer residents to an audiologist when indicated, but these were not followed in a timely manner for this resident.
Failure to Complete and Share Signed Personal Effects Inventory
Penalty
Summary
The facility failed to ensure that a personal effects inventory was properly completed, signed, and shared for one resident. The resident, who had diagnoses including a left femur fracture, Parkinson’s disease, and dysphagia, was documented in the History and Physical as lacking capacity to understand and make decisions, and the MDS showed severely impaired cognitive skills and total dependence on staff for several ADLs. On review of the resident’s Personal Effects Inventory Form dated 10/23/2025, the form was found not to be signed by the resident or a resident representative, nor by facility staff at the time of admission. The resident’s representative was not provided a copy of the initial admission inventory form. RN 1 stated that the Personal Effects Inventory Form should be completed upon admission, readmission, and as needed, and acknowledged that it had never been the facility’s practice to inform and provide a copy of the inventory to the resident’s representative for items brought from the hospital. RN 1 also stated that the inventory form is part of the medical record and should be completed accurately for transparency and continuity of care. The Social Service Director stated it is important to properly document and sign the Personal Effects Inventory Form for items brought for safekeeping. The DON stated that facility staff and the resident representative should sign the form and that a copy should be provided to the representative, and that not completing and signing the form creates a risk for missing or lost personal items and incomplete medical records. The facility’s policies titled “Personal Property” and “Completion and Correction” required that the personal property inventory form be signed, placed in the medical record, and a copy provided to the resident or representative, and that medical records be complete and accurate, which was not followed in this case.
Improper Single-Person Transfer of Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with paraplegia, muscle weakness, and contractures, who was dependent for transfers and unable to stand, was transferred from a wheelchair to bed by a single CNA using an inappropriate technique. The resident's care plan specified the need for assistance with locomotion, and the physical therapy discharge summary indicated that transfers required two or more helpers for safety. Despite these documented requirements, the CNA transferred the resident alone, lifting the resident under the arms and placing him in bed without assistance. The resident reported discomfort and stated that the CNA 'picks me up and throws me in the bed,' and that this had previously resulted in foot pain. Interviews with facility staff confirmed that the resident should have been transferred with a two-person assist for safety, and that it would be difficult and unsafe for one person to perform the transfer. The CNA involved was unable to explain how he determined it was appropriate to transfer the resident alone and could not articulate how he is informed of residents' assistance needs. Facility policies reviewed emphasized the importance of safe and efficient transfers based on residents' physical abilities and the need to provide care that maintains dignity and quality of life.
Annual Skills Competency Not Completed for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had an annual skills competency assessment completed as required. During an interview and review of employee records with the Director of Staff Development (DSD), it was found that the CNA's new hire competency was completed, but the annual competency, which was due, had not been performed. The DSD acknowledged that the annual competency was missed due to an oversight. According to the facility's policy and procedure, annual competency validation is necessary to evaluate staff performance, meet regulatory standards, and address any problematic issues to protect residents' health, safety, and well-being.
Failure to Label and Date Resident's Food
Penalty
Summary
The facility failed to ensure that a sandwich for a resident was properly labeled and dated, which is a violation of food safety standards. During an observation and interview, an undated and unlabeled sandwich was found on the bedside table of a resident who was admitted with diagnoses including anxiety, COPD, and muscle weakness. The resident, who had intact cognitive skills and required assistance for activities of daily living, expressed uncertainty about the sandwich's freshness, indicating it looked old and should be discarded. Interviews with the Dietary Service Supervisor and the Registered Dietitian revealed a lack of clarity and adherence to food labeling and dating protocols. The Dietary Service Supervisor admitted to not knowing when food should be disposed of and expressed hope that staff would discard old food to prevent food poisoning. The Registered Dietitian confirmed that all sandwiches should be labeled and dated to prevent residents from consuming old food, which could lead to illness. The facility's policy, dated 2019, mandates that all food items be stored, thawed, and prepared according to good sanitary practices, including proper labeling and dating.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. During an observation, it was noted that the call light was hanging on the side of the bed and not accessible to the resident. The resident, who has chronic obstructive pulmonary disease, diabetes mellitus, and gastro-esophageal reflux disease, was dependent on staff for various activities of daily living. The resident's care plan specifically indicated that the call light should always be within reach to prevent falls and encourage the resident to use it for assistance. Interviews with staff, including a Certified Nursing Assistant and the Director of Staff Development, confirmed the importance of having the call light within reach as it serves as a critical communication tool for residents to alert staff when they need assistance. The facility's policy and procedure also mandated that call cords be placed within reach in residents' rooms. Despite these guidelines, the call light was not positioned correctly, placing the resident at risk for accidents and potentially delaying the meeting of their physical and emotional needs.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to inform the physician about a resident's persistent refusal to take trazodone, a medication prescribed for major depressive disorder. The resident, who was admitted with diagnoses including major depressive disorder, diabetes mellitus, and muscle weakness, had a physician's order for trazodone to be taken six days a week. Despite the resident's capacity to understand and make decisions, as noted in their History and Physical, the Minimum Data Set indicated moderately impaired cognitive skills for daily decision-making. The resident refused the medication on 19 occasions throughout October, but there was no documentation that the physician was notified of these refusals. The Director of Nursing confirmed that the facility's process for medication refusal includes notifying the physician and documenting the refusal in the progress notes. However, there was no evidence that the physician was informed of the resident's continued refusal, which was necessary for evaluating the reason for refusal and considering alternative treatments. The facility's policies on refusal of treatment and medication administration require documentation of the physician's notification and response, which was not adhered to in this case.
Inaccurate MDS Assessment for Resident Receiving Dialysis
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, leading to incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS). The deficiency was identified during a review of the resident's records, which revealed discrepancies between the resident's documented medical needs and the information recorded in the MDS. Specifically, the MDS indicated that the resident's cognitive skills for daily decision-making were moderately impaired, and that they required maximum assistance with toileting hygiene and dressing. However, the MDS Nurse acknowledged that there was an error in the MDS section regarding the resident's dialysis treatment, which was not accurately marked despite the resident receiving dialysis three times a week. The resident involved had been admitted with diagnoses including End Stage Renal Disease (ESRD) and congestive heart failure (CHF), and had the capacity to understand and make decisions according to their History and Physical (H&P) report. The facility's policy and procedure for the Resident Assessment Instrument (RAI) process emphasized the importance of accurate resident assessments to meet state and federal guidelines. The MDS Nurse confirmed that the inaccurate MDS assessment did not reflect the resident's actual condition and care needs, which is a mandated requirement for proper care planning and service delivery.
Failure to Monitor Resident's Diet and Outside Food Intake
Penalty
Summary
The facility failed to ensure that a care plan was in place for a resident, identified as Resident 26, to monitor the frequency and type of outside food brought in by family members. This deficiency was observed when surveyors found an empty box of a burger, a large bag of potato chips, crackers, and cans of soda in the resident's room. Despite the resident being on a prescribed pureed texture diet due to medical conditions such as COPD, diabetes mellitus, and GERD, there was no documentation or care plan addressing the monitoring of food brought by family members. The resident reported that certain foods brought by family caused coughing, and staff did not check on her ability to tolerate these foods. Interviews with the Director of Nursing (DON) and the Registered Dietitian (RD) revealed a lack of awareness and documentation regarding the resident's consumption of non-prescribed food. The DON acknowledged the absence of a care plan to monitor the resident's intake of regular textured food, which could lead to issues such as choking or aspiration. The RD confirmed that the resident should have been monitored for the types of food and textures being brought in by the family, and a care plan should have been developed to prevent potential risks during mealtimes.
Failure to Revise Care Plan for Aspiration Precautions
Penalty
Summary
The facility failed to revise the care plan for one of the residents, identified as Resident 26, who was at risk of aspiration. Resident 26 had a history of chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and gastro-esophageal reflux disease (GERD). The resident was on a pureed textured diet and required oxygen therapy, as well as assistance with toileting hygiene, showering, and dressing. During a Multidisciplinary Care Conference, it was noted that Resident 26 needed monitoring for medical management and observation due to complex medical conditions, including the need to keep the head of the bed elevated to prevent shortness of breath and to observe aspiration precautions. Despite these identified needs, the care plan for Resident 26 was not revised to include the necessary aspiration precaution interventions. This oversight was confirmed during interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), who acknowledged that the care plan should have been updated following the care conference. The facility's policy on Comprehensive Person-Centered Care Planning, which mandates periodic review and revision of care plans by the Interdisciplinary Team (IDT), was not adhered to in this instance, leading to the deficiency.
Failure to Reposition Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a stage 4 pressure ulcer was turned and repositioned every two hours, as required for proper care and prevention of further deterioration. The resident, who was admitted with multiple diagnoses including anxiety, COPD, muscle weakness, major depressive disorder, and schizoaffective disorder, was observed multiple times over two days lying in a supine position without evidence of repositioning. The resident's Minimum Data Set indicated severe cognitive impairment and a dependency on two or more helpers for activities, highlighting the need for diligent care. Interviews with facility staff, including a CNA, LVN, and the Director of Nursing, revealed a lack of documentation and clarity regarding the resident's repositioning schedule. The facility's policy on pressure injury prevention required interventions such as repositioning, but there was no specific documentation in the electronic health record to confirm that the resident was being repositioned every two hours. This oversight in care and documentation had the potential to worsen the resident's condition and delay wound healing.
Failure to Provide Timely Podiatry Care for Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident 36, who had long, thick, and elongated toenails. Despite the resident's repeated requests to see a podiatrist, no action was taken by the facility staff. The resident's toenails were observed to be causing discomfort and hindering mobility, as they hurt when touching the linen and prevented walking. The resident was admitted with diagnoses including muscle weakness, iron deficiency anemia, and protein calorie malnutrition, and was noted to have moderately impaired cognitive skills requiring moderate assistance with personal hygiene. Certified Nurse Assistant 2 acknowledged awareness of the resident's condition but did not report it to the Social Service Director, considering it not serious. The Social Service Director, responsible for referring residents to podiatry services, stated that residents with such toenail conditions should be referred immediately due to the risk of ingrown toenails and potential infections. The facility's policies on foot care and grooming indicated that high-risk residents should be referred to a podiatrist, but this protocol was not followed for Resident 36.
Failure to Maintain Bed in Lowest Position for Fall Risk Resident
Penalty
Summary
The facility failed to ensure that a resident's bed was placed in the lowest position to prevent injuries during a fall. This deficiency was identified for one of the three sampled residents, who was at high risk for falls. The resident, who had been diagnosed with chronic obstructive pulmonary disease, diabetes mellitus, and gastro-esophageal reflux disease, was dependent on staff for toileting hygiene, showering, and dressing. The resident's care plan specifically indicated that the bed should be in the lowest position as a preventive measure against falls. During an observation and interview, a Certified Nursing Assistant (CNA) confirmed that the bed was too high and should have been lowered to prevent potential injuries. The Director of Staff Development also acknowledged that the resident was at high risk for falls and that the bed should have been in the lowest position to avoid injury. The facility's policies on fall management and resident safety emphasized providing a safe environment and implementing a fall management program to minimize fall hazards, which were not adhered to in this instance.
Failure to Implement Scheduled Toileting Plan for Resident
Penalty
Summary
The facility failed to provide a scheduled toileting plan for a resident, identified as Resident 146, who was admitted with diagnoses including muscle weakness, a nondisplaced fracture of the left femur, and chronic obstructive pulmonary disease. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for toileting hygiene and lower body dressing. Despite being a candidate for scheduled toileting, as indicated by a Bowel and Bladder Program Screener score of 7, there was no documented evidence of a scheduled toileting plan being implemented for the resident. Interviews with the MDS Nurse and the Director of Nursing (DON) revealed that a scheduled toileting plan is essential for managing incontinence and preventing complications such as skin breakdown. The facility's policy requires that each resident who is incontinent be assessed and provided with appropriate treatment and services, including an individualized scheduled toileting program. However, the facility did not adhere to this policy for Resident 146, as there was no evidence of such a plan in the resident's clinical records.
Failure to Communicate Dietitian's Recommendation for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis treatment received care in accordance with standards of practice. The resident, who was admitted with diagnoses including End Stage Renal Disease and congestive heart failure, had a recommendation from a Registered Dietitian to receive a high-calorie nutritional supplement, Novasource, due to variable oral intake. However, there was no documentation indicating that the resident's physician was notified of this recommendation. The Director of Nursing confirmed that the licensed nurses did not communicate the dietitian's recommendation to the physician within the required 72-hour timeframe because the facility did not have the Novasource supplement available. This lack of communication and failure to provide the recommended nutritional supplement put the resident at risk for weight loss and dehydration, potentially leading to a decline in health condition. The facility's policy required regular collaboration between nursing staff, dialysis provider staff, and the attending physician concerning the resident's care, which was not adhered to in this case.
Medication Labeling Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly label and date medications for two residents, leading to potential harm. For Resident 34, who has glaucoma, muscle weakness, and hypertension, the facility did not label the open date on ketorolac and prednisolone acetate ophthalmic solutions. These medications are crucial for reducing inflammation after eye surgery. The Licensed Vocational Nurse (LVN) acknowledged the absence of open dates and stated it was the responsibility of the nurse who opened the medication to label it. The facility's policy requires medications to be labeled according to state and federal laws. For Resident 40, who suffers from chronic obstructive pulmonary disease (COPD) and anxiety disorder, the facility failed to label and remove an expired pouch of ipratropium with albuterol inhalation solution. This medication is essential for treating shortness of breath. The LVN found the expired medication in the medication cart without an open date, and it was unknown when it was opened. The Director of Nursing (DON) confirmed that all medications should be labeled with open and expiration dates to ensure efficacy. The report highlights the facility's non-compliance with medication labeling and storage requirements, which could lead to ineffective treatment and potential harm to residents. The manufacturer's guidelines for ipratropium with albuterol specify that opened vials should be used within one week, emphasizing the importance of proper labeling and timely usage.
Failure to Date and Label Nasal Cannula
Penalty
Summary
The facility failed to ensure that a nasal cannula used by one of the residents was properly dated and labeled, which is a requirement for maintaining sanitary conditions and preventing respiratory infections. During observations on multiple occasions, it was noted that the nasal cannula in the resident's room was neither dated nor labeled. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the nasal cannula should be changed weekly and dated to prevent the risk of respiratory infections. The facility's policy on oxygen therapy, dated November 2017, also indicated that the tubing should be changed every seven days and labeled with the date of change. The resident involved had a history of chronic obstructive pulmonary disease (COPD), diabetes mellitus, and gastro-esophageal reflux disease (GERD). The resident required oxygen therapy and was dependent on staff for various activities of daily living. The failure to date and label the nasal cannula placed the resident at risk for respiratory infection, as confirmed by both the DSD and the DON during their interviews. The facility's oversight in adhering to its own policy and procedure for oxygen therapy contributed to this deficiency.
Facility Exceeds Resident Capacity in Two Rooms
Penalty
Summary
The facility failed to ensure that two of the sampled resident rooms accommodated no more than four residents per room, as required by regulations. Observations conducted over several days revealed that room [ROOM NUMBER] had beds labeled A, B, C, D, and E, and room [ROOM NUMBER] also had beds labeled A, B, C, D, and E, indicating that each room accommodated five residents. Although some beds were empty during the observations, the facility's Client Accommodations Analysis confirmed the presence of five beds in each room. This situation was further documented in a Request for Waiver/Variance to Section 483.70, where the Administrator sought a renewal for a variation of the existing variance.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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