Penn Mar Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Monte, California.
- Location
- 3938 Cogswell Road, El Monte, California 91732
- CMS Provider Number
- 05A360
- Inspections on file
- 40
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Penn Mar Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of schizophrenia and aggression was not provided with the required 1:1 supervision as outlined in their care plan, allowing them to strike another resident without provocation. This resulted in significant injuries, including facial lacerations and a nasal bone fracture, requiring emergency medical treatment. Staff interviews confirmed the resident's unpredictable behavior and lack of clear triggers, and the discontinuation of supervision was made without physician order or documented team review.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Annual performance evaluations for three CNAs were not completed as required by facility policy. The DSD confirmed that evaluations had not been done consistently, and personnel files showed missing evaluations for multiple years.
Two residents involved in a physical altercation with potential for head trauma did not receive neurological assessments at the required 15-minute intervals during the first hour post-incident, as mandated by facility policy. Instead, neuro checks were performed only every hour for 72 hours, missing the critical initial monitoring period. The DON confirmed the deviation from policy during record review.
The facility did not post daily nurse staffing information in a prominent and accessible location as required by policy. Surveyors observed that the staffing data was not displayed anywhere in the facility, and an interview with the DSD confirmed that updates had not been made for nearly two weeks. Review of records showed no staffing postings for 13 consecutive days, despite facility policy mandating daily updates.
A resident with paranoid schizophrenia and insomnia was identified as being at risk for inappropriate social behavior, but the care plan lacked specific goals and interventions to address these behaviors. Both the ADON and Program Director confirmed the care plan was incomplete, and facility policy requiring comprehensive, measurable care plans was not followed.
A resident who was struck in the face by another resident did not receive complete neurological assessments for the required 72-hour period, as facility policy mandates after head injuries. Review of documentation showed missing neurocheck entries for one shift, and staff confirmed the assessments were not fully performed or recorded.
A resident with schizophrenia and other medical conditions was physically assaulted by another resident, resulting in facial injuries and a hospital transfer. The incident was discovered by a CNA who intervened, and staff interviews confirmed the need for monitoring residents for agitation. Despite a zero-tolerance abuse policy, the facility failed to prevent this resident-to-resident altercation.
A CNA worked for 30 days with an expired certification, as the facility failed to monitor certification expiration. The Director of Nursing confirmed the lapse, which violated the facility's policy requiring current CNA certification.
The facility failed to maintain in-service training records for CNAs in 2024, as required by policy. Interviews revealed that CNAs were unsure or confirmed not receiving necessary training in dementia care and abuse prevention. The DSD, who started in December 2024, confirmed the absence of records and training, which are crucial for staff competency and resident safety.
A facility failed to develop a care plan for a resident at high risk for elopement, resulting in the resident eloping during a court hearing. The resident, diagnosed with schizophrenia and lacking capacity for medical decisions, was part of a special treatment program where all residents were at high risk for elopement. Despite this, no care plan was created, leaving staff unaware of the specific risks and necessary interventions.
A facility failed to conduct an elopement risk assessment for a resident with schizophrenia, leading to the resident eloping during a court hearing. The LVN did not complete the assessment upon admission, and the DON confirmed it was required by policy. The resident was not identified as high risk, and proper protocols were not followed, resulting in the elopement.
A resident with schizophrenia eloped from a court hearing, and the facility failed to document the MD's notification of this change of condition in the medical record. Although the MD was informed via text, this communication was not recorded, contrary to the facility's policy. The DON acknowledged the oversight, emphasizing the importance of documentation for care team awareness.
The facility failed to complete Advance Directive Acknowledge (ADA) Forms for three residents upon admission, as required by policy. One resident's form was not initialed, another's was not check marked, and a third resident's form was missing entirely. This lack of documentation indicated that residents were not informed about their rights to refuse or accept treatment and to develop advance directives.
The facility failed to complete MDS assessments within federal time frames for three residents, potentially affecting their care. One resident's assessment was overdue, another's was not submitted before discharge, and a third's was prepared but not exported. The facility's policy requires timely transmission of MDS assessments as per CMS guidelines.
The facility failed to ensure that initial face-to-face visits were conducted by a physician for two residents. One resident was seen by a PA in person, while another was seen via telemedicine by a PA. Both residents had intact cognition and were independent in personal hygiene. The DON confirmed that initial visits should be conducted by the attending physician, as per facility policy.
The facility failed to provide RN coverage for at least 8 consecutive hours a day on three occasions, as confirmed by the DON. The absence of RN coverage was identified through a review of the facility's Assignment/Sign-In Sheet, and the DON highlighted the importance of RN availability for resident assessments, which LVNs cannot legally perform. The facility lacked a policy specifying the need for RN services for the required hours.
The facility did not conduct annual performance reviews for two CNAs, with the last reviews dated over a year ago. The DON acknowledged the importance of yearly evaluations to ensure CNAs' competencies but noted the absence of a policy requiring such reviews.
The facility failed to maintain safe food storage and handling practices, as observed in the kitchen and dry storage area. A sealed frozen roast beef lacked a received date, and expired frozen raspberries and bread products were not discarded. The DSS and DON confirmed the importance of labeling food items with received and opened dates to prevent food-borne illnesses, as per the facility's policy.
A facility failed to create a comprehensive care plan for a resident with PTSD, despite the resident's admission records indicating this diagnosis. The resident, who was independent in daily activities and had intact cognition, did not have a care plan addressing PTSD. Interviews with staff revealed a lack of awareness about the resident's PTSD, and the DON acknowledged the oversight, emphasizing the importance of care plans in addressing residents' needs.
A resident with limited range of motion and leg edema did not receive the ordered intervention of elevating her legs, as observed during a survey. Despite having an order to elevate both lower extremities due to swelling, the resident was not informed to do so and was seen limping with a swollen ankle. There was no documentation of the intervention being implemented or monitored, contrary to the facility's policies.
A CNA at the facility was scheduled to work despite having an expired CPR certification, which is a job requirement. The DON acknowledged the lapse, noting the importance of active CPR certification for responding to emergencies. The facility's policy requires licensed staff to maintain active CPR certification, but the facility failed to ensure compliance, potentially risking resident safety.
A facility failed to act on a pharmacist's recommendation regarding a resident's off-label use of Propranolol for anxiety, which was not addressed by the nurses or reviewed by the physician. The resident, diagnosed with depression and schizophrenia, was independent in daily activities. The absence of a DON during two months contributed to the oversight, as the facility did not respond to the pharmacist's monthly review as required by policy.
A facility failed to specify a behavior for the use of Ativan in a resident's physician order, which is required by policy. The resident, with diagnoses including major depression disorder and schizophrenia, had an order for Ativan for agitation/anxiety without a specific behavior indicated. The DON confirmed that specific behaviors should be noted to monitor and measure medication effectiveness.
The facility was found non-compliant with regulations as five resident rooms each housed five residents, exceeding the maximum of four per room. Despite a waiver request and claims of adequate space, the facility's policy mandates no more than four residents per room, leading to the deficiency.
A facility failed to provide individual deodorants to residents, leading to shared use and potential infection risk. Residents with schizoaffective disorder, who were independent in personal hygiene, used a shared deodorant from the nurses' station. The Interim Director of Nursing acknowledged the need for individualized deodorants to prevent infection, contrary to the facility's infection control policy.
The facility failed to protect residents from physical abuse, with multiple incidents involving aggressive behavior among residents. A resident with psychosis assaulted another resident, and staff did not intervene. Another resident was attacked with a broken plate, and two more residents were punched in separate incidents. The facility's policy emphasizes zero tolerance for abuse, yet these incidents occurred.
The facility failed to implement specific action plans under its QAPI program after identifying 31 resident-to-resident altercations over several months. Meeting minutes lacked detailed plans, only noting behavior monitoring, contrary to the facility's policy emphasizing structured processes to correct deficiencies.
A resident receiving Clozaril for hallucinations was not monitored as ordered, leading to an incident where the resident hit another. The MAR showed missing documentation for several shifts, which was confirmed by both an LVN and the DON. The facility's policy required daily monitoring of psychotropic drug use, which was not adhered to.
The facility failed to protect residents from abuse, as evidenced by incidents of physical altercations and inadequate supervision. A resident sustained a cut during a fight, and another resident with a history of aggression had an outdated care plan, increasing the risk of further incidents. Staff interviews highlighted the unpredictability of the aggressive resident, yet the facility did not revise care plans or ensure adequate supervision.
A facility failed to notify the MD of a physical altercation between two residents, where one resident punched another in the eye and forehead. Despite the incident being reported to the Administrator, DON, and Social Worker, the MD was not informed, and no change of condition was completed. This oversight could have led to serious injury, as no medical orders were obtained for monitoring the residents' conditions.
A resident with schizophrenia and auditory hallucinations was not adequately monitored by the LTC facility, despite MD orders for regular behavior checks and one-to-one supervision. The resident, who was on Depakote, was involved in physical altercations with other residents, yet monitoring lapses occurred on specific dates, increasing the risk of further incidents.
A facility failed to report an alleged abuse incident where a resident with schizophrenia hit another resident in the face. Despite the incident being reported to a charge nurse, it was not communicated to the CDPH or other authorities. Staff interviews revealed a lack of action and adherence to the facility's abuse reporting policy, which mandates reporting known or suspected abuse.
The facility failed to protect residents from physical abuse, resulting in two incidents where one resident was slapped on the head and another was kicked on the elbow by other residents. Both incidents were unprovoked and witnessed by staff, leading to feelings of fear and insecurity among the affected residents.
The facility failed to follow an MD's order for neuro-checks for a resident who sustained a head injury from a physical altercation. The checks were not completed as ordered, placing the resident at risk of not properly assessing their neurological functions.
The facility failed to prevent the elopement of a resident diagnosed with anxiety, psychosis, and schizoaffective disorder by not ensuring that locked gates were opened one at a time. Staff members simultaneously opened two gates, allowing the resident to push past them and leave the facility, resulting in the resident being missing for four days.
The facility failed to revise care plans for three residents to address specific behaviors and incidents, including inappropriate sexual behavior and physical altercations. The care plans were not individualized, and no new interventions were placed despite multiple incidents.
The facility failed to provide adequate supervision and monitoring for three residents, leading to incidents of inappropriate sexual behavior. One resident reported that another resident pulled down his pants and asked for oral sex, causing significant distress. Another resident reported a similar incident and subsequently hit the perpetrator out of frustration. Despite the facility's policies requiring 15-minute rounds and continuous monitoring, these measures were not effectively implemented.
The facility failed to report an alleged sexual abuse incident between two residents within the mandated timeframe. Despite Resident 1's report of Resident 2's inappropriate behavior, the required notifications to authorities were not made promptly, delaying the investigation. Interviews revealed that key staff were unaware of the incident, and the facility did not follow its abuse prevention policy.
Failure to Provide Supervision Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a known history of schizophrenia, anxiety, and aggressive behaviors, as outlined in the resident's care plan. The care plan specified that the resident was at risk for aggression and unsafe behaviors, with documented incidents of striking peers due to paranoid ideation. Interventions included 1:1 supervision during meals and restricted access to common areas unless accompanied by staff and deemed psychiatrically stable. However, the care plan did not specify the duration of these interventions, and there was no documented behavioral evaluation or interdisciplinary team note addressing the discontinuation of 1:1 supervision prior to the incident. On the day of the incident, the resident was not under 1:1 supervision and was able to access the patio area where another resident was present. The unsupervised resident struck the other resident in the face without provocation, resulting in significant injuries including a laceration under the left eye, a skin tear on the eyelid, and a displaced fracture of the left nasal bone. The injured resident required transfer to an emergency department for further evaluation and treatment. Staff interviews confirmed that the resident who initiated the altercation had a history of unpredictable aggression, paranoia, and auditory hallucinations, and that staff had difficulty identifying specific triggers for the aggressive behavior. Facility staff, including the administrator and mental health workers, acknowledged that the resident was no longer on 1:1 supervision based on staff discretion, without a physician's order or documented interdisciplinary review. The facility's policy required comprehensive care planning and revision as needed based on changes in the resident's condition or behavior, but there was no evidence that the care plan was appropriately updated or that supervision protocols were maintained in accordance with the resident's assessed needs. This lapse in supervision directly led to the resident-to-resident altercation and subsequent injury.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of four Certified Nursing Assistants (CNAs) as required by its own policy and procedure on performance evaluations. During an interview, the Director of Staff Development (DSD) confirmed that CNA skills evaluations had not been conducted consistently or annually, and acknowledged not having reviewed all staff evaluations since starting in the role. Personnel file reviews revealed that one CNA had no evaluation for 2024, another had no evaluations for 2022, 2023, or 2024, and a third had no evaluations for 2023 and 2024. The facility's policy, revised in August 2010, specifies that each employee's job performance must be reviewed and evaluated at least annually.
Failure to Perform Timely Neurological Assessments After Altercation
Penalty
Summary
The facility failed to perform neurological assessments according to its own policy for two residents following a physical altercation that had the potential for head trauma. Both residents were involved in a fist fight, with one sustaining minor cuts and a bruised cheek, while the other had no visible physical marks. The facility's policy required neurological checks every 15 minutes for the first hour after such incidents, but the medical records showed that neuro checks were only performed every hour for 72 hours post-incident, omitting the more frequent assessments required immediately after the event. Resident records indicated that one resident had diagnoses including schizophrenia and seizures, with intact cognitive skills and independence in daily living, while the other had schizophrenia and insomnia, also with intact cognitive skills and independence. The Director of Nursing confirmed that the neurological checks were not completed per policy, as the initial 15-minute interval checks were missed for both residents. The facility's policy, last revised in 2014, clearly outlined the required frequency of neurological assessments following potential head injuries, which was not followed in these cases.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent and accessible location as required by its own policy and procedure. During an observation, surveyors noted that the daily nurse staffing posting was not displayed outside the nursing station or anywhere else in the facility. An interview with the Director of Staff Development (DSD) revealed that the required nurse staffing information had not been updated since the beginning of the month, and the DSD acknowledged overlooking this responsibility after recently starting in the role. A review of the facility's nurse staffing posting log confirmed that no updates had been made for 13 consecutive days. The facility's policy specified that nurse staffing data must be posted daily at the beginning of each shift in a clear and readable format in a prominent place accessible to residents and visitors.
Incomplete Care Plan for Resident with Behavioral Needs
Penalty
Summary
The facility failed to develop a complete, individualized, and comprehensive care plan for one resident. The resident was admitted with diagnoses including paranoid schizophrenia and insomnia, and was noted to be cognitively intact and able to ambulate independently. The resident's Behavior Care Plan identified a risk of inappropriate social behavior, specifically touching or scratching himself in common areas. However, the care plan did not include a goal or specify interventions to address this behavior. During interviews and record reviews, both the Acting Director of Nursing and the Program Director confirmed that the care plan was incomplete. They acknowledged that without a comprehensive care plan, staff would not be informed about the necessary interventions or goals for the resident. The facility's policy required that care plans include measurable objectives and timetables to meet residents' needs, but this was not followed in this case.
Incomplete Neurological Assessments After Resident Altercation
Penalty
Summary
The facility failed to ensure that a resident received complete neurological assessments for the required 72-hour monitoring period following a resident-to-resident altercation that resulted in a hit to the face. The resident, who had diagnoses including schizophrenia and depression and was assessed as having intact cognition and decision-making capacity, reported that staff had not performed neurochecks after the incident. Review of the resident's neurocheck flowsheet revealed missing documentation for one shift during the monitoring period, and staff interviews confirmed that the assigned licensed nurse did not complete the required assessments and documentation. Facility policy required neurological assessments and documentation following any head injury or when indicated by a change in condition. The Director of Nursing and a Licensed Vocational Nurse both acknowledged the importance of these assessments and that the facility's process was not followed in this case. The incomplete neurochecks and lack of documentation after the altercation constituted a failure to provide necessary care and services as outlined in the facility's policies.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in injury. On the evening of 3/17/2025, a resident with a history of schizophrenia, diabetes mellitus, and hyperlipidemia, who was cognitively intact and independent in daily activities, was physically assaulted by another resident. The incident occurred in the victim's room, where the aggressor entered and began punching the resident on the head and face without prior interaction or provocation. The assaulted resident sustained bleeding from the nose, facial discoloration, and redness on the nose, and was subsequently transferred to a general acute care hospital for evaluation. Medical imaging confirmed there were no fractures or intracranial hemorrhage, and the resident returned to the facility with visible injuries. The aggressor, also diagnosed with schizophrenia, depression, and epilepsy, was noted to have intact cognition and independence in personal care. Following the altercation, the aggressor exhibited increased agitation and physical aggression, but was later observed to be calm and interacting well with others. Staff interviews revealed that the incident was discovered when a certified nurse assistant heard calls for help and witnessed the assault in progress. The staff member immediately intervened, separating the residents. Both the CNA and an LVN confirmed the injuries and described the need for monitoring residents for agitation and behavioral changes to prevent such incidents. The facility's policy on abuse prevention explicitly states a zero-tolerance approach to abuse, neglect, and mistreatment by anyone, including other residents. Despite this policy, the incident demonstrated a failure to ensure the safety of residents from physical abuse by peers. The deficiency was identified through direct observation, interviews with staff and residents, and review of medical records and facility policies.
CNA Worked with Expired Certification for 30 Days
Penalty
Summary
The facility failed to ensure that one of its Certified Nursing Assistants (CNA 6) maintained an active CNA certification, resulting in CNA 6 working for 30 days with an expired certification. This lapse was identified through interviews and record reviews, which revealed that CNA 6's certification had expired, yet they continued to work during this period. The Director of Staff Development acknowledged the expiration, and the Director of Nursing confirmed that CNA 6 worked for 30 days post-expiration, indicating a lack of monitoring for staff certification expiration. The facility's policy requires CNAs to have a current certification, which was not adhered to in this case.
Deficiency in CNA In-Service Training Records
Penalty
Summary
The facility failed to maintain and provide necessary in-service training records for Certified Nursing Assistants (CNAs) for the year 2024, as required by their policy on record retention. This deficiency was identified during interviews and record reviews involving three CNAs and the Director of Staff Development (DSD). CNA 3 was unsure about receiving dementia care training, while CNA 4 confirmed not receiving such training. CNA 5 reported receiving only three in-services throughout the year, indicating irregular training schedules. The DSD, who began working at the facility in December 2024, confirmed the absence of training records for 2024 and the lack of in-services on critical topics like dementia care and abuse prevention. The Director of Nursing (DON) corroborated the absence of documented evidence of in-services for the entire year of 2024, which is crucial for ensuring staff competency in resident care. The facility's policy mandates that all CNA training records be retained for four years, but the records for 2024 were missing. The DSD emphasized the importance of these records in ensuring staff are trained on relevant topics to maintain resident safety and care standards. The lack of in-service training records and the failure to provide necessary training could potentially impact the quality of care provided to residents.
Failure to Develop Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a care plan for a resident identified as high risk for elopement, which resulted in the resident eloping while attending a court hearing. The resident was admitted with a diagnosis of schizophrenia and lacked the capacity to make medical decisions, as indicated in their History and Physical. Despite this, the Minimum Data Set showed the resident's cognitive abilities were intact. The Director of Nursing acknowledged that all residents in the special treatment program were at high risk for elopement, yet no care plan was in place for this resident. Interviews with the Director of Nursing and a Licensed Vocational Nurse revealed that there was no care plan addressing the risk of elopement for the resident. The facility's policy required a licensed nurse to initiate and update care plans as needed, but this was not done for the resident in question. The absence of a care plan meant that staff were not informed of the specific at-risk behavior or how to provide appropriate care, leading to the resident's elopement.
Failure to Conduct Elopement Risk Assessment
Penalty
Summary
The facility failed to implement its policy on wandering and elopement by not performing an elopement risk assessment upon admission for a resident diagnosed with schizophrenia. This oversight was identified during a review of the resident's admission records, which showed that the section for wandering and elopement assessment was left blank. A Licensed Vocational Nurse (LVN) confirmed that the elopement risk assessment was not completed and expressed uncertainty about whether it was required at the time of admission. The Director of Nursing (DON) acknowledged that the assessment should have been completed according to facility policy. The deficiency resulted in the resident eloping during a court hearing attended with their public conservator. The facility's policy required that residents identified as high risk for elopement be placed in restraints and escorted by trained staff when leaving the facility. However, this protocol was not followed because the resident had previously left with the conservator without incident. The failure to complete the elopement risk assessment meant that staff could not identify the resident as a high risk for elopement, potentially leading to serious injury during the incident.
Failure to Document MD Notification of Resident Elopement
Penalty
Summary
The facility failed to document the Medical Doctor's (MD) notification of a change of condition (COC) in the medical record of a resident who eloped from a court hearing. The resident, who was admitted with schizophrenia and had a history indicating a lack of capacity to make medical decisions, eloped from a court hearing. Despite the resident's cognitive abilities being noted as intact in a recent assessment, the facility did not document the MD's notification of this significant event in the resident's medical record. Licensed Vocational Nurse 1 (LVN 1) confirmed that the MD was notified via text message on the day of the elopement, but this communication was not recorded in the resident's medical record. The Director of Nursing (DON) acknowledged that the COC should have been documented in the medical record to ensure all care team members were aware of the situation. The facility's policy required documentation of the time, method, and response of the MD notification, which was not followed in this instance.
Failure to Complete Advance Directive Acknowledge Forms
Penalty
Summary
The facility failed to implement its Policy and Procedure on Advance Directives for three residents by not ensuring the completion of the Advance Directive Acknowledge (ADA) Form upon admission. For Resident 41, the ADA Form was not initialed, indicating that the resident was not provided with written materials or informed about her rights to refuse or accept treatment and to develop an advance directive. During an interview, Resident 41 could not recall receiving information about advance directives, and the Licensed Vocational Nurse confirmed the form was incomplete. Similarly, Resident 2's ADA Form was not check marked to indicate that the resident was informed about their rights regarding medical treatment and advance directives. The Licensed Vocational Nurse was unsure if the discussion about advance directives took place. The Director of Nursing emphasized the importance of knowing the resident's wishes to provide appropriate emergency treatment when incapacitated. For Resident 20, there was no ADA Form in the medical record, and the Director of Nursing stated that the form should have been part of the admission package. The absence of the form meant that the facility did not have documented information about the resident's wishes in case of incapacitation. The facility's policy required that residents be informed and provided with written information about their rights to accept or refuse medical treatment, which was not adhered to in these cases.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) quarterly assessments were completed within the federal time frames as required by the Centers for Medicare and Medicaid Services (CMS) for three residents. Resident 1's quarterly MDS assessment was not completed on time, as the last assessment was done on 7/13/2024, and the next was due on 11/5/2024, but was missed. The MDS Coordinator acknowledged the oversight and emphasized the importance of timely assessments to prevent deterioration or decompensation of the resident's health condition. Resident 7's quarterly MDS was not submitted before the resident was discharged, and Resident 14's MDS was prepared but not exported, causing it to be overdue. The facility's policy and procedure require MDS assessments to be transmitted according to the CMS RAI OBRA Required Assessment Summary schedule, which mandates that the Assessment Reference Date (ARD) should be no later than 92 calendar days from the previous assessment, and completion should be within 14 days after the ARD. These lapses in timely MDS submissions could potentially affect the care provided to the residents.
Failure to Ensure Physician Conducted Initial Visits
Penalty
Summary
The facility failed to ensure that the initial face-to-face visit was conducted by a physician for two residents. Resident 41 was admitted with diagnoses including pain in the left ankle and joints, alcohol use, and schizophrenia. The initial face-to-face visit for Resident 41 was conducted by a physician assistant (PA) instead of a physician. Similarly, Resident 247, who was admitted with anxiety and psychosis, had their initial visit conducted via telemedicine by a PA. Both residents had intact cognition and were independent in personal hygiene activities. During interviews and record reviews, it was confirmed that the initial visits for both residents were not conducted by the attending physician as required. The Director of Nursing acknowledged that initial comprehensive assessments should be conducted face-to-face by the attending physician to determine the medical needs of the residents. The facility's policy indicated that initial comprehensive visits should not be performed by PAs or nurse practitioners not employed by the facility.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day for three out of seven days in the specified period. This deficiency was identified through a review of the facility's Assignment/Sign-In Sheet for all shifts, which indicated no RN coverage on the dates of 4/7/2024, 5/5/2024, and 6/9/2024. During an interview, the Director of Nursing (DON) confirmed the absence of RN coverage on these days and emphasized the importance of having an RN available to perform resident assessments, which Licensed Vocational Nurses (LVNs) are not legally permitted to do. The lack of RN coverage could potentially lead to improper resident treatment and hospitalization. Additionally, the facility did not have a policy and procedure specifying the need for RN services at least 8 consecutive hours a day, 7 days a week.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for two Certified Nursing Assistants (CNAs), specifically CNA 2 and CNA 3, as required. During an interview and review of personal files with the Director of Staff Development (DSD), it was found that CNA 2's last performance review was conducted on September 6, 2022, and CNA 3's on September 9, 2022. No subsequent reviews were completed for these CNAs in 2023 or 2024. The Director of Nursing (DON) confirmed that the facility should perform yearly evaluations to assess CNAs' strengths, weaknesses, and competencies, which are crucial for ensuring quality and safe care for residents. However, the facility lacked a policy mandating annual performance reviews for nurse aides.
Deficiency in Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain safe food storage and handling practices in its kitchen, as observed during a survey. Specifically, a sealed frozen roast beef in Freezer 1 was not labeled with a received date, which is necessary to track the freshness and safety of the food. Additionally, in the dairy freezer, an opened bag of frozen raspberries and an unopened bag of frozen raspberries were found with expiration dates but without received or opened dates labeled. This lack of labeling prevents the facility from ensuring that food items are used while they are still safe and of high quality. Further observations in the dry storage area revealed two bags of toasted bread and three bags of hamburger buns that were past their best by dates, indicating they were expired. The Dietetic Services Supervisor (DSS) confirmed that all food items should be labeled with received and opened dates to ensure they are consumed before expiration, thus preventing food-borne illnesses. The Director of Nursing (DON) also emphasized the importance of labeling to prevent the use of expired food. The facility's policy on receiving food and supplies requires items to be dated and rotated using the FIFO method, which was not adhered to in these instances.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who was admitted with diagnoses including mood disorder, anxiety, and PTSD, had intact cognition and was independent in activities such as oral care, toileting, and personal hygiene. Despite these diagnoses, the resident's care plan did not address PTSD, which is a significant oversight given the resident's mental health needs. Interviews with facility staff revealed a lack of awareness and understanding of the resident's PTSD diagnosis. A Licensed Vocational Nurse (LVN) was unaware of the resident's PTSD and did not know of any interventions for this condition. The Director of Nursing (DON) acknowledged the importance of care plans in guiding staff to address residents' needs and stated that a care plan for PTSD should have been created upon the resident's admission. The facility's policy on care planning emphasized the need for comprehensive, person-centered care plans based on individual assessed needs, which was not adhered to in this case.
Failure to Implement Interventions for Resident's Leg Edema
Penalty
Summary
The facility failed to implement necessary interventions for a resident with limited range of motion and leg edema, as observed during a survey. The resident, who was admitted with diagnoses including pain in the left ankle and schizophrenia, had an order to elevate both lower extremities due to swelling. However, during an observation and interview, the resident was seen limping and dragging her left leg, with a swollen ankle, and reported not being informed to elevate her legs at night. Further investigation revealed that there was no documentation of the resident's legs being elevated or the swelling being monitored since the order was given. The Licensed Vocational Nurse confirmed the lack of documentation, and the Director of Nursing acknowledged the staff's responsibility to manage both the psychological and medical conditions of residents. The facility's policies emphasized maintaining residents' abilities in activities of daily living and proper documentation of physician orders, which were not adhered to in this case.
Expired CPR Certification for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 3) maintained an active Basic Life Support/Cardiopulmonary Resuscitation (BLS/CPR) certification, which is a requirement for employment at the facility. CNA 3 was hired and scheduled to work four days a week despite having an expired CPR certificate. The Director of Nursing (DON) acknowledged that CNA 3's CPR certification had expired and emphasized that maintaining an active CPR certification is crucial for CNAs to respond effectively to breathing and cardiac emergencies, which is a part of their job requirement. The facility's policy mandates that licensed nursing staff must be certified in basic CPR and maintain active certification. However, the facility did not follow up on the CPR status of CNA 3, leading to the scheduling of CNA 3 without an active CPR certificate. This oversight had the potential to place residents at risk by not ensuring that staff could competently respond to emergencies, thereby affecting the residents' rights and well-being.
Failure to Address Pharmacist's Medication Regimen Review Recommendation
Penalty
Summary
The facility failed to act upon the pharmacist's medication regimen review (MRR) recommendation for one of the sampled residents, Resident 24. The pharmacist identified that Resident 24 was prescribed Propranolol 10 mg twice a day for anxiety, which is an off-label use not approved by the FDA for this indication. According to CMS guidelines, this could be considered duplicate or unnecessary therapy. The facility's policy required that clinical recommendations from the pharmacist be addressed within 14 days, but there was no documentation indicating that the recommendation was addressed by the nurses, notified to the physician, or reviewed by the physician. Resident 24 was admitted with diagnoses including depression disorder and schizophrenia. The resident was independent in various activities of daily living and had clear communication abilities. The Director of Nursing (DON) confirmed that the facility had no DON in position during September and October 2024, which contributed to the oversight. The consultant pharmacist visited the facility monthly to review medication regimens and provide recommendations, but the facility staff failed to respond to the pharmacist's recommendation, potentially affecting the resident's health conditions and thought processes.
Lack of Specific Behavior Indication for Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure that a physician's order for the psychotropic medication Ativan for a resident included a specific indicated behavior for its use. The resident, who was admitted with diagnoses including major depression disorder, diabetes mellitus, and schizophrenia, had a physician order for Ativan to be administered as needed for agitation/anxiety related to an anxiety disorder. However, the order did not specify the exact behavior that would necessitate the use of Ativan, which is a requirement according to the facility's policy. During an interview, the Director of Nursing acknowledged that the psychotropic medication order should indicate specific behaviors to be monitored and care planned. Without this information, staff would not be able to determine if the resident's behavior was improving or worsening, nor could they measure the effectiveness of the medication properly. This oversight had the potential to result in the resident receiving unnecessary medications, experiencing side effects, and not maintaining their highest practicable level of well-being.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to ensure compliance with the regulation that resident rooms accommodate no more than four residents. During an observation, it was noted that five out of eleven resident bedrooms, specifically Rooms 25, 27, 29, 31, and 33, each housed five residents. This arrangement was contrary to the facility's policy and procedure, which mandates that resident rooms should not accommodate more than four residents. The facility had requested a waiver for these rooms, citing that the rooms had adequate space for residents' use and movement, and there were no adverse effects on nursing care, comfort, and privacy. The Client Accommodation Analysis form confirmed that each of these rooms, measuring 464.96 square feet, was occupied by five ambulatory residents. The facility's Room Waiver Request Letter supported the claim that there was ample space for wheelchairs, medical equipment, and resident mobility. During an interview, the Administrator verified the occupancy and stated that the rooms provided adequate space for care without jeopardizing residents' health and safety. Despite these assertions, the facility's policy clearly indicated that rooms should not accommodate more than four residents, leading to the identified deficiency.
Shared Deodorant Use Among Residents
Penalty
Summary
The facility failed to ensure that three sampled residents were provided with their own deodorant for personal use, which had the potential to increase the risk of spreading infection among them. The residents involved were diagnosed with schizoaffective disorder, and they were independent in personal hygiene activities according to their Minimum Data Set (MDS) assessments. During an observation, an unlabeled deodorant spray was found in a tray at the nurses' station, which was used as a shared deodorant among residents. Interviews with the Licensed Vocational Nurse (LVN) and the Interim Director of Nursing (IDON) revealed that residents would request the deodorant from the nurses' station, use it, and then return it. The IDON acknowledged that deodorants should be individualized and not shared to prevent infection. The facility's policy and procedure on infection prevention and control emphasized maintaining a safe environment to prevent disease transmission, but this practice was not followed in the case of deodorant use.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving aggressive behavior among residents. Resident 1, who was admitted with a diagnosis of psychosis, physically assaulted Resident 2 by kicking and hitting them on the face and arms. Despite staff presence during the altercation, they did not physically intervene, and Resident 1 was able to attack Resident 2 a second time. The facility's video recording confirmed that staff did not attempt to physically stop the fight, and Resident 1 was left unescorted after the incident. In another incident, Resident 1 attacked Resident 3 with a broken plastic plate, causing multiple wounds. The attack occurred during breakfast in the dining room, where Resident 1 broke the plate and used it to stab Resident 3. The facility's video recording showed Resident 1 intentionally hitting and stabbing Resident 3, and staff did not intervene to prevent the attack. Resident 1's actions were reportedly motivated by Resident 3's involvement in a previous altercation between Residents 1 and 2. Additionally, Resident 5 was involved in two separate incidents of physical aggression. Resident 5 punched Resident 7 on the patio and later punched Resident 6 in the medication line. Both incidents were captured on video, showing Resident 5's aggressive behavior towards other residents. The facility's policy on abuse prevention and resident rights emphasizes zero tolerance for abuse, yet these incidents demonstrate a failure to protect residents from harm.
Failure to Implement QAPI Action Plans for Resident Altercations
Penalty
Summary
The facility failed to implement appropriate plans of action under its Quality Assurance and Performance Improvement (QAPI) program after identifying 31 resident-to-resident altercations from January to July 2024. During a review of the facility's Quality Assurance/Risk Management Committee Meeting minutes, it was noted that there were multiple altercations each month, with 4 in January, 1 in February, and 10 in March. Despite these incidents, the minutes only indicated that nursing staff would continue to monitor resident behavior to prevent altercations, without specifying any concrete plans of action or expected outcomes. Further review of the meeting minutes from July 2024 revealed a lack of detailed documentation on the number of altercations from April to July, and again, no specific plans of action were noted. The Administrator acknowledged that the QAPI minutes did not include specific plans to address the altercations, only mentioning behavior monitoring. The facility's Policy and Procedure on Quality Assessment & Assurance emphasized the need for structured processes to correct deficiencies and monitor the effects of action plans, which were not reflected in the QAPI minutes.
Failure to Monitor Resident on Psychotropic Medication
Penalty
Summary
The facility failed to adequately monitor a resident who was receiving Clozaril for auditory and visual hallucinations as ordered by the physician. The resident, who was admitted with diagnoses including schizophrenia and tobacco use, was supposed to be monitored every shift for hallucinations. However, the Medication Administration Record (MAR) showed that behavior monitoring was not documented on several night shifts. This lack of monitoring was confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the monitoring should have been completed and documented as ordered. The deficiency was highlighted when the resident, experiencing auditory hallucinations, hit another resident. The facility's policy on psychotherapeutic drug management required daily monitoring of psychotropic drug use and the use of non-pharmacological interventions when indicated. The failure to monitor the resident's condition as ordered prevented the facility from updating interventions to address the resident's specific behaviors, potentially leading to harm.
Failure to Prevent Resident Abuse and Update Care Plans
Penalty
Summary
The facility failed to protect residents from emotional and physical abuse, as evidenced by multiple incidents involving residents. On one occasion, two residents engaged in a physical altercation on the patio, resulting in one resident sustaining a superficial cut on the lip. The altercation was preceded by verbal aggression, and no staff was present to intervene when the fight began. The facility's policy mandates zero tolerance for abuse, yet the staff failed to prevent the altercation or provide adequate supervision. Another incident involved a resident who repeatedly exhibited aggressive behavior towards peers and staff. This resident's care plan was not updated despite multiple instances of aggression, including hitting other residents and staff members. The facility's policy requires care plans to be revised following any change in condition or behavior, but this was not adhered to, leaving other residents at risk of further incidents. Interviews with staff and residents revealed that the aggressive resident was known to be unpredictable and had a history of altercations. Despite this, the facility did not take appropriate measures to manage the resident's behavior or ensure the safety of others. The lack of timely updates to the care plan and insufficient staff intervention contributed to the ongoing risk of abuse within the facility.
Failure to Notify MD of Resident Altercation
Penalty
Summary
The facility failed to notify the Medical Doctor (MD) of a physical altercation between two residents, which occurred on 5/24/2024. Resident 6 punched Resident 5 in the left eye and forehead, but the incident was not reported to the MD, and a change of condition (COC) was not completed for either resident. This oversight was identified during interviews and record reviews, where it was noted that the incident was reported to the Administrator, Director of Nursing (DON), and the facility's Social Worker, but not to the MD. The facility's policy and procedure for Change of Condition Notification requires that physicians be informed of changes in residents' conditions in a timely manner, which was not adhered to in this case. Resident 5, who was admitted with diagnoses including schizoaffective disorder and insomnia, complained of a headache with a pain level of five out of ten following the altercation. Resident 6, diagnosed with schizophrenia and insomnia, was noted to have intact cognitive abilities. Despite the altercation and Resident 5's complaint of pain, no medical orders such as neurological checks or x-rays were obtained due to the failure to notify the MD. This lack of notification had the potential to result in serious injury to the residents involved.
Failure to Monitor Resident with Auditory Hallucinations
Penalty
Summary
The facility failed to adequately supervise and monitor a resident, identified as Resident 6, who was receiving Depakote for behavior problems related to auditory hallucinations. The facility did not monitor Resident 6's behavior on specific dates, despite having an MD order to do so every shift. Additionally, the facility did not provide one-to-one monitoring for Resident 6 on a day when it was ordered due to aggressive behavior towards others. These lapses in monitoring occurred even after Resident 6 had been involved in physical altercations with other residents, which were documented in nursing notes. Resident 6, who was admitted with diagnoses including schizophrenia and insomnia, had intact cognitive abilities according to a recent assessment. Despite this, the resident reported hearing voices that instructed them to harm others, leading to incidents where Resident 6 pushed and punched another resident. Interviews with staff confirmed that Resident 6's behavior was unpredictable and required close monitoring. The facility's failure to adhere to the MD's orders for monitoring and supervision posed a risk of further altercations and potential harm to Resident 6 and others.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to adhere to its Policy and Procedure on Abuse Reporting by not reporting an alleged physical abuse incident involving two residents to the California Department of Public Health (CDPH). Resident 9, who has a diagnosis of schizophrenia and intact cognitive abilities, hit Resident 5 on the left side of the face. This incident occurred in the hallway when Resident 5 was exiting their room. Despite Resident 5 reporting the incident to the charge nurse and expressing concerns about future altercations due to shared bathroom facilities, the incident was not reported to the appropriate authorities. Interviews with facility staff revealed a lack of communication and action regarding the incident. Certified Nursing Assistant 3 was aware of the incident but unsure if it was reported to CDPH, Police, or Ombudsman. The RN Supervisor did not report the incident to the Administrator, as there were no visible injuries on either resident, although it was considered alleged physical abuse. The Director of Nursing confirmed that the incident was not reported to the Administrator or themselves, acknowledging the risk of recurrence. The facility's policy mandates staff to report known or suspected abuse, which was not followed in this case.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two incidents involving residents. In the first incident, Resident 1, who has schizophrenia, type 2 diabetes mellitus, and hyperlipidemia, was slapped on the back of the head by Resident 2 while sitting on the patio. Resident 1, who is moderately impaired in cognitive skills, expressed feeling afraid and unsafe after the incident. Resident 2, who also has schizophrenia and no cognitive impairment, had a history of aggressive behavior, including hitting female residents on consecutive days. The incident was witnessed by a Certified Nursing Assistant (CNA), who confirmed that Resident 2 slapped Resident 1 without provocation, causing Resident 1 to feel fearful and seek comfort from the CNA. In the second incident, Resident 3, who has schizophrenia, anxiety disorder, and major depressive disorder, was kicked on the left elbow by Resident 4 while lying on the hallway floor. Resident 3, who has no cognitive impairment, was unable to explain why Resident 4 kicked him. Resident 4, who has schizophrenia, type 2 diabetes mellitus, and hyperlipidemia, admitted to kicking Resident 3 intentionally and has a history of aggressive behavior towards both staff and residents. This incident was also witnessed by a CNA, who observed Resident 4 walking up to Resident 3 and kicking him without provocation. The facility's policy on abuse prevention and prohibition, which emphasizes zero tolerance for abuse, neglect, and mistreatment, was not effectively implemented in these cases. Both incidents highlight the facility's failure to protect residents from physical abuse, resulting in feelings of fear and insecurity among the affected residents. The facility's documentation and staff interviews corroborate the occurrences of these unprovoked attacks, indicating a lapse in ensuring a safe environment for all residents.
Failure to Follow MD Orders for Neurological Checks
Penalty
Summary
The facility failed to follow a Medical Doctor's (MD) order for neurological checks (neuro-checks) for Resident 3 after the resident sustained a hit to the head from a physical altercation with another resident. The MD's order, dated 3/27/2024 at 9:59 PM, required neuro-checks every four hours for 24 hours, then every shift for two days. However, the neuro-checks were not completed as ordered. The Director of Nurses (DON) confirmed that the neuro-checks should have continued until the evening of 3/30/2024 but were not properly carried out, with gaps in the assessments noted on 3/28/2024. Resident 3, who was admitted with diagnoses including anxiety, insomnia, and stimulant abuse, reported being hit on the left side of the face by another resident during a medication pass. The resident developed a headache following the incident. Licensed Vocational Nurse (LVN) 1 confirmed the incident and the subsequent MD order for neuro-checks and Tylenol. The failure to complete the neuro-checks as ordered was acknowledged by the DON, who stated that this placed the resident at risk of not properly assessing their neurological functions. The facility's policy and procedure for physician orders, dated 10/1/2023, indicated that licensed nurses are responsible for documenting and implementing MD orders, which was not followed in this case.
Failure to Prevent Resident Elopement Due to Improper Gate Management
Penalty
Summary
The facility failed to prevent the elopement of a resident by not ensuring that locked gates were opened one at a time. The Director of Staff Development (DSD) and another staff member simultaneously opened two locked gates, allowing Resident 4 to push past them and leave the facility. This resulted in Resident 4 being missing for four days, with the potential for injury and harm. Resident 4 had been admitted with diagnoses including anxiety, psychosis, and schizoaffective disorder. The resident was on absent without leave (AWOL) precautions, and staff were instructed to ensure the resident was not on the patio and to perform one-to-one therapy to monitor AWOL behavior. Despite these precautions, the resident was able to elope when both gates were opened simultaneously by staff members who did not see each other. Interviews with various staff members, including the DSD, Licensed Vocational Nurse (LVN), and other staff members, revealed that the facility's policy required one gate to be locked before opening the next. Staff members admitted that they did not follow this protocol, leading to the resident's elopement. The Director of Nursing (DON) confirmed that staff did not adhere to the facility's policies and procedures, which contributed to the incident.
Failure to Revise Care Plans for Residents with Behavioral Issues
Penalty
Summary
The facility failed to revise the care plans for three residents (Resident 2, 4, and 7) to address specific behaviors and incidents. For Resident 2, the care plan was not updated after three incidents of alleged inappropriate sexual behavior. These incidents included Resident 2 asking another resident for oral sex, engaging in oral sex with a roommate, and entering another resident's room at night to ask for oral sex. Despite these incidents, no new interventions were placed, and the care plan remained unchanged. For Resident 4, the care plan was not revised after Resident 4 hit Resident 2 in the face. This incident occurred after Resident 2 allegedly entered Resident 4's room at night and engaged in inappropriate sexual behavior. The care plan did not address Resident 4's aggressive behavior or the psychosocial impact of the alleged sexual abuse. For Resident 7, the care plan was not updated after multiple physical altercations with another resident. These altercations occurred on several occasions, but the care plan did not include new interventions to address Resident 7's aggressive behavior. The facility's Director of Nursing acknowledged that the care plans were not individualized to meet the residents' needs and that the Interdisciplinary Team meetings were not completed to address these incidents.
Inadequate Supervision and Monitoring Leading to Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for three residents, leading to incidents of inappropriate sexual behavior. Resident 1 reported that Resident 2 pulled down his pants and asked Resident 1 to perform oral sex in Resident 2's room. This incident caused Resident 1 significant mental and emotional distress until Resident 2 was moved to another room. Resident 1's cognitive abilities were intact, and he had a history of schizoaffective disorder, suicidal behavior, and insomnia. The incident was reported to the Recreational Activities Assistant (RAA) and documented in the Nursing Note (NN) dated 2/14/2024. Resident 2 denied the allegations, and the previous Director of Nursing and Social Worker were notified through phone and voicemail, respectively. Resident 4 reported that Resident 2 came into his room in the middle of the night, pulled down his blanket, and tried to grab his genitals while asking for oral sex. This incident led Resident 4 to hit Resident 2 on the back of the head the following morning due to feeling upset. Resident 4's cognitive abilities were also intact, and he had a history of schizophrenia, hyperlipidemia, and tobacco use. The incident was documented in the Nursing Notes (NN) and Social Services Notes (SSN) dated 3/18/2024. Resident 4 did not report the incident to staff immediately but later identified Resident 2 as the perpetrator. Interviews with staff confirmed that Resident 4 was visibly upset and identified Resident 2, who was wearing a red shirt at the time. Resident 2 had a history of socially inappropriate behavior, including going into other residents' rooms, being intrusive, and removing clothing in front of others. Despite these behaviors, the facility's care plan for Resident 2 included interventions such as identifying triggers, discussing medication effectiveness, and attending group therapy sessions. The facility's policies and procedures required staff to monitor residents every 15 minutes and conduct continuous rounds/headcounts. However, these measures were not effectively implemented, leading to the incidents involving Resident 1 and Resident 4. Interviews with staff, including the Director of Nursing (DON), confirmed that residents with inappropriate sexual behavior required closer monitoring, which was not adequately provided in these cases.
Failure to Report Alleged Sexual Abuse Incident Timely
Penalty
Summary
The facility failed to report an alleged sexual abuse incident between two residents within the federally mandated timeframe. Resident 1, who has schizoaffective disorder and other mental health issues, reported that Resident 2, also diagnosed with schizoaffective disorder, had pulled down his pants and asked for oral sex. This incident was reported to a Recreational Activities Assistant and subsequently to an LVN, but the required notifications to the California Department of Public Health, local law enforcement, and the Ombudsman were not made within the two-hour window as stipulated by the facility's policy and procedure on abuse prevention and prohibition. Interviews and record reviews revealed that the Social Worker was not informed of the incident, and the Director of Nursing was unaware of the event until much later. Resident 1 expressed feelings of unsafety and distress following the incident, and Resident 2 admitted to exposing himself to Resident 1. Despite the severity of the allegations, the facility did not take immediate action to report the incident to the appropriate authorities, thereby delaying the initiation of an investigation. The facility's policy requires immediate reporting of any abuse allegations, but this protocol was not followed. The Administrator confirmed that the incident should have been reported as alleged sexual abuse and acknowledged the failure to adhere to the reporting requirements. The lack of timely reporting and appropriate intervention measures highlights a significant lapse in the facility's abuse prevention and reporting procedures.
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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