Rancho Mirage Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rancho Mirage, California.
- Location
- 39950 Vista Del Sol, Rancho Mirage, California 92270
- CMS Provider Number
- 555247
- Inspections on file
- 31
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Rancho Mirage Health And Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively impaired, wheelchair-bound resident with hemiplegia and hemiparesis was allowed to exit through automatic doors to an unsupervised front patio and parking lot area that lacked caution signage, barriers, or staff monitoring. The resident’s MDS showed moderate cognitive impairment, but the care plan did not include interventions for injury risk related to impaired cognition. While self-propelling in the parking lot, the resident was struck on the side of the wheelchair by a backing SUV whose driver did not see the resident, resulting in elbow pain. Multiple staff, including the DON, LVNs, CNA, and COTA, acknowledged that cognitively impaired residents required supervision outside and should not be in the front patio or parking lot alone.
A resident recovering from joint replacement surgery was awakened late at night by a CNA, at the direction of an RN, to discuss a non-urgent room change, despite facility policy and standard practice to address such matters when residents are awake. This action failed to respect the resident's dignity and right to self-determination.
A resident at risk for falls due to impaired mobility and a history of falls was not provided with a tab monitor while in a wheelchair, as required by the care plan. The resident experienced a fall after attempting to ambulate without assistance. Staff interviews confirmed the oversight, and facility policy mandates the use of tab alarms for such residents.
The facility failed to properly dispose of garbage, as observed when three dumpsters had open lids and trash scattered around them. The Dietary Supervisor and Maintenance Supervisor confirmed the dumpsters should have been closed and the area clean to prevent pest infestations. The facility's policy requires dumpsters to be closed and free from litter.
The facility failed to properly label and store medications, including bisacodyl suppositories without proper labels, multi-dose medications without open dates, and a ferrous sulfate solution with an illegible expiration date. Additionally, the medication room temperature exceeded recommended levels, potentially affecting medication efficacy.
The facility failed to maintain sanitary food preparation and storage practices, as observed during a survey. A puree blender had food residue, spilled oatmeal was on the storage room floor, and ovens had grime buildup. A staff's cup was improperly stored, and a cook's beard was uncovered during food preparation. These issues posed a risk of foodborne illness to residents.
A facility failed to maintain a functioning paper towel dispenser in a resident's bathroom, impacting hand hygiene and infection prevention. Despite the resident reporting the issue to the Case Manager and Infection Preventionist nurse, the problem was not resolved due to a lack of follow-up and communication breakdown. The Director of Nursing highlighted the importance of hand hygiene in preventing infection spread.
A facility failed to notify the LTC Ombudsman of a resident's discharge to a hospital at the same time the resident received the notice, as required by policy. The resident, who was cognitively intact and diagnosed with fatty liver, was discharged due to jaundice. The notice was sent to the Ombudsman 27 days late, as admitted by the Case Manager responsible for the task.
The facility failed to remove expired medications from use, as observed during an inspection of medication carts. A discontinued hydroxyzine bubble pack and an expired Humalog Qwikpen were found in the carts. Staff acknowledged that these items should have been removed according to the facility's medication labeling and storage policy, which requires multi-dose vials to be discarded within 28 days.
A facility failed to transcribe a physician's order for oxygen therapy into the electronic medical record for a resident with pneumonia and dementia under hospice care. The order was placed in the physical chart by a hospice nurse but was not entered into the electronic system, leading to an incomplete medical record. Staff interviews revealed that the responsibility for transcription lay with the licensed nurse who received the order, but it was overlooked.
A facility failed to provide a CNA with education on the risks and benefits of the COVID-19 vaccine, as required by their policy. The CNA's last vaccination was three years prior, and there was no documentation of the necessary education being provided. The Infection Preventionist admitted to not providing the education, despite being responsible for it. This deficiency was identified through interviews and record reviews.
A resident with limited mobility and cognitive impairment was found unable to reach her call light, which was tied to the bed rail and hanging towards the floor. Staff confirmed that the call light should have been clipped to the resident's clothing for accessibility, as per facility policy and expectations.
A resident with a brain hemorrhage and mild cognitive impairment was not provided with a care plan addressing her hearing impairment, despite wearing hearing aids and reporting difficulty hearing. The facility's baseline and comprehensive care plans failed to include her hearing issues, and staff interviews revealed a lack of communication and documentation regarding her condition. The DON acknowledged the oversight, which was contrary to the facility's policy on comprehensive, person-centered care plans.
A facility failed to implement fall prevention measures for two residents, leading to one resident sustaining a scalp hematoma after a fall. The first resident, assessed as a fall risk, did not have a care plan or interventions in place, despite requests for a bed alarm. The second resident's bed alarm was not properly attached, rendering it ineffective. The facility lacked a specific policy for bed alarm use, contributing to these deficiencies.
A facility failed to follow up with a physician regarding a dietitian's recommendation to reduce a resident's high protein nourishment (HPN) intake, contributing to a significant weight gain. Despite the resident's cognitive awareness and the dietitian's monitoring, the recommendation to limit HPN to breakfast was not communicated to the physician, and the resident continued receiving HPN with all meals. The Director of Nursing confirmed that the recommendation was not implemented, as no physician order was obtained.
A resident with cognitive capacity and a diagnosis of left shoulder osteoarthritis was not monitored following an allegation of physical abuse by a CNA, who reportedly caused pain during a transfer. Despite the facility's standard practice to monitor for 72 hours after such allegations, there was no documentation of monitoring for emotional distress or physical injuries. Interviews with the LVN and DON confirmed the oversight, highlighting a deviation from expected practices.
A resident with diabetes was administered 100 units of Lantus insulin instead of the prescribed 10 units, leading to hospital transfer for blood sugar monitoring. The error was acknowledged by the LVN and DON, who noted that such a high dose should have been questioned and verified against the physician's order and MAR.
Failure to Supervise Cognitively Impaired Wheelchair User in Parking Lot
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention measures for a cognitively impaired, wheelchair-bound resident who was allowed to be outside unsupervised. Surveyors observed that the facility had a large parking lot directly connected to a u‑shaped driveway and the main entrance, with no caution signage, patio seating, or safety barriers for pedestrians despite expected vehicle traffic. The entrance doors were automatic sliding doors that opened by motion sensor, and the receptionist’s view of the entrance was obstructed by a tall countertop with items on it. The facility did not have staff assigned to monitor exits or the parking lot, and exit doors were unlocked and lacked alarms. The resident involved had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side and used a wheelchair. The resident’s MDS showed a BIMS score of 9, indicating moderate cognitive impairment. Despite this, the resident’s care plan did not include interventions addressing the risk for injury related to impaired cognition. Staff interviews, including with the DON, LVN, CNA, and COTA, confirmed that the resident had impaired judgment, was oriented only to self and place, and required increased supervision, particularly when outside. Staff also stated that residents with cognitive impairment should not be on the front patio or in the parking lot without supervision. On the day of the incident, the resident requested candy from the receptionist and then exited to the front patio unsupervised through the automatic doors. While the resident was propelling the wheelchair in the left side parking lot, a small white SUV was backing out of a parking space. The resident was behind the vehicle, and the driver did not see the resident, striking the left side of the wheelchair. Witnesses honked and alerted the driver while the resident yelled for the car to stop. The resident subsequently reported left elbow discomfort, and hospital documentation recorded a diagnosis of pain in the left elbow. The COTA stated that a resident with cognitive impairment should not be outside without supervision and that the incident could have been prevented by the facility.
Resident Awakened at Night for Non-Urgent Room Change Decision
Penalty
Summary
Staff failed to ensure that a resident was treated with dignity and respect when a Certified Nurse Assistant (CNA) awakened her late at night to ask about a potential room change. The resident, who had osteoarthritis and was recovering from joint replacement surgery, had previously requested a room move but declined an offer earlier in the day, stating she would move in the morning. Despite this, the CNA, following instructions from the outgoing Registered Nurse (RN), approached the resident between 11:00 p.m. and 11:15 p.m. to ask if she wanted to move that night or the following day, thereby disturbing her sleep. Facility policy and the resident's rights documents both indicate that residents should be treated with consideration and respect, and that room changes should be discussed when residents are awake unless medically necessary or for safety reasons. The Director of Nursing (DON) confirmed that the facility's practice is not to disturb residents during sleep for such discussions. This incident demonstrated a failure to honor the resident's right to a dignified existence and self-determination by unnecessarily disrupting her rest.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement a fall prevention intervention for a resident by not ensuring the tab monitor was attached while the resident was in a wheelchair, as specified in the resident's care plan. The resident, who was admitted with a diagnosis of a fracture to the lower back and muscle weakness, was identified as being at risk for falls due to impaired mobility and a history of falls. The care plan included an intervention to apply a tab monitor in the wheelchair to remind the resident to get assistance for ambulation and transfers. On observation, the tab monitor was found hanging from the bed rail and not attached to the resident while she was in the wheelchair. The resident reported a fall on a previous date because she did not use her call light to request assistance before getting out of the wheelchair. Interviews with staff, including a CNA and the DON, confirmed that the tab monitor was not attached as required by the care plan, and the CNA acknowledged the oversight. The facility's policy indicated that tab alarms should be used for residents at risk for falls and documented in the care plan, with checks to ensure they are functioning properly.
Improper Garbage Disposal and Open Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage, as observed on February 3, 2025, when three dumpsters had their lids open and trash was scattered around them. This was confirmed during an observation and interview with the Dietary Supervisor, who acknowledged that the dumpsters should have been closed and free of surrounding trash to prevent pest infestations. Additionally, on February 5, 2025, the Maintenance Supervisor confirmed his responsibility for keeping the dumpster lids closed and the area clean, acknowledging that the open dumpsters and surrounding trash could lead to rodent infestations and infection control issues. The facility's policy, dated October 2017, requires that garbage and refuse containing food wastes be stored in a manner inaccessible to pests, with dumpsters kept closed and free from surrounding litter.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during an inspection. Bisacodyl suppositories were found in the medication room and on a medication cart without proper pharmacy labels, making it unclear to whom they belonged. Licensed Vocational Nurses (LVNs) acknowledged the lack of labeling and indicated that these medications were usually kept as house supply, but the bags did not indicate this. The facility's policy requires floor stock medications to be labeled as such and kept in the original manufacturer's container with specific information, which was not adhered to in this case. Additionally, multi-dose medications were not properly labeled with open dates. During an inspection, a latanoprost eye drop and a vial of cyanocobalamin were found without open dates, despite the facility's policy requiring multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer. The prescribing information for latanoprost indicates it can be stored at room temperature for up to six weeks once opened, but this was not followed due to the lack of an open date. Furthermore, a bottle of ferrous sulfate solution was found with a smudged expiration date, making it illegible. The facility's policy states that if medication containers have missing or incorrect labels, the dispensing pharmacy should be contacted for instructions. Lastly, the room temperature in the Nursing Station 2 Medication Room was recorded at 82 degrees Fahrenheit, exceeding the controlled room temperature range of 68-77 degrees Fahrenheit as per the United States Pharmacopeia standards. This failure to maintain appropriate storage conditions could potentially affect the efficacy of the medications stored there.
Sanitation and Hygiene Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. A puree blender was found with white and yellow food residue, indicating it was not cleaned after use, which could lead to cross-contamination. Additionally, spilled dry oatmeal was observed on the floor inside the dry storage room, which the Dietary Supervisor acknowledged should be kept clean to prevent pest infestation. Further observations revealed that two ovens had a buildup of food crumbs, grease, yellow grime, and dark brown residue, which the Dietary Supervisor admitted should be kept clean and sanitary to prevent foodborne illness. A dietary staff's plastic cup was also found on the bottom shelf of the tray line table, which the Dietary Supervisor stated should not be stored in the kitchen area to avoid cross-contamination. Moreover, a cook was observed preparing pureed carrots without covering his beard and mustache, which the Dietary Supervisor noted should be covered to prevent hair from falling into the food. These deficiencies were identified as potential causes of foodborne illness among the facility's residents, who are a vulnerable population.
Non-Functioning Paper Towel Dispenser in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that a resident's bathroom had a functioning paper towel dispenser, which is essential for proper hand hygiene and infection prevention. On February 6, 2025, during an observation and interview, the Maintenance Supervisor (MS) confirmed that the paper towel dispenser in the resident's bathroom was not dispensing paper towels. The resident had previously reported the issue to both the Case Manager (CM) and the Infection Preventionist (IP) nurse. However, the IP nurse, despite being informed of the issue on February 4, 2025, did not follow up to ensure it was resolved. Further interviews revealed that the CM had notified the front desk to inform Maintenance, but the front desk staff did not relay this information to the MS. The MS stated that the facility's process requires a maintenance request form to be filled out, which he never received regarding the paper towel dispenser issue. The Director of Nursing (DON) emphasized the importance of a functioning towel dispenser for hand hygiene to prevent infection spread. The facility's policy on maintaining a homelike environment includes ensuring a clean, sanitary, and orderly setting.
Failure to Timely Notify LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman at the same time the notice was given to a resident, impacting the resident's rights and continuity of care. The resident, who was cognitively intact, was admitted with a diagnosis that included fatty liver and was discharged to a hospital due to jaundice. The discharge notice was given to the resident upon discharge, but the facility did not send the notice to the LTC Ombudsman until 27 days later. Interviews with the Social Service Director and Case Manager revealed that the facility's policy required the LTC Ombudsman to be notified at the same time as the resident. However, the Case Manager admitted to not sending the notification letter, which was her responsibility. This oversight had the potential to delay advocacy and oversight of the resident's discharge plan.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure that expired medications were not available for use by residents, as observed during an inspection of medication carts. On the 8400 Floor Medication Cart, a discontinued bubble pack of hydroxyzine for a resident was found alongside active medications. LVN 5 confirmed that the medication had been discontinued and should have been removed from the cart. Similarly, on Medication Cart 3A, a used Humalog Qwikpen with an open date of December 1, 2024, was found, which exceeded the 28-day usage period as per the facility's policy. LVN 3 acknowledged that the insulin pen should have been discarded according to the policy. These findings indicate that the facility did not adhere to its own policy and procedure titled 'Medication Labeling and Storage,' which requires multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer. This oversight had the potential to result in residents receiving ineffective medication therapy.
Failure to Transcribe Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a physician's order for oxygen therapy was transcribed into the electronic medical record for a resident. This oversight was identified during an observation on February 3, 2025, when the resident was seen receiving oxygen at 2 liters per minute via nasal cannula. The resident, who was admitted with diagnoses of pneumonia and dementia and was under hospice care, did not have a corresponding physician order for the oxygen therapy documented in the electronic medical record. Interviews with facility staff revealed that the order was initially placed in the resident's physical chart by a hospice nurse upon admission on January 21, 2025, but was not transcribed into the electronic system. The Licensed Vocational Nurse (LVN) acknowledged that all physician orders should be transcribed at the time of admission. The Medical Records Director confirmed that the responsibility for transcribing the order lay with the licensed nurse who received it. The Director of Nursing (DON) stated that the order should have been transcribed immediately to ensure all staff were aware of the prescribed treatment, but the facility's licensed nurse forgot to do so.
Failure to Educate Staff on COVID-19 Vaccine Risks and Benefits
Penalty
Summary
The facility failed to provide education regarding the risks and benefits of the COVID-19 vaccine to one of the three staff members reviewed for immunization, specifically a Certified Nurse Assistant (CNA). This deficiency was identified through interviews and record reviews, which revealed that there was no documented evidence that the CNA received the necessary education about COVID-19 immunization. The CNA's last COVID-19 vaccination was recorded as being administered approximately three years prior, and the Director of Staff Development (DSD) confirmed the lack of documentation for the required education. During interviews, the Infection Preventionist (IP) acknowledged the responsibility for ensuring all facility staff received education on COVID-19 during their scheduled vaccinations. However, the IP admitted to not providing the CNA with the necessary education on the risks and benefits of the COVID-19 vaccine. The facility's policy, dated June 2023, mandates that staff are educated about the benefits and risks of the COVID-19 vaccine, and this education should be provided again if the vaccination requires multiple doses. The failure to adhere to this policy potentially left staff without proper guidance and information, which could affect their decision-making and increase the risk of infection transmission within the facility.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a critical aspect of accommodating the needs and preferences of residents. During an unannounced visit, it was observed that the call light for a resident with a contracted right hand and limited mobility due to a stroke and multiple sclerosis was tied around the bed rail and hanging towards the floor, making it inaccessible. The resident, who was moderately cognitively impaired, reported that she often could not reach her call light and had to rely on her roommate to call for assistance. Interviews with facility staff, including a CNA and an LVN, confirmed that the call light should have been clipped to the resident's clothing at chest level to ensure accessibility. However, during the observation, the call light was not clipped as required, and both staff members acknowledged that it was out of reach. The Director of Nursing also stated that call lights should always be within reach to allow residents to call for assistance. The facility's policy on answering call lights, revised in September 2022, also emphasized the importance of ensuring call lights are accessible to residents when in bed.
Failure to Initiate Care Plan for Hearing Impairment
Penalty
Summary
The facility failed to initiate a care plan for a resident who was hard of hearing, which was identified during an observation and interview. The resident, who was wearing hearing aids, reported difficulty hearing even with the aids. The resident's medical records indicated a diagnosis of a brain hemorrhage and a mild cognitive impairment. Despite these indicators, the baseline care plan did not include an assessment for hearing, and the comprehensive care plan did not address the resident's hearing issues. The Minimum Data Set (MDS) also inaccurately reflected the resident's hearing status, stating that the resident had adequate hearing and did not wear hearing aids. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Minimum Data Set Nurse (MDSN), revealed that the resident's hearing issues were known but not communicated to relevant parties or included in the care plan. The Director of Nursing (DON) confirmed that a care plan should have been initiated to address the resident's hearing difficulties, including interventions for the use of hearing aids and actions to take if the aids were not functioning. The facility's policy on care plans emphasized the need for comprehensive, person-centered plans developed from thorough assessments, which was not adhered to in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide fall prevention interventions for a resident assessed as a fall risk, leading to the resident falling and sustaining a scalp hematoma. The resident, who was admitted with a neck fracture and muscle weakness, was assessed as a fall risk upon admission. However, a fall risk care plan with safety interventions was not initiated. The Director of Nursing (DON) acknowledged that fall precaution interventions should have been individualized and implemented, but they were not. The resident's representative had requested a bed alarm due to increased activity, but the Licensed Vocational Nurse (LVN) did not inform the physician or place the alarm, which could have prevented the fall. Another deficiency involved the improper attachment of a bed alarm for a resident with severe cognitive impairment and a high risk for falls. The resident's care plan indicated the use of a bed alarm as a fall risk intervention. However, during an observation, the bed alarm was found not attached to the resident, rendering it ineffective. The LVN responsible for checking the alarm admitted that sometimes the Certified Nursing Assistant (CNA) forgets to reattach it. The DON confirmed that the alarm should have been attached to the resident, and the CNA admitted to not verifying the alarm's attachment after changing the resident's shirt. The facility lacked a specific policy and procedure for the use of bed alarms, which contributed to the oversight in ensuring the alarms were properly attached and functional. The DON expressed disappointment in the staff's failure to adhere to expectations for checking and ensuring bed alarms were attached and turned on when entering and exiting resident rooms. The Administrator confirmed the absence of a policy for bed alarm use, highlighting a gap in the facility's fall prevention measures.
Failure to Implement Dietitian's Recommendation Leads to Resident's Weight Gain
Penalty
Summary
The facility failed to follow up with the physician regarding the Registered Dietitian's (RD) recommendation to discontinue a resident's high protein nourishment (HPN) for one of the sampled residents. This oversight potentially contributed to the resident's significant weight gain of 29 pounds, or 26.6%, over a six-month period. The resident, who was cognitively intact, expressed that they had gained enough weight and did not need to gain more. The RD had recommended reducing the HPN to breakfast only, but this recommendation was not communicated to the physician, and the resident continued to receive HPN with all meals. The RD stated that she monitored and managed weight variance by conducting weekly interdisciplinary team (IDT) meetings and made dietary recommendations to the Director of Nursing (DON), Director of Staff Services (DSS), and licensed nurses. However, the nursing staff did not follow up with the physician to obtain an order to change the HPN as recommended. The DON confirmed that the RD's recommendations were not carried out by the licensed nurses, as no physician order was written to decrease the HPN to breakfast only. The facility's policy and procedure required verbal orders to be recorded immediately, but this was not adhered to in this case.
Failure to Monitor Resident After Abuse Allegation
Penalty
Summary
The facility failed to monitor a resident following an allegation of physical abuse, which was reported on August 26, 2024. The resident, who was cognitively intact and had mental capacity, was admitted with a diagnosis of left shoulder osteoarthritis. The allegation involved a certified nursing assistant (CNA) who reportedly handled the resident roughly during a transfer, causing moderate to severe pain in the resident's left shoulder. Despite the facility's standard practice to monitor residents for 72 hours after any abuse allegations, there was no documented evidence that the resident was monitored for emotional distress, behavioral changes, or delayed physical injuries from August 26 to August 29, 2024. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the resident was not monitored as required. Both the LVN and the DON acknowledged the importance of monitoring residents involved in abuse allegations to detect any negative effects, including emotional or psychosocial impacts and latent physical injuries. The DON stated that it is the facility's standard practice to conduct 72-hour monitoring and documentation after an abuse incident or allegation, although there was no specific policy in place. The lack of monitoring was a deviation from the facility's standard practice and expectations.
Incorrect Insulin Dose Administration
Penalty
Summary
The facility failed to ensure the correct insulin dose was administered as prescribed by the physician for one resident. The resident, who had diabetes mellitus, was supposed to receive 10 units of Lantus insulin subcutaneously at bedtime. However, on the evening of February 26, 2024, a Licensed Vocational Nurse (LVN) administered 100 units of Lantus instead of the prescribed 10 units. This error was documented in the Medication Administration Note and led to the resident being transferred to the hospital for blood sugar monitoring. The Interdisciplinary Team reviewed the incident and confirmed that the LVN had inadvertently administered the incorrect dose. During interviews, both the LVN and the Director of Nursing (DON) acknowledged that 100 units of Lantus is an unusually high dose and should have been questioned. The DON emphasized that the licensed nurse should have double-checked the physician's order and the Medication Administration Record (MAR) before administering the insulin. The facility's policies on administering medications and subcutaneous injections were reviewed, which indicated that medications must be administered as prescribed and that the correct dose should be verified before administration. The failure to follow these procedures resulted in the resident being at risk of hypoglycemia and necessitated hospital transfer.
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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