Rancho Seco Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Galt, California.
- Location
- 144 F Street, Galt, California 95632
- CMS Provider Number
- 055858
- Inspections on file
- 55
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 30 (1 serious)
Citation history
Health deficiencies cited at Rancho Seco Care Center during CMS and state inspections, most recent first.
A cognitively intact resident with COPD was not protected from abuse by a co-resident with dementia and severe memory impairment. According to documentation and interviews, the resident with dementia accused the other of stealing a stuffed animal, then scratched her arm, swung the stuffed animal at her in a foyer area, and later kicked her leg in their shared room while cussing and repeatedly threatening to kill her. Staff reported hearing arguing, observing the stuffed animal being swung, and later hearing yelling and death threats from the room. An observed scabbed wound with redness on the victim’s arm was attributed to the aggressor’s fingernail. These incidents occurred despite a facility abuse prevention policy stating residents must be protected from verbal and physical abuse by anyone, including other residents.
Multiple residents engaged in physical altercations, including slapping and hitting each other on the arms, resulting in abrasions and bruising. Staff and a housekeeper intervened to separate the residents, but the incidents indicate a failure to prevent resident-to-resident abuse as required by facility policy.
Multiple residents and staff reported persistent cold temperatures throughout the facility, with room thermostats registering below required levels and no warm air from vents. Despite repeated complaints and visible resident discomfort, staff were unable to adjust thermostats or resolve the issue, and administration was initially unaware of the extent of the problem. The facility's boiler was found to be non-functional, and required temperatures were not maintained, contrary to facility policy.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
A resident with severe cognitive impairment was repeatedly observed spitting on floors and having bowel movements on the facility patio, with staff confirming these behaviors and noting their impact on others. No care plan or interventions were in place to address these actions, despite facility policy requiring residents be treated with dignity and respect.
A resident with severe cognitive impairment sustained a bloody nose after being pushed in the face by another cognitively intact resident during an altercation on the patio. The incident occurred while the impaired resident was attempting to have a bowel movement outside, a behavior known to staff. The facility was aware of the ongoing issue but did not prevent the physical abuse, resulting in injury.
Two residents were involved in a physical altercation when one, who was alert and oriented, struck another resident with a wooden and metal reacher after the latter fell onto her bed. The incident resulted in minor injuries to both individuals and was witnessed by a CNA. The facility's abuse prevention policy was not effectively followed, as the reacher was accessible and prior similar incidents had not been reported.
A resident with cognitive impairment repeatedly hit another resident, who was cognitively intact and had a history of hemiplegia and epilepsy. The incident was witnessed by another resident and resulted in the victim experiencing fear and requiring medication to calm down. Staff confirmed the event and acknowledged the emotional impact on the victim.
Two residents experienced a persistent and strong urine odor in their shared room due to a soiled diaper left unaddressed on a potty chair. Both residents, who were alert and able to communicate, reported feeling undignified and uncomfortable. Staff, including a CNA and a nurse, confirmed the ongoing odor and the presence of the soiled brief, acknowledging that the situation was not dignified and did not meet facility policy standards.
A resident with moderate cognitive impairment and anxiety disorder was subjected to abuse when another cognitively intact resident deliberately ran over his foot twice with a wheelchair after being told to stop. Multiple staff, including a CNA and an LPN supervisor, witnessed the incident, and the affected resident expressed fear and distress following the event.
Surveyors found that the facility's main HVAC system, including all four air handlers, was inoperable, and portable AC units were being used throughout the building. Staff reported the cooling system had been down for over a year, affecting all residents and preventing the maintenance of required temperatures.
Surveyors observed multiple instances where portable air conditioning units and other devices were plugged into extension cords and power strips in corridors, resident rooms, and a medication storage closet. Staff interviews indicated that these items were brought in by residents or their families, resulting in non-compliance with electrical safety regulations throughout the facility.
The facility did not conduct fire drills at varied times and failed to provide required shift fire drills for multiple quarters, with staff confirming that overlapping drills led to missing required drills for individual shifts. This affected all residents in the facility.
Surveyors found multiple failures in food storage, kitchen sanitation, and equipment maintenance, including unsealed and undated dry goods, damaged and unclean kitchen surfaces, lack of backflow prevention at a produce sink, improper storage of wet kitchenware, and use of damaged utensils and equipment. These deficiencies were confirmed by the Registered Dietitian and maintenance staff, and were not in compliance with facility policy or FDA Food Code.
A resident with multiple medical conditions and moderate cognitive impairment, who required substantial assistance with ADLs, was not provided with necessary nail care despite repeated documentation and staff awareness of the issue. The resident's long fingernails and toenails caused discomfort and potential skin injury, and no interventions or referrals were made, contrary to facility policy and care plan requirements.
A resident with dementia, Alzheimer's, and major depressive disorder was not provided with activities meeting psychosocial needs for several weeks, despite a care plan outlining the importance of such engagement. Observations showed the resident unresponsive and without access to preferred activities, and staff confirmed the absence of appropriate activity programming during this period.
Surveyors found that two residents' discontinued controlled medications, specifically Ativan, were left in medication carts instead of being promptly removed and destroyed as required. Nurses and the DON confirmed that these medications should have been surrendered for destruction, but instead remained accessible in the carts for extended periods after completion or discontinuation.
Staff failed to follow recipes and used unmeasured amounts of water to thin pureed foods, resulting in diluted flavor and reduced nutritional value for several residents. The dietary cook did not use measuring tools or have recipes available, and the registered dietitian confirmed that these practices can negatively impact meal quality.
Staff failed to follow infection control protocols by not wearing required PPE during care of a resident on Enhanced Barrier Precautions, not disinfecting a blood pressure cuff between use on three residents, and returning used wound care supplies to a treatment cart, contrary to facility policy and training.
Two residents with dysphagia and orders for nectar-thick liquids were observed consuming unthickened beverages, contrary to their prescribed diets. Staff confirmed that no dysphagia care plans were documented in the electronic medical records, despite facility policy and federal requirements.
A resident with multiple health conditions did not consistently receive physician-ordered wound care for a right ankle wound, as documented in treatment records and confirmed by staff interviews. The missed treatments led to pain, increased bleeding, confusion, and ultimately a hospital transfer, where the wound was found to be infected with MRSA and Pseudomonas, requiring IV antibiotics.
A resident with a suprapubic catheter did not consistently receive catheter flushing and site cleansing as ordered by the physician, with multiple missed treatments documented over several months. Facility staff confirmed that care was not provided as required by policy and professional standards.
The facility did not change a resident's PICC line dressing within the required timeframe as per physician order and policy, and also failed to follow a physician's order for oxygen therapy for another resident with respiratory conditions.
A resident with chronic lung disease and hypoxia was observed receiving oxygen at a lower rate than prescribed by the physician. Staff confirmed the oxygen was set at three liters per minute instead of the ordered four liters, and there was no order to adjust the rate. The care plan and facility policy both required adherence to the physician's order, but this was not followed.
Two residents with dysphagia and physician orders for nectar-thick liquids were given regular fluids instead of thickened liquids. One resident drank regular water, and another coughed after drinking unthickened hot chocolate. Both incidents were confirmed by staff, who acknowledged the drinks should have been thickened according to the residents' dietary orders.
A resident with dementia, Alzheimer's, dysphagia, and major depressive disorder was not provided with the physician-ordered fortified diet, as meal trays lacked the required extra butter or fortification despite clear orders and care plan instructions. Staff confirmed the omission during meal observations, and the resident experienced significant weight loss over several months.
Two residents with severe cognitive impairment and high dependence on staff were found with their call light buttons on the floor, out of reach, preventing them from calling for assistance. Staff and facility leadership confirmed that call lights should be accessible, and facility policy required staff to ensure call lights are within reach.
Two medication carts were found unlocked and unattended, as confirmed by interviews with nursing staff and the DON, in violation of facility policy requiring all drugs and biologicals to be stored in locked compartments. Staff acknowledged that the carts should have been locked at all times to prevent unauthorized access.
Staff failed to follow infection control protocols during wound care for a resident with a diabetic foot ulcer. An LPN, another nurse, and a wound doctor entered an Enhanced Barrier Precaution room without wearing gowns, and the LPN did not perform hand hygiene before donning gloves. Facility policy required gowns and gloves to be available and used, and hand hygiene to be performed before glove use.
A resident with moderate memory impairment was assaulted by another resident with severe memory impairment during a smoke break, resulting in a fall and an elbow abrasion. The incident occurred despite supervision, and staff were aware of prior accusations made by the aggressor. The DON acknowledged the violation of the resident's right to be free from abuse.
A facility employed a CNA with a known criminal history of assault, leading to the sexual abuse of nine residents. Despite a background check revealing a misdemeanor charge, the ADM and DSD hired the CNA, who later assaulted residents. The facility's failure to adhere to its policy on screening potential employees for abuse history resulted in this deficiency.
A facility failed to protect residents from sexual abuse by a CNA, who assaulted nine residents. The CNA was hired despite a known criminal history of abuse, leading to incidents of unwanted sexual touching and exposure. Residents, with varying cognitive impairments and medical conditions, experienced fear, anxiety, and behavioral changes. The abuse was reported by staff, and the CNA admitted to the assaults. The facility's policies on abuse prevention and resident rights were not effectively implemented.
A facility failed to thoroughly investigate sexual abuse allegations involving a CNA and multiple residents, delaying necessary interventions. Initial reports identified three victims, but further investigation revealed nine. The facility's documentation was inconsistent, and interviews revealed that allegations were unsubstantiated due to lack of witnesses, despite a police report confirming the CNA's admission. The facility's abuse prevention policy was not adequately followed.
The facility failed to manage effectively by hiring a CNA with a known history of abuse, leading to the sexual abuse of nine residents. Despite being aware of the CNA's misdemeanor charge, the ADM and DSD did not verify previous employment references. This oversight violated the facility's policies on abuse prevention and hiring, which require thorough background checks and reference verification.
The facility failed to report three allegations of sexual abuse involving three residents to the Department within the required two-hour timeframe. A resident with severe cognitive impairment reported an incident involving a shirtless CNA, while another resident with intact cognition alleged sexual assault by the same CNA. A third resident with moderate cognitive impairment was involved in an incident where the CNA was found with his pants down near the resident's room. The Administrator confirmed the reports were sent late, contrary to the facility's policy requiring immediate reporting.
A resident was physically and verbally abused by another resident during an altercation in a shared bathroom. The aggressor used profanity and kicked the victim's shin, causing an abrasion. Both residents were cognitively intact and had histories of anxiety and depression. Staff noted the aggressor's tendency to instigate altercations. The facility's Administrator confirmed the incident as substantiated abuse, violating the facility's zero-tolerance policy for abuse.
A resident with a history of constipation did not receive prescribed bowel management treatments, leading to severe discomfort and distress. Despite having physician orders for various laxatives, the resident did not receive these medications, and the facility staff failed to notify the physician of the resident's condition. The resident experienced significant abdominal pain and was unable to eat or attend dialysis sessions due to the constipation.
A resident with severe cognitive impairment and dysphagia waited 38 minutes for feeding assistance during lunch, while other residents finished their meals and left. A CNA acknowledged the delay and the Director of Nursing confirmed that residents should not wait longer than 10-15 minutes to be fed, indicating a failure to maintain dignity and respect as per facility policy.
A facility failed to provide and document resident-centered activities for a resident with multiple sclerosis and depression. Despite the resident's care plan highlighting the importance of activities like reading and puzzles, the activities director did not conduct or document one-on-one visits for 21 days. The resident expressed feeling neglected, and the Activities Director admitted to lacking documentation. The Administrator confirmed the absence of records, which contradicted the facility's policy to support residents' well-being through activities.
A resident admitted with osteomyelitis, cellulitis, and diabetes had a documented deep wound on the right foot, but the MDS inaccurately indicated no foot problems. This error was confirmed by the IP and DON, highlighting a failure to ensure accurate assessments, potentially impacting the resident's care plan.
A resident with acute osteomyelitis and cellulitis was admitted to the facility, but a necessary podiatry consultation was not scheduled until nearly a month later, despite hospital discharge instructions. Interviews with staff revealed that the oversight occurred due to a lack of orders for the referral upon admission, contrary to facility policies requiring immediate care orders.
A resident with a cognitive impairment was physically assaulted by another resident who was cognitively intact. The incident occurred in the hallway, where the aggressor, in a wheelchair, struck the victim in the face, causing swelling and pain. A CNA intervened to separate the residents, but the aggressor became belligerent towards the staff. The facility's policy on abuse prevention was in place, but the incident was substantiated, indicating a failure to protect the resident from abuse.
A resident in a LTC facility was subjected to abuse when another resident threw urine and feces at him, an incident witnessed by the victim's daughter. The aggressor, who was frustrated over a shared bathroom issue, admitted to his actions. The victim, who was cognitively intact, felt angry and embarrassed. Staff confirmed the incident and the facility's policy emphasizes residents' rights to be free from abuse.
A resident with dementia physically assaulted another resident, causing bruising, in an LTC facility. The incident was witnessed by staff, and the victim expressed fear and discomfort following the event. The facility's policy on abuse reporting was reviewed, but the facility failed to prevent the incident, compromising the victim's right to be free from abuse.
A resident with pressure ulcers did not receive consistent wound care as ordered, leading to infection and hospitalization. Despite multiple refusals of care, the physician was not notified, contrary to facility policy. Staff interviews confirmed the need for physician notification and adherence to wound care orders.
A resident's privacy was violated when another resident entered her room and attempted to get into her bed without permission. The incident was confirmed by a Licensed Nurse and acknowledged by the Director of Nursing as a breach of the facility's policy on resident rights, which guarantees personal privacy.
A resident's privacy was violated when another resident attempted to enter her bed without permission. The incident involved a resident with no cognitive impairment and another with cerebrovascular disease and a cognitive communication deficit. The facility's policy on resident rights, which includes the right to personal privacy, was not upheld.
The facility failed to ensure accurate reconciliation and accountability of controlled medications and proper medication administration. Audits revealed discrepancies where medications were signed out of the CDR but not documented on the MAR, and one resident's pain medication was administered too frequently. Additionally, another resident's medications were left unattended on their bedside table.
The facility failed to ensure that two residents did not receive unnecessary narcotic pain medication. One resident was administered oxycodone despite having pain ratings below the physician-ordered threshold, and another resident was given Norco despite having a pain rating of 0. Both the Desk Nurse and the Director of Nursing confirmed that the medications should not have been administered under these conditions.
The facility failed to properly label and store medications, with 22 loose pills found in medication carts and an opened vial of PPD in the refrigerator without a date label. Staff confirmed these issues, highlighting risks to infection control and resident safety.
Failure to Protect Resident From Physical and Verbal Abuse by Co-Resident
Penalty
Summary
The facility failed to protect a cognitively intact resident from physical and verbal abuse by a co-resident. Resident 1, admitted with COPD and documented as having intact cognition with a BIMS score of 15/15, reported that on the evening of 2/14/26 she was accused of stealing Resident 2’s stuffed animal. According to Resident 1 and an SBAR Communication Form dated 2/14/26, Resident 2 scratched and kicked Resident 1 during this altercation. An SBAR for Resident 2 on the same date documented that Resident 2 was involved in a physical and verbal altercation with Resident 1. On observation several days later, Resident 1 had a scabbed wound approximately 1/8 inch in length with surrounding redness on her right arm, which she stated resulted from Resident 2’s fingernail when Resident 2 grabbed her arm in the foyer while swinging the stuffed animal at her. Resident 2, who had dementia and a severely impaired BIMS score of 3/15, was observed and described by staff as engaging in both physical and verbal aggression toward Resident 1. An LPN (LN 2) reported that between 7:30 p.m. and 8 p.m. on 2/14/26, while charting at the nurse’s station near the foyer, he heard the two residents arguing and saw Resident 2 swing a stuffed animal at Resident 1 while cussing at her, with Resident 1 using her arm to block the blow. Resident 1 later stated that after they were separated, Resident 2 waited for her in their shared room, kicked her right leg, continued cussing, and threatened to kill her. Another nurse (LN 1) stated that around 9:30 p.m. that same night, she heard yelling from the room and heard Resident 2 threaten Resident 1, telling her to get out of the room and stating, “I want to kill you.” These events occurred despite the facility’s written Abuse Prevention Program policy, which states residents have the right to be free from verbal and physical abuse and that residents must be protected from abuse by anyone, including other residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect three residents from abuse when multiple incidents of physical altercations occurred between them. On two separate occasions, residents were observed slapping and hitting each other on the arms. In the first incident, two residents engaged in a physical altercation after an argument about seating, resulting in both slapping each other on the arms. In the second incident, two residents began hitting each other after one resident grabbed the other's belongings while sitting at the same table in the dining room. These altercations were witnessed by staff and a housekeeper, who intervened to separate the residents. As a result of these incidents, two residents sustained abrasions with bleeding, and one resident displayed bruising on her forearm. The involved residents had varying cognitive statuses, with one resident having severe memory impairment and others being cognitively intact. The facility's policy required the prevention and prohibition of all types of abuse, neglect, and exploitation, but these measures were not effectively implemented to prevent the physical altercations and resulting injuries.
Failure to Maintain Safe and Comfortable Temperatures Due to Inoperable Heating System
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents, as evidenced by multiple complaints of cold temperatures and room temperatures consistently below regulatory requirements. Observations and interviews revealed that residents were dressed in multiple layers, using extra blankets, and still experiencing discomfort and difficulty sleeping due to the cold. Thermostats in several rooms registered temperatures as low as 61 to 65 degrees Fahrenheit, with no warm air coming from the vents, and staff were unable to adjust the thermostats or provide effective relief. Residents repeatedly reported their discomfort to staff, but the only response was the provision of additional blankets, and no effective action was taken to resolve the underlying issue. Staff interviews confirmed that the facility had been cold for at least a week, particularly at night, and that the heating system was not functioning properly. Staff members acknowledged their inability to adjust thermostats or confirm whether the heating system was operational. Maintenance staff and facility administration were aware of the heating issue, specifically a non-functioning boiler, but failed to act in a timely manner to restore adequate heating. The Director of Nursing and Administrator initially denied awareness of the problem, despite direct observations and multiple resident complaints. A review of facility policies indicated that immediate action was required when heating systems were inoperable, with a mandate to maintain temperatures between 71 and 81 degrees Fahrenheit. However, the facility did not follow these policies, as evidenced by the lack of timely repairs and inadequate interim measures to ensure resident comfort. Temperature logs provided by maintenance were inconsistent with observed room temperatures, and staff could not explain the discrepancies. The failure to maintain appropriate temperatures resulted in ongoing resident discomfort and a failure to provide a safe, homelike environment as required by facility policy.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Promote Dignity and Address Inappropriate Resident Behaviors
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15 and a diagnosis of dementia, was observed engaging in behaviors that did not promote dignity and respect. The resident was seen spitting on the hallway floors and was reported by staff to have frequent bowel movements on the facility's outside patio. These behaviors were witnessed by multiple staff members, including a CNA and two licensed nurses, who confirmed the incidents and noted that the actions could be distressing to other residents. Additionally, there was an altercation between this resident and another after the latter observed the resident with his pants down on the patio. A review of the resident's clinical record revealed that there were no care plans or interventions in place to address the resident's behaviors of spitting and having bowel movements outside. The Director of Nursing confirmed the absence of such interventions and acknowledged the altercation resulting from the resident's actions. The facility's policy on resident rights and dignity requires that all residents be treated with kindness, respect, and dignity, but this was not upheld in the care provided to this resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia was physically abused by another resident who was cognitively intact. The incident took place in the patio area, where the cognitively intact resident pushed the other resident in the face with his forearm, resulting in a bloody nose. The aggressor stated that he acted to block the other resident, who had his pants down and was attempting to have a bowel movement on the patio. Staff interviews and clinical record reviews confirmed the incident and the resulting injury. The facility was aware that the resident with dementia had a pattern of having bowel movements on the patio, but this behavior was not effectively managed or prevented. Staff, including a CNA and the DON, acknowledged knowledge of the ongoing issue. The facility's policy on abuse and neglect defines abuse as the willful infliction of injury with resulting physical harm, which was consistent with the events described. The failure to prevent the altercation led to physical harm to a vulnerable resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident struck another with a wooden and metal reacher during an altercation. One resident, who had severe memory impairment and multiple diagnoses including dementia, was involved in an incident with her roommate, who was alert and oriented. According to nurse's notes and staff interviews, the altercation began when the resident with dementia lost her balance and fell across her roommate's bed, prompting the roommate to hit her in the face with a stick. The roommate admitted to striking her with the reacher, and both residents sustained minor injuries during the incident. Observations and interviews confirmed that the reacher was accessible to the resident who used it as a weapon, and both residents recalled aspects of the altercation, with one stating that similar incidents had occurred before but were not reported. Staff responded to the commotion and witnessed the physical altercation, noting that both residents were upset. The facility's abuse prevention policy states that residents have the right to be free from abuse, including abuse by other residents, but this policy was not effectively implemented in this case.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when another resident repeatedly hit her on the arm. The resident who was hit had a history of flaccid hemiplegia, epilepsy, and muscle weakness, and was cognitively intact. The aggressor resident had severe cognitive impairment. The incident was witnessed by another resident, who confirmed that the aggressor hit the victim on the arm, causing the victim to yell. The victim reported feeling scared and stated that she did not like being touched due to past trauma. She required medication to calm down after the incident. Staff interviews confirmed awareness of the incident, with a licensed nurse and the Director of Nursing both acknowledging that the resident was upset and required medication for nervousness. The facility's policy defined abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish, and stated that all residents, regardless of mental or physical condition, are protected from such abuse. The report of suspected abuse was documented, and the incident was corroborated by both the victim and a witness.
Failure to Maintain Resident Dignity Due to Persistent Urine Odor
Penalty
Summary
The facility failed to promote dignity for two residents sharing a room, as evidenced by a persistent and strong urine odor in their shared bedroom. Observations revealed a soiled diaper left on top of a potty chair since the morning, which had not been cleaned or removed by staff. Both residents were alert and able to communicate, with one resident expressing that the constant urine smell made her feel undignified and that staff did not care about maintaining a clean environment. The other resident reported feeling uncomfortable and likened the experience to being inside a bathroom, stating that there was no dignity in the situation. Staff interviews confirmed the presence of the strong urine odor and the soiled brief, with a CNA acknowledging that the room often smelled this way and a licensed nurse describing the situation as undignified. The Social Service Director and Director of Nursing both agreed that the environment was not dignified and that the room should be kept clean to promote residents' dignity and quality of life. The facility's own policies require care that enhances residents' well-being and prohibits practices that compromise dignity, but these standards were not upheld in this instance.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident intentionally ran over another resident's foot with a wheelchair on two separate occasions during the same incident. The first resident, who was cognitively intact according to a recent BIMS assessment, was observed by staff and other residents to be yelling and screaming at staff before backing his wheelchair over the second resident's foot. When notified by staff that he had run over the other resident's foot, the first resident responded, "I don't care," and proceeded to run over the foot again. Multiple staff members, including a CNA and a Licensed Nurse Supervisor, witnessed the incident and confirmed the sequence of events. The second resident, who had moderate cognitive impairment and a history of anxiety disorder, expressed fear and distress following the incident and stated he did not want to be hit again. The incident was documented in progress notes and corroborated by interviews with both residents, staff witnesses, and the Social Services Director. The facility's policy defines abuse as the willful infliction of injury, and the actions of the first resident were described as deliberate. The second resident reported the incident to staff and indicated a desire to press charges. The administrator acknowledged that abuse is not tolerated at the facility.
Failure to Maintain HVAC System Resulting in Inoperable Cooling
Penalty
Summary
The facility failed to maintain its Heating, Ventilation, and Air Conditioning (HVAC) system as required by federal regulations and the National Fire Protection Association (NFPA) Life Safety Code. During a facility tour and staff interviews, surveyors observed that the chiller system, which includes four air handlers serving each wing, was completely inoperable. As a result, the facility was using six portable air conditioning units distributed throughout the corridors and dining room. Staff confirmed that the main cooling system had been nonfunctional for over a year, and the facility was in the process of obtaining a new system while relying on portable units in the interim. This deficiency affected all 95 residents across all four compartments of the facility, resulting in the inability to maintain required temperatures.
Plan Of Correction
HVAC How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Facility completed contract to have chiller replaced on 04/05/2024. Chiller install date is May of 2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) All areas have the potential to be affected by this deficient practice. No other areas were identified. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-service was conducted by the facility Administrator to the Maintenance Director on 04/17/2025 regarding the importance of ensuring the facility maintains functional HVAC system to maintain facility temperatures. d) Maintenance Director and/or designee will conduct weekly facility inspections focusing on functioning HVAC system and maintaining facility temperature. Issues identified will be corrected immediately by the Maintenance Director and/or designee and will be validated by the Administrator. Maintenance Director and/or designee will do trending/analysis and will report to the quarterly QAPI committee for further evaluation and/or recommendations.
Improper Use of Extension Cords and Power Strips for Electrical Equipment
Penalty
Summary
The facility failed to maintain electrical equipment in accordance with NFPA 101 and related standards, as evidenced by the use of extension cords and power strips in multiple areas. During a facility tour, surveyors observed several instances where portable air conditioning units were plugged into orange extension cords in corridors near resident rooms 9, 23, 36, and 50. Additionally, an extension cord was found in use by bed A in resident room 20, and another was observed in the medication storage closet in nurses station 2, where it was connected to an air conditioning unit placed on a cabinet. In each case, staff interviews revealed that either residents or their families had brought the extension cords or power strips into the facility. These observations indicate that extension cords and power strips were being used as a substitute for fixed wiring, which is not permitted under the cited regulations. The use of such equipment was not limited to personal electronics in resident rooms without patient-care-related electrical equipment, but extended to areas where it is explicitly prohibited. The deficiency affected all 95 residents and all four smoke compartments of the facility, as the improper use of electrical equipment was widespread throughout the building.
Plan Of Correction
and for all three shifts. Issues identified will be immediately addressed and corrected by the Maintenance Director and/or designee and will be validated by the Administrator. How the facility plans to monitor its performance to make sure that solutions are sustained: e) Maintenance Director and/or designee will bring monthly to the department manager morning meeting the fire drill binder to validate that fire drills are being conducted as required and for all three shifts. Issues identified will be immediately addressed and corrected by the Maintenance Director and/or designee and will be validated by the Administrator. Maintenance Director and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. Completion Date: 04/17/2025 K920 Electrical Equipment - Power Cords and Extens How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: (a) The Maintenance Director immediately removed the orange extension cord plugged into the portable air conditioning found in the corridor near resident room 23 on 04/16/2025. (b) The Maintenance Director immediately removed the extension cord plugged into the resident room 20 on 04/16/2025. (c) The Maintenance Director immediately removed the orange extension cord plugged into the portable air conditioning found in the corridor near resident room 50 on 04/16/2025. (d) The Maintenance Director immediately removed the orange extension cord plugged into the portable air conditioning found in the corridor near resident room 36 on 04/16/2025. (e) The Maintenance Director immediately removed the extension cord plugged into the air conditioning in the medication storage closet 04/16/2025. (f) The Maintenance Director immediately removed the orange extension cord plugged into the portable air conditioning found in the corridor near resident room 9 on 04/16/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: g) All areas have the potential to be affected by this deficient practice. No other areas were identified as being affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: h) In-Service was conducted by Administrator to the Maintenance Director on 04/17/2025 regarding the importance of ensuring that the facility is following the proper procedures and regulations as it pertains to the use of extension cords within the facility. i) Maintenance Director and/or designee will conduct weekly facility inspections focusing on the facility use of extension cords. Issues identified will be corrected immediately by the Maintenance Director and/or designee and will be validated by the Administrator. How the facility plans to monitor its performance to make sure that solutions are sustained: j) Maintenance Director and/or designee will conduct weekly facility inspections focusing on the facility use of extension cords. Issues identified will be corrected immediately by the Maintenance Director and/or designee and will be validated by the Maintenance Director and/or designee and will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. Completion Date: 04/17/2025
Failure to Conduct Timely and Varied Fire Drills
Penalty
Summary
The facility failed to properly maintain fire drill procedures as required by NFPA 101. Fire drill records showed that drills were conducted at the same time on multiple occasions, specifically with PM shift fire drills occurring at 3:30 p.m. on two separate dates. Additionally, the facility did not provide evidence of conducting required shift fire drills for several quarters, including the first, second, and fourth quarters of the specified years. Staff interviews confirmed that drills were sometimes scheduled to overlap shifts in an attempt to involve more staff, but this resulted in missing required drills for individual shifts. These deficiencies affected all 95 residents across four smoke compartments.
Plan Of Correction
How the facility plans to monitor its performance to make sure that solutions are sustained: e) Maintenance Director and/or designee will conduct weekly facility inspections focusing on the facility maintaining a functional HVAC system to ensure proper facility temperatures. Issues identified will be corrected immediately by the Maintenance Director and/or designee and will be validated by the Maintenance Director and/or designee. The Maintenance Director and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. Completion Date: 04/17/2025 K712 Fire Drills: How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) A fire drill was conducted for PM shift on 01/31/2025, for NOC shift on 02/27/2025, and for AM shift on 03/25/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) All areas have the potential to be affected by this deficient practice. No other areas were identified as being affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by the Administrator to the Maintenance Director on 04/17/2025 regarding the importance of ensuring that the facility is following the proper procedures and regulations as it pertains to fire drills for all three shifts (AM, PM, and NOC). d) Maintenance Director and/or designee will bring monthly to the department manager morning meeting the fire drill binder to validate that fire drills are being conducted as required.
Deficient Food Storage, Sanitation, and Equipment Maintenance in Kitchen
Penalty
Summary
The facility failed to maintain food storage, preparation, and kitchen equipment in accordance with professional standards for food service safety. During a kitchen tour, an open bag of grits was found unsealed and undated in dry storage, contrary to facility policy requiring opened dry food items to be tightly closed, labeled, and dated. The Registered Dietitian (RD) confirmed the lack of proper sealing and dating, acknowledging the risk of contamination. Additionally, several kitchen environment issues were observed, including a worn and damaged walk-in refrigerator floor, walls and ceilings with missing paint, texture, and signs of water damage, and a fruit and vegetable sink lacking an air gap for backflow prevention. The Maintenance Supervisor stated that maintenance needs should be logged by kitchen staff, but no requests for repairs had been made according to the facility's work history report. Further deficiencies included improper storage of kitchenware, with five metal bowls and nine steam table pans stacked and stored while still wet, which the RD confirmed was not compliant with air-drying requirements. Damaged small wares were not discarded as required by policy; a fry pan with extensive markings and scratches, a discolored and deeply scored cutting board, beverage pitcher lids with cracks and chips, and a can opener with missing metal were all found in use or storage. The RD and facility policies confirmed these items should have been discarded or replaced due to their condition, which could harbor bacteria or introduce foreign objects into food. Additionally, a large mixer was found with hardened, crusted build-up and rust-colored debris behind the mixing bowl, indicating inadequate cleaning. The RD confirmed the mixer was dirty and needed cleaning. These findings, based on direct observation, interviews, and record review, demonstrated a failure to adhere to both facility policies and FDA Food Code requirements for food safety, sanitation, and equipment maintenance. The deficiencies had the potential to cause foodborne illness for the 91 residents consuming facility-prepared meals.
Plan Of Correction
04/07/2025. b) The rough textured scratch was repaired by Maintenance Supervisor on 05/07/2025. c) The walk-in refrigerator floor was repaired by Maintenance Supervisor on 05/07/2025. d) The fruit and vegetable cleaning sink was repaired by Maintenance Supervisor on 05/07/2025. e) The ceiling cracks above the food service area were repaired by Maintenance Supervisor on 04/11/2025. f) The fruit and vegetable cleaning sink was repaired to have an airgap by Maintenance Supervisor on 05/07/2025. g) The wet metal bowls and steam table pans were removed, washed and left to air dry on 04/07/2025. h) The discolored fry pan and cutting board were removed and thrown away on 04/07/2025. i) The can opener was removed and thrown away on 04/07/2025. j) The discolored and cracked beverage lids pan and cutting board were removed and thrown away on 04/07/2025. k) The large mixer was removed and cleaned on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: I) All residents have the potential to be affected by this deficient practice. No other areas were identified as having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: m) In-Service was provided by the Registered Dietician to the dietary staff on 04/11/2025 through 04/15/2025 regarding the importance of labeling and dating food items, ensuring that staff are monitoring properly air drying items before placing them for storage. In-Service was provided by the Administrator to the Maintenance Department staff on 05/07/2025 regarding the importance of making rounds in all of the necessary areas in the kitchen and that there is no buildup on equipment that items needing repair are reported immediately in an effort to avoid foods becoming affected. n) Dietary Manager and/or designee to conduct random audits of the kitchen to look for food that may be unlabeled or undated and checks that equipment is stored properly, clean and not discolored along with items requiring to be reported for repair/replacement. Any issues identified will be reviewed, validated and immediately corrected. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. o) Dietary Manager and/or designee to conduct random audits of the kitchen to look for food that may be unlabeled or undated and checks that equipment is stored properly, clean and not discolored along with items requiring to be reported for repair/replacement. Any issues identified will be reviewed, validated and immediately corrected. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations until negative trends resolve. F 812 F880 Infection Prevention & Control How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADLs) was not provided with necessary nail care. The resident, who had diagnoses including metabolic encephalopathy, diabetes, gait abnormalities, and depression, required substantial to maximal assistance with personal hygiene, including nail care, as documented in her care plan. Despite this, observations revealed that the resident had long fingernails and toenails, with some toenails curved and causing discomfort by poking her other toes. The resident reported that she had requested nail trimming from staff over a month prior, but the care had not been provided. Certified Nurse Assistant (CNA) staff confirmed awareness of the resident's long nails, noting that they had observed the issue during showers and reported it to nursing staff approximately two weeks earlier. Facility documentation, including multiple "Skin Monitoring: Comprehensive CNA Shower Review" sheets, consistently indicated that the resident needed her toenails cut, with both CNA and nurse signatures, but no interventions were documented in response. The facility's process required nurses to perform nail care for diabetic residents and to refer residents needing special tools to a podiatrist, but the resident was not included on the podiatry referral list, and no action was taken to address her nail care needs. Interviews with facility leadership, including the Social Services Director, Director of Staff Development, and Director of Nursing, confirmed that nail care should be assessed and performed regularly, particularly for residents with diabetes, and that failure to provide this care could result in skin injury or infection. The facility's policy required provision of necessary services for residents unable to perform ADLs, including grooming and personal hygiene, but this was not followed in the resident's case.
Plan Of Correction
F677 ADL Care Provided for Dependent Residents How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #70 had their fingernails trimmed and toes trimmed on 04/10/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of all residents was completed on 04/09/2025 by MDS LVN/designee to ensure that residents had cleaned, well-trimmed fingernails and toenails. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON / DSD to LN and CNA staff from 04/10/2025 through 04/17/2025 regarding the importance of ensuring that all residents have cleaned, well-trimmed fingernails and toenails. d) LN supervisor / designee review shower sheets and check resident nails the following day to ensure that nails and toenails are being kept cleaned, and well-trimmed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained: e) LN Supervisor / designee review shower sheets and check resident nails the following day to ensure that nails and toenails are being kept cleaned, and well-trimmed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. Administrator and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 04/17/2025
Failure to Provide Ongoing Activities Meeting Psychosocial Needs
Penalty
Summary
A deficiency was identified when a resident with dementia, Alzheimer's disease, and major depressive disorder was not provided with an ongoing activity program that met her psychosocial needs for multiple periods. The resident's care plan specified the importance of activities such as reading, listening to music, being around animals, staying updated with the news, participating in group activities, going outdoors, and engaging in religious practices. The care plan also included goals for both in-room and out-of-room activities, with interventions to invite, encourage, and assist the resident in participating as tolerated. Observations over several days showed the resident lying in bed, unresponsive to greetings, with no music playing and the television turned off. There was no evidence of activities being provided in the resident's room during these times. The Activities Director confirmed that the resident did not receive any activities that met her psychosocial needs during two specific periods, and acknowledged that this lack of engagement would not maintain the resident's activity level as intended by the care plan. Interviews with facility staff, including the Activities Director and the DON, revealed that residents unable to attend group activities should be provided with bedside activities to keep them engaged. The DON stated that it was unacceptable for a resident to go without activities meeting psychosocial needs for several weeks, as this could lead to a decline in activity level and self-isolation. Review of the facility's policy confirmed the requirement to provide individualized, ongoing activity programs based on resident assessments and preferences, including special considerations for residents with dementia.
Plan Of Correction
Activities Meet Interest/Needs Each Resident How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #30 plan of care was updated to include alternate activities on 04/11/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Activities Director completed an audit on 04/17/2025 to ensure that residents have activities offered. All residents in the facility have the potential to be affected by this deficient practice. No other residents were identified. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was initiated by facility Administrator on 04/11/2025 to Activities Director regarding the importance of offering residents activities. e) DON and/or designee will conduct weekly random audits of residents' activities charting to ensure that residents are offered activities. Issues identified during these audits will be brought forth to the five-day a week clinical department manager meeting for review, validation, and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: f) DON and/or designee will conduct weekly random audits of residents' activities charting to ensure that residents are offered activities. Issues identified during these audits will be brought forth to the five-day a week clinical department manager meeting for review, validation, and immediate correction. All non-compliance issues identified will be corrected immediately and reported to the Administrator for review, validation, and resolution. DON will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations. 04/17/2025
Failure to Remove and Destroy Discontinued Controlled Medications
Penalty
Summary
The facility failed to ensure that completed or discontinued controlled medications were promptly removed from medication carts and properly destroyed, as required by federal regulations and facility policy. During observations and interviews, surveyors found that controlled medications, specifically Ativan 0.5 mg tablets, remained in the medication carts for two residents after the medications had been discontinued or completed. In one instance, a nurse confirmed that a bubble pack containing forty Ativan tablets for a resident with a history of radiculopathy, convulsions, and muscle spasm was still present in the cart, despite the medication order having ended weeks prior. The nurse acknowledged that the medication should have been surrendered to the DON for destruction. A similar situation was observed with another resident diagnosed with dementia, psychotic disturbance, and pain. Two bubble packs of Ativan, containing a total of thirty tablets, were found in the medication cart, even though the medications had been completed the previous year. The nurse responsible for the cart confirmed that the medications should have been removed and given to the DON for destruction, and acknowledged that keeping discontinued controlled medications in the cart was unsafe. Interviews with the DON and the pharmacy consultant confirmed that the facility's policy requires discontinued or completed controlled medications to be immediately removed from medication carts, documented, and stored securely until destruction. Record reviews corroborated that the medications in question had not been administered for several months, yet remained accessible in the carts. The facility's failure to follow its own procedures and federal requirements resulted in the presence of unused controlled substances in medication carts, as directly observed by surveyors.
Plan Of Correction
F755 Pharmacy Srvcs/Procedures/Pharmacist/Records How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #8 and Resident #59 discontinued medications were removed from the cart immediately on 04/09/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) An audit of all medication carts was completed on 05/01/2025 by Nurse Supervisor to ensure all discontinued medications were removed from the cart and logged for destruction. All residents have the potential to be affected by this deficient practice. No other residents were identified to have this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all resident's discontinued medications were removed from the medication cart. d) DON and/or designee will conduct random audits of medication carts for discontinued medications. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. This plan of correction is integrated into the quality assurance system: e) DON and/or designee will conduct random audits of medication carts for discontinued medications. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/01/2025
Improper Preparation of Pureed Foods Reduces Nutritional Value and Palatability
Penalty
Summary
The facility failed to prepare pureed foods for ten residents according to established recipes and methods that conserve nutritive value, flavor, and appearance. During meal preparation, the dietary cook did not use measuring tools and added unmeasured amounts of water to various foods, including pasta, meatballs, and spinach, to achieve a pureed consistency. The cook also did not have pureed diet recipes available at the workstation during food preparation. Observations revealed that water was used as the primary thinning agent for pureed foods, rather than recommended liquids such as low sodium broth or gravy. For example, the cook added unmeasured water to pasta and spinach, and used cooking juice and water for the meatballs, resulting in a watery consistency. The cook expressed dissatisfaction with the texture of the pureed spinach and continued to add more water to adjust it. These practices were inconsistent with the facility's documented recipes and guidelines, which specifically state that water should not be used as it dilutes flavors and results in a poorly accepted product. The registered dietitian confirmed that adding water to pureed foods can dilute taste and alter the nutrient content of meals. Review of facility documents and recipes further supported that water should not be used in pureed foods, and that warm liquid such as broth or gravy should be added gradually to achieve the desired consistency. The failure to follow these procedures affected the quality and nutritional value of meals provided to the residents on pureed diets.
Plan Of Correction
Nutritive Value/Appear, Palatable/Prefer Temp How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Dietary Cook 1 disposed of the pureed that was made with water on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking at preparation of pureed food to ensure it was prepared according to the recipe to maintain nutritional value. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the recipe for pureed food to ensure that residents are provided the correct nutritional content. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking at preparation of pureed food to ensure it was prepared according to the recipe to maintain nutritional value. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: f) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking at preparation of pureed food to ensure it was prepared according to the recipe to maintain nutritional value. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. Issues identified will be reported to the Administrator and/or DON for immediate resolution. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025 F 804
Infection Control Lapses in PPE Use, Equipment Disinfection, and Supply Handling
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols in several instances. Two CNAs did not wear the required gowns, only gloves, while providing care to a resident on Enhanced Barrier Precautions (EBP) for an arteriovenous shunt used in dialysis. The EBP signage and facility policy clearly indicated that both gown and gloves were required for high-contact activities such as dressing and transferring, and both CNAs acknowledged awareness of these requirements. The Infection Preventionist and Director of Nursing confirmed that the expectation was for staff to wear both gown and gloves during such care, and records showed both CNAs had received recent in-service training on EBP prior to the incident. A licensed nurse failed to disinfect a blood pressure cuff between uses on three different residents during medication administration. The nurse used the same cuff on each resident consecutively without cleaning it, and later acknowledged this lapse. Facility policy required that multi-resident use equipment be cleaned and disinfected after each use, but this was not followed in these instances. During a wound care procedure, a nurse placed excess treatment supplies, including opened packs of gauze and silicone foam dressings, back into the treatment cart after use in a resident's room. Both the nurse and the Infection Preventionist confirmed that this practice could lead to cross-contamination, and facility policy specified that supplies removed from the cart and exposed during treatment should not be returned unless sanitized. The Director of Nursing also stated that returning such supplies to the cart was not appropriate due to the risk of spreading infection.
Plan Of Correction
a) On 04/09/2025 CNA 1 and CNA 2 immediately put on PPE required for Resident 73's Enhanced Barrier Precaution. b) On 04/08/2025 Licensed Nurse 9 immediately cleaned and disinfected the blood pressure cuff. c) On 04/08/2025 Licensed Nurse 1 removed and disposed of the excess treatment supplies from the treatment cart. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: d) Infection Prevention Nurse Consultant completed an audit on 04/09/2025 of staff to ensure no other staff were identified with having the same deficient practice of not wearing enhanced barrier precaution PPE. No other areas were identified with having the same deficient practice. e) Infection Prevention Nurse / designee completed an audit on 04/09/2025 of staff to ensure no other licensed nurses were identified with having the same deficient practice of not cleaning and disinfecting the blood pressure cuff between residents. No other areas were identified with having the same deficient practice. f) Infection Prevention Nurse / designee completed an audit on 04/09/2025 of staff to ensure no other licensed nurses were placing excessive treatment supplies back into the treatment cart. No other areas were identified with having the same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: g) DON in-served Licensed Nurses on 04/17/2025 regarding the importance of wearing enhanced barrier precaution PPE, cleaning and disinfecting resident equipment between uses, and not putting excess treatment supplies back into the treatment cart. h) Infection Preventionist and/or designee will conduct random audits of staff to ensure that enhanced barrier precaution PPE is worn, disinfecting of resident equipment between uses, and excess treatment supplies are not placed back into the treatment cart. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Infection Preventionist will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation/s. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: i) Infection Preventionist and/or designee will conduct random audits of staff to ensure that enhanced barrier precaution PPE is worn, disinfecting of resident equipment between uses, and excess treatment supplies are not placed back into the treatment cart. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Infection Preventionist will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation/s. 04/17/2025
Failure to Develop and Implement Dysphagia Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with dysphagia, as required by federal regulations. Both residents had documented diagnoses including acute respiratory failure with hypoxia and orders for nectar-thick liquids to address their swallowing difficulties. Despite these orders, one resident was observed drinking regular water and another was observed drinking unthickened hot chocolate, both contrary to their prescribed diet orders. The Activity Director and Director of Nursing confirmed that the drinks should have been thickened according to the residents' meal tickets to prevent choking or aspiration. Further review of the electronic medical records for both residents revealed no documented evidence of a dysphagia care plan. This was confirmed by both a licensed nurse and the Director of Nursing, who acknowledged that a care plan should have been in place as a means of communication for nursing staff. The facility's own policy requires the development and implementation of a comprehensive, person-centered care plan for each resident, including all services identified in the comprehensive assessment.
Plan Of Correction
Either by the governmental agencies or third party. Any changes to provider policy or procedures should be considered to be subsequent remedial measures as that concept is employed in Rule 407 of the federal rules of evidence and California evidence code section 1151 and should be inadmissible in any proceeding on that basis. F656 Develop/Implement Comprehensive Care Plan How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) On 04/09/25 Resident 49 and Resident 79 care plans were updated to include dysphagia diagnosis. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Clinical Resource Nurse completed an audit on 05/01/2025 to ensure all current residents with a dysphagia diagnosis/diets had a completed care plan to reflect their dysphagia diagnosis. All residents have the potential to be affected by this deficient practice. No other areas were identified with having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) An in-service was initiated by facility DON on 04/11/2025 to LN staff regarding the importance of completing dysphagia care plans for residents with a dysphagia diagnosis. d) Medical Records / designee will pull the report of new admissions each morning and bring to the clinical meeting 5 days per week to ensure dysphagia care plans have been completed. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) Medical Records / designee will pull the report of new admissions and bring to the clinical meeting 5 days per week to ensure dysphagia care plans have been completed. Any issues identified during the audit will be brought forth to the IDT members and physician for review and resolution. All non-compliance issues identified will be brought forth immediately and reported to the IDT members for review, validation and resolution. DON / designee will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations. F 656
Failure to Consistently Provide Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including multiple sclerosis, malnutrition, depression, and anxiety disorder, did not consistently receive prescribed wound care for a right ankle wound. The resident was cognitively intact and reported that staff were not cleaning the wound as frequently as ordered by the physician. The care plan required monitoring and documentation of the wound, as well as reporting abnormalities to the physician. Physician orders specified daily evening wound care, with changes as needed if soiled or dislodged, and later included specific wound care products. However, treatment administration records showed that wound care was missed on several specific dates. Interviews with facility staff, including the Nurse Supervisor, Director of Staff Development, and Director of Nursing, confirmed that the wound care was not performed as ordered. Staff acknowledged that failure to follow wound care orders could result in infection, delayed healing, or worsening of the wound. The facility's policies required wound treatments to be provided according to physician orders and professional standards of practice. As a result of the missed wound care, the resident experienced right ankle pain, increased bleeding, confusion, elevated heart rate, and temperature, which led to a hospital transfer. Hospital records indicated the presence of an infected wound with MRSA and Pseudomonas, requiring intravenous antibiotics. The failure to provide consistent wound care as ordered by the physician and outlined in facility policy directly contributed to the resident's condition and subsequent hospitalization.
Plan Of Correction
**Quality of Care** How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #346 right ankle wound care was completed on 04/08/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with wounds was completed on 04/11/2025 by Medical Records Director to ensure that residents had their treatments completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents treatments are done consistently. d) LN Supervisor will review treatment administration records to ensure treatments are being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: e) LN Supervisor and/or designee will review treatment administration records to ensure treatments are being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 04/17/2025
Failure to Consistently Provide Suprapubic Catheter Care per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter did not consistently receive care and treatment in accordance with professional standards of practice, facility policy and procedure, and physician's orders. The resident, who had multiple diagnoses including multiple sclerosis, malnutrition, neuromuscular dysfunction of the bladder, depression, and anxiety disorder, was cognitively intact and able to report her care. She stated that staff would miss days of catheter care and treatment. Review of the resident's care plan and physician's orders showed that the suprapubic catheter was to be flushed with 60 cc saline every shift to prevent sedimentation and clogging, and the insertion site was to be cleansed every evening shift. However, treatment administration records revealed multiple missed shifts for both catheter flushing and site cleansing across several months. These omissions were confirmed by the nurse supervisor, who acknowledged that the care and treatment were not done consistently as ordered. Interviews with facility staff, including the nurse supervisor, director of staff development, and DON, confirmed that the expected standard was to follow the physician's orders for catheter care and treatment. The facility's policies also required that care be provided in accordance with physician orders and professional standards. The lack of consistent documentation and performance of the required catheter care constituted the deficiency.
Plan Of Correction
Bowel/Bladder Incontinence, Catheter, UTI How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #346 suprapubic catheter care was completed on 04/09/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with catheters was completed on 04/11/2025 by Medical Records Director to ensure that residents had their catheter care completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents' catheter care is done consistently. d) DON and/or designee will review treatment administration records to ensure catheter care is being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation, and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. The facility will identify other residents having the potential to be affected by the same deficient practice and take action: b) Audit of current residents with catheters was completed on 04/11/2025 by Medical Records Director to ensure that residents had their catheter care completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. Measures to prevent recurrence: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents' catheter care is done consistently. d) DON and/or designee will review treatment administration records to ensure catheter care is being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation, and immediate correction. Monitoring and evaluation: e) DON and/or designee will review treatment administration records to ensure catheter care is being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation, and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. Date of review: 04/17/2025
Failure to Change PICC Line Dressing and Follow Oxygen Therapy Orders
Penalty
Summary
The facility failed to change the peripherally inserted central catheter (PICC) line dressing for a resident diagnosed with osteomyelitis. During an observation and interview, it was noted that the PICC line dressing was dated ten days prior, and the resident was unsure when it was last changed. The DON confirmed that PICC line dressings should be changed weekly, and the physician's order as well as facility policy required weekly dressing changes. The dressing had not been changed within the required timeframe. Additionally, the facility failed to follow a physician's order for oxygen therapy for another resident with chronic obstructive pulmonary disease and respiratory failure with hypoxia. During observation and interview, the resident's oxygen was set at three liters per minute, but the report does not specify if this matched the physician's order. The resident was able to understand and communicate but was unaware of the details of their oxygen therapy.
Plan Of Correction
Parenteral/IV Fluids How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident # 3 PICC line was changed on 04/30/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with PICC lines was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had their PICC lines changed completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents PICC lines are changed. d) DON and/or designee will review treatment administration records to ensure PICC lines are changed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with PICC lines was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had their PICC lines changed completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents PICC lines are changed. d) DON and/or designee will review treatment administration records to ensure PICC lines are changed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) DON and/or designee will review treatment administration records to ensure PICC lines are changed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. --- Respiratory/Tracheostomy Care and Suctioning How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident # 49 oxygen order was changed on 04/26/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with oxygen orders was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had the correct liters flow per their MD order. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents oxygen orders are followed. d) LN Supervisor and/or designee will review oxygen orders to ensure that the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) LN Supervisor and/or designee will review oxygen orders to ensure the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for oxygen therapy for a resident with chronic obstructive pulmonary disease and respiratory failure with hypoxia. The resident was observed receiving oxygen at three liters per minute, while the physician's order specified four liters per minute. The resident was not aware of the prescribed oxygen setting, stating that the nurses handled it. A licensed nurse confirmed the oxygen was set incorrectly and verified the physician's order for four liters per minute. The care plan also directed staff to administer oxygen as ordered by the physician. Further review and interviews with the respiratory therapist and the Director of Nursing confirmed that there was no order to titrate the oxygen and that the expectation was to follow the physician's order exactly. Facility policy required oxygen to be administered under a physician's order. The failure to administer oxygen at the prescribed rate constituted a deviation from both the physician's order and facility policy.
Plan Of Correction
b) Audit of current residents with oxygen orders was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had the correct liters flow per their MD order. All residents have the potential to be affected by this deficient practice. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents oxygen orders are followed. d) LN Supervisor and/or designee will review oxygen orders to ensure the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) LN Supervisor and/or designee will review oxygen orders to ensure the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025
Failure to Provide Thickened Liquids as Ordered for Residents with Dysphagia
Penalty
Summary
The facility failed to follow physician-ordered diet instructions regarding fluid consistency for two residents with dysphagia. One resident, with a history of acute respiratory failure with hypoxia and gastro-esophageal reflux, was observed drinking regular water despite an order for nectar-thick liquids. The resident's meal ticket also indicated the need for thickened liquids, and this was confirmed by the Activity Director, who acknowledged that the water should have been thickened as per the order. Another resident, also diagnosed with acute respiratory failure with hypoxia and pneumonia, was observed coughing after drinking hot chocolate that was not thickened, despite an order for nectar-thick liquids. The Director of Nursing confirmed that the drink should have been thickened according to the resident's meal ticket and physician's order. The facility's policy on nutritional management of thickened liquids emphasizes the importance of following thickened liquid orders to prevent aspiration in residents with dysphagia.
Plan Of Correction
Drinks Available to Meet Needs/Preferences/Hydration How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #49 and Resident #79 were provided with thickened beverages according to their diet orders on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the meal tray diet order to ensure that residents are provided the correct beverages according to their diet. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. f) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. Issues identified will be reported to the Administrator and/or DON for immediate resolution. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025
Failure to Provide Physician-Ordered Fortified Diet
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, Alzheimer's disease, dysphagia, and major depressive disorder, was not provided with food in accordance with the physician's prescribed fortified diet. The resident's care plan and physician's order specified a dysphagia Level 1 puree texture with thin consistency and a fortified diet to increase caloric intake. However, during multiple observations, staff assisting the resident with meals confirmed that the meal trays did not contain extra butter or other means of fortification, despite the meal ticket indicating a fortified diet was required. Interviews with certified nurse assistants and the facility cook revealed that the standard practice for a fortified diet was to include a packet of extra butter on the meal tray, but this was not done for the resident in question. The registered dietitian confirmed that the fortified diet was intended to add extra calories and expected diet orders to be followed. The director of nursing also stated that diet orders should be followed and acknowledged the risk of nutritional problems if residents do not receive enough calories. A review of the resident's weight records showed a consistent decline in weight over several months, with the resident losing 23 pounds from September to April. The facility's policy required that therapeutic diets be provided as prescribed by a physician, with dietary and nursing staff responsible for ensuring the appropriate nutritive content. Despite these policies and clear orders, the resident did not receive the prescribed fortified diet during the observed meals.
Plan Of Correction
Therapeutic Diet Prescribed by Physician How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #30 was provided a fortified meal on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Registered Dietician / designee completed an audit of residents with fortified diet orders on 04/11/2025 to ensure those residents had the appropriate fortified meal provided. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: d) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the meal tray diet order to ensure that residents are provided the correct meal according to their diet. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. b) Registered Dietician / designee completed an audit of residents with fortified diet orders on 04/11/2025 to ensure those residents had the appropriate fortified meal provided. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: d) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the meal tray diet order to ensure that residents are provided the correct meal according to their diet. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. f) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. Issues identified will be reported to the Administrator and/or DON for immediate resolution. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025 F 808 F812 Food Procurement, Store/Prepare/Serve - Sanitary How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Opened and undated food items removed and thrown away on
Deficiency: Inaccessible Resident Call Light System
Penalty
Summary
Surveyors identified a deficiency related to the accessibility of the resident call light system for two residents. Both residents were observed lying in bed with their call light buttons on the floor, out of their reach. Interviews with the residents revealed that they were unaware of the location of their call light buttons and could not access them when needed. Certified Nurse Assistant (CNA) 3 confirmed during interviews that the call light buttons were not within reach and acknowledged that they should have been accessible to the residents. Resident 85 had a history of dementia with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. This resident was dependent on staff for most activities of daily living, including transfers and hygiene. Resident 39 also had severely impaired cognition, with diagnoses including metabolic encephalopathy, schizophrenia, and depression. This resident was similarly dependent on staff for toileting, bathing, dressing, and mobility. Both residents' care plans and the facility's policy required that call lights be within reach and accessible at all times. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed the expectation that call light buttons should be placed within reach of residents. The facility's policy also stated that staff are responsible for ensuring the call light is accessible to residents while in bed or other sleeping accommodations. The failure to ensure the call light system was within reach for these two residents constituted a deficiency under federal regulations.
Plan Of Correction
F919 Resident Call System How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) On 04/07/2025 CNA 3 moved Resident #85 and Resident #39's call light within reach. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) On 04/08/2025 DSD and/or designee completed an audit ensuring that no further residents had call light out of reach. There were no other areas identified with the same deficient practice. All other rooms were observed to have call lights within reach. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) An in-service was initiated by facility DSD on 04/10/2025 to licensed nurses and CNAs regarding the importance of keeping the call light within resident's reach. d) Department Managers will conduct random audits of call lights during their facility guardian angel rounds to ensure they are within resident's reach. All issues identified will be corrected immediately and brought forth to the five day a week department manager meeting for review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: e) Department Managers will conduct random audits of call lights during their facility guardian angel rounds to ensure they are within resident's reach. All issues identified will be corrected immediately and brought forth to the five day a week department manager meeting for review and resolution. Administrator and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 04/10/2025
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that two medication carts, labeled as cart A and cart B, were left unlocked and unattended in the facility. These observations occurred in the facility's lobby and were confirmed by interviews with two licensed nurses, both of whom acknowledged that the carts should have been locked at all times. The Director of Nursing also confirmed that medication carts are required to be locked to prevent drug diversion. A review of the facility's own policy on medication storage, dated 2024, indicated that all drugs and biologicals must be stored in locked compartments. The failure to keep the medication carts locked and attended was identified during a survey for a facility with a census of 93 residents. The unlocked carts contained medications, and the staff interviewed recognized that leaving them unsecured could allow unauthorized access. No specific residents or patient medical histories were mentioned in the report, and the deficiency was based on the direct observation of the unlocked and unattended medication carts.
Plan Of Correction
Civil, criminal action or proceedings against the provider or its employees, agents, officers, directors, or shareholders. The provider reserves the right to challenge the cited findings if at any time the provider determines that the disputed findings are relied upon in a manner adverse to the interest of the provider either by the governmental agencies or third parties. Any changes to provider policy or procedures should be considered to be subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and California Evidence Code Section 1151 and should be inadmissible in any proceeding on that basis. F761 Label/Store Drugs and Biologics How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A) On 04/03/2025, upon discovery of medication cart being unlocked, Licensed Nurse 1 and Licensed Nurse 2 immediately locked both carts. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: B) DON / designee completed an audit on 04/03/2025 of medication carts to ensure all were locked. All residents have the potential to be affected by this deficient practice. No other areas were identified with having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: C) An in-service was initiated by facility DSD / DON on 04/03/2025 and will continue until completion of 100% of Licensed Nurses regarding the importance of locking medication carts. D) DON / designee will conduct random audits of medication carts during their rounds to ensure that the facility process for securing medications is being adhered to. How the facility plans to monitor its performance to make sure that solutions are sustained: E) DON / designee will conduct random audits of medication carts during their rounds to ensure that the facility process for securing medications is being adhered to. Any issues identified during the audit rounds will be brought forth to the Department Managers five days a week during the morning meeting for review and immediate resolution. All non-compliance issues identified will be brought forth to the daily morning manager meeting and corrected immediately and reported to the Administrator for review, validation, and resolution. The Administrator will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency was identified when staff failed to follow infection prevention and control practices during wound care for a resident with a diabetic foot ulcer. Specifically, a licensed nurse entered an Enhanced Barrier Precaution (EBP) room without wearing a gown, donned gloves without performing hand hygiene, and proceeded to open the resident's wound dressing. The nurse acknowledged that both a gown and hand hygiene should have been used prior to the procedure to prevent infection. Further observations revealed that a wound doctor and another licensed nurse also entered the same EBP room to assess the resident's wound without wearing gowns. The wound doctor admitted that the required personal protective equipment (PPE), including a gown and gloves, should have been used in the EBP room. The second nurse confirmed that there were no gowns available by the door or in the medication cart and stated that the use of gown and gloves is necessary to prevent the spread of infection. The facility's infection preventionist confirmed that staff are expected to wash hands or use hand sanitizer before donning gloves and that gowns and gloves are required PPE for EBP rooms. Facility policy indicated that gowns and gloves should be made available immediately near or outside the resident's room and that hand hygiene must be performed prior to donning gloves. These lapses in infection control practices were observed during care for a resident admitted with a diabetic foot ulcer.
Plan Of Correction
04/03/2025 F880 Infection Prevention & Control How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A.) On 04/01/2025 Licensed Nurse 2 immediately performed hand hygiene. On 04/01/2025 Licensed Nurse 2, Licensed Nurse 3, and Wound Doctor donned enhanced barrier precaution PPE. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: B.) Infection Preventionist completed an audit of staff to ensure no other staff were identified with having the same deficient practice of not performing hand hygiene and donning enhanced barrier precaution PPE. No other areas were identified with having the same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: C.) Staff have been in serviced 04/01/2025 through 04/04/2025 by Infection Preventionist regarding the importance of hand hygiene and ensuring that enhanced barrier precaution PPE is donned. D.) Infection Preventionist and/or designee will conduct random audits of staff to ensure that hand hygiene is performed and enhanced barrier precaution PPE is donned. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Administrator will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation(s). How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: E.) Infection Preventionist and/or designee will conduct random audits of staff to ensure hand hygiene is performed and enhanced barrier precaution PPE is donned. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Administrator will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation(s). Include dates when corrective action will be completed. The corrective action completion date must be acceptable to the State: 04/04/2025 Integrated into the quality assurance system: E.) Infection Preventionist and/or designee will conduct random audits of staff to ensure hand hygiene is performed and enhanced barrier precaution PPE is donned. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Administrator will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation(s). Include dates when corrective action will be completed. The corrective action completion date must be acceptable to the State: 04/04/2025
Resident Assaulted by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when another resident physically assaulted him. Resident 1, who has moderate memory impairment and was admitted with pancytopenia, was punched in the head by Resident 2 during a smoke break. This incident resulted in Resident 1 falling from his wheelchair and sustaining an abrasion to his left elbow. The altercation occurred despite the presence of a Restorative Nursing Assistant (RNA) who was supervising through a window but was unable to intervene in time. Resident 2, who has severe memory impairment and was admitted with unspecified dementia and anxiety, was identified as the aggressor. Prior to the incident, Resident 2 had been accusing Resident 1 of stealing money, a situation that staff were aware of. The Director of Nursing (DON) acknowledged that the altercation violated Resident 1's right to be free from abuse, as outlined in the facility's Abuse Prevention and Prohibition Program policy. This policy emphasizes that each resident has the right to be free from mistreatment, neglect, and abuse.
Plan Of Correction
F600 Free from Abuse and Neglect How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A) On 03/14/2025 Resident #1 was moved to a different hallway of the facility. B) Resident #1 monitored elbow abrasion and for delayed injury doctor will be notified of any changes. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: C) DON completed an audit on 03/26/2025 of residents who pose a risk for altercation. All residents have the potential to be affected by this deficient practice. No other areas were identified with having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: D) An in-service was initiated by facility DSD on 03/26/2025 to licensed staff regarding the importance of preventing abuse and reporting abuse. E) Nursing staff to monitor resident #1's abrasion and for delayed injury for the next 7 days and report any changes to the doctor. How the facility plans to monitor its performance to make sure that solutions are sustained: F) Nursing staff to monitor resident #1's abrasion and for delayed injury for the next 7 days and report any changes to the doctor. G) IDT team will review COC the following day during the five day a week clinical morning meeting to ensure abuse prevention efforts were made ensure reoccurrence does not. All non-compliance issues identified will be brought forth to the daily morning manager meeting and corrected immediately and reported to the Administrator for review, validation, and resolution. Administrator will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations.
Failure to Protect Residents from Sexual Abuse by Employing CNA with Criminal History
Penalty
Summary
The facility failed to protect nine residents from sexual abuse by employing a Certified Nursing Assistant (CNA 1) with a known criminal misdemeanor history. The CNA was hired despite a background screening report indicating a charge of knowingly touching with the intention to injure, insult, or provoke a person. The Administrator (ADM) and Director of Staff Development (DSD) were aware of this history prior to hiring CNA 1, who explained the charge as a domestic incident with his husband. The deficiency was identified when allegations of sexual abuse toward a resident were reported by another CNA. The ADM confirmed that CNA 1 was suspended and removed from the facility following these allegations. Despite the facility's policy to screen potential employees for a history of abuse, the ADM and DSD failed to adequately verify CNA 1's background and references, leading to the employment of an individual with a history of assault. The facility's policy and procedure on abuse, neglect, and exploitation clearly state the need for background checks to prevent abuse. However, the ADM and DSD did not adhere to these procedures, resulting in the employment of CNA 1, who subsequently sexually assaulted multiple residents. This failure to follow established protocols directly contributed to the deficiency and placed all residents at risk of harm.
Removal Plan
- Immediate suspension of CNA 1
- Audit of all current employee files to review background investigations
- In-serviced ADM to not hire employees with background/history of abuse.
- ADM and/or designee to review applicant backgrounds
- Director of Staff Development (DSD) and/or designee will contact listed references for new hires.
Failure to Protect Residents from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect the residents' right to be free from sexual abuse by a staff member, specifically a Certified Nursing Assistant (CNA 1), who sexually assaulted nine residents. The incidents involved various forms of sexual misconduct, including unwanted sexual touching and exposure, which were confirmed through interviews, observations, and record reviews. The facility's Administrator was aware of CNA 1's criminal history of abuse prior to hiring him, yet proceeded with the employment, which led to the abuse of multiple residents. The residents affected by the abuse had varying degrees of cognitive impairment and medical conditions, such as muscle weakness, encephalopathy, cerebral infarction, and depression. Some residents were incapable of making health care decisions, while others had intact cognition. The abuse caused significant distress among the residents, with reports of fear, anxiety, and changes in behavior following the incidents. Several residents expressed feelings of shame and embarrassment, and some were unable to sleep due to fear of further abuse. The incidents were reported by other staff members who witnessed suspicious behavior by CNA 1, such as being in residents' rooms with the curtains closed and without a shirt. The police were involved, and CNA 1 admitted to the sexual assaults during interviews. The facility's policies on abuse prevention and resident rights were not effectively implemented, as evidenced by the hiring of CNA 1 despite his known criminal history and the subsequent abuse of residents.
Removal Plan
- Immediate suspension of CNA 1
- Physician visits to residents subjected to abuse
- Activity Director visits to residents subjected to abuse
- Psychosocial assessments, and trauma assessment completed for all victims
- Every shift monitoring of victims by nursing staff, reviewed by ADM or designee
- Audit of all current employee files for history of abuse, adverse actions on background
- In-service on preventing abuse and reporting abuse
- Physical assessment and interview of all victims
Failure to Investigate Sexual Abuse Allegations Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate allegations of sexual abuse involving a Certified Nursing Assistant (CNA 1) and multiple residents. Initial reports identified three residents as victims, but further investigation revealed additional victims, totaling nine residents. The facility's initial investigation did not identify all victims promptly, delaying necessary interventions such as counseling and monitoring for emotional trauma. The report details the clinical backgrounds of the affected residents, who were admitted with various diagnoses including muscle weakness, encephalopathy, cerebral infarction, depression, dementia, and other cognitive impairments. These conditions rendered some residents incapable of providing consent, making them particularly vulnerable to abuse. The facility's documentation of suspected abuse was inconsistent, with reports being faxed to the Department at different times, and some incidents not being reported until days later. Interviews with the Administrator and Director of Nursing revealed that the facility unsubstantiated the allegations in their five-day follow-up reports, citing a lack of witnesses. This decision was made despite a police report confirming the CNA's admission to the assaults. The facility's policy on abuse prevention and investigation was not adequately followed, as the investigation did not immediately identify all involved persons or determine the full extent of the abuse.
Failure to Prevent Hiring of CNA with Abuse History
Penalty
Summary
The facility failed to ensure effective management by the Administrator (ADM) and Director of Staff Development (DSD) when they hired a Certified Nursing Assistant (CNA1) with a known history of abuse. Despite being aware of CNA1's background screening report, which indicated a misdemeanor charge for knowingly touching with the intention to injure, insult, or provoke a person, the ADM and DSD proceeded with the hiring. The ADM confirmed awareness of the background check results and stated that CNA1 explained the charge as a fight with his husband. The DSD did not verify CNA1's previous employment references, as calls to the previous employer were not returned. The facility's policies and procedures on abuse prevention and hiring were not adhered to, as they require thorough background checks and reference verification for potential employees. The failure to follow these protocols resulted in CNA1 being employed at the facility, which subsequently led to the sexual abuse of nine residents. The facility's policy mandates the designation of an Abuse Prevention Coordinator and ongoing staff supervision to prevent abuse, which was not effectively implemented in this case.
Delayed Reporting of Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to report three allegations of sexual abuse involving three residents to the Department within the required two-hour timeframe. Resident 1, who was admitted in early 2022 and had a severe cognitive impairment, reported an incident involving a shirtless Certified Nursing Assistant (CNA 1) in his room. The report for this incident was faxed to the Department over four hours after the alleged abuse occurred. Resident 2, admitted in late 2023 with intact cognition, alleged sexual assault by CNA 1, and this report was also delayed beyond the two-hour requirement. Resident 5, admitted in early 2023 with moderate cognitive impairment, was involved in an incident where CNA 1 was found with his pants down near Resident 5's room. This report was sent to the Department more than seven hours after the incident was discovered. During an interview, the Administrator confirmed that the reports were sent late and acknowledged that they should have been reported within two hours to ensure resident safety and compliance with abuse reporting requirements. The facility's policy on abuse, neglect, and exploitation mandates immediate reporting, but not later than two hours after an allegation is made if it involves abuse or results in serious bodily injury. The delay in reporting these incidents decreased the facility's potential to protect vulnerable residents and provide a safe environment.
Failure to Protect Resident from Abuse in Shared Bathroom
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident during an altercation in a shared bathroom. Resident 1, who was admitted with anxiety and depression and was cognitively intact, was involved in a physical and verbal altercation with Resident 2. During the incident, Resident 2 opened the bathroom door from his side, used profanity, and kicked Resident 1's left shin, resulting in an abrasion. This incident left Resident 1 feeling afraid to leave his room due to fear of encountering Resident 2. Resident 2, also admitted with anxiety and depression and cognitively intact, acknowledged the altercation and admitted to using derogatory language and kicking Resident 1. Staff interviews revealed that Resident 2 had a history of being argumentative and instigating altercations with peers. The facility's Administrator confirmed that the incident was substantiated as abuse, as Resident 2's actions caused injury to Resident 1. The facility's 'Abuse Prevention and Prohibition Program' emphasizes a zero-tolerance policy for abuse, highlighting the failure to protect residents from mistreatment.
Failure to Administer Bowel Management as Ordered
Penalty
Summary
The facility failed to provide appropriate bowel management for a resident with a known history of constipation, resulting in significant discomfort and distress. The resident, who was admitted with multiple diagnoses including diabetes, kidney disease, and a below-knee amputation, had physician orders for various laxatives and bowel care interventions. Despite these orders, the resident did not receive the prescribed treatments, and the facility staff failed to notify the physician when the resident had no bowel movement for six days. Observations and interviews revealed that the resident was in visible distress, experiencing abdominal pain and discomfort due to constipation. The resident repeatedly requested an enema, which was part of the physician's orders, but was told by the nursing staff that there was no order for it. The resident's care plan, which included monitoring bowel movements and administering medications as ordered, was not followed, leading to the resident's condition worsening over several days. The Director of Nursing acknowledged the oversight and confirmed that the resident had not received any 'as needed' laxatives, nor was the physician informed of the resident's condition. The facility's policy on bowel management was not adhered to, resulting in the resident experiencing severe discomfort and being unable to eat or attend dialysis sessions due to the pain and bloating caused by constipation.
Resident Waited 38 Minutes for Feeding Assistance
Penalty
Summary
The facility failed to promote and maintain dignity and respect for a resident who waited 38 minutes to be assisted with feeding. The resident, who was admitted in 2023 with diagnoses including dysphagia and Huntington's disease, was observed in the dining room during lunch. Despite being dependent on staff for all activities of daily living due to severe cognitive impairment, the resident's lunch tray remained untouched while other residents finished their meals and left the dining room. A Certified Nursing Assistant (CNA) acknowledged the delay, stating that lunch was served around 11:20 a.m., and the resident was not assisted with feeding until 11:58 a.m. The CNA admitted that the resident should have been assisted at the same time as others and recognized it was inappropriate for the resident to watch others eat without being fed. The Director of Nursing confirmed that residents should not wait longer than 10-15 minutes to be fed, highlighting the failure to adhere to the facility's policy on maintaining resident dignity during mealtimes.
Failure to Implement Resident-Centered Activities
Penalty
Summary
The facility failed to implement resident-centered activities for a resident diagnosed with multiple sclerosis and depression, who had intact cognition. The resident's care plan emphasized the importance of engaging in recreational activities such as playing cards, reading, and doing word search puzzles. However, the facility did not conduct or document one-on-one visits for the resident, as confirmed by the resident and a Certified Nursing Assistant (CNA). The resident expressed dissatisfaction, noting that the activities director had not visited for 21 days, leaving the resident without the necessary materials for preferred activities. The Activities Director admitted to not having documentation of the room visits and was in the process of organizing it. The facility's policy and procedure emphasized the importance of providing activities that support residents' physical, mental, and psychosocial well-being, and the need to document these activities. The Administrator confirmed the lack of documentation for the resident's activity participation tasks, acknowledging that what is not documented is considered not to have happened. This oversight decreased the facility's potential to support and enhance the resident's well-being.
Inaccurate MDS Documentation of Resident's Wound
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) for a resident accurately reflected the resident's wound condition. The resident was admitted with diagnoses including acute osteomyelitis, cellulitis, and Type 2 Diabetes Mellitus. Despite having a deep wound on the right foot, the MDS Section M Skin Conditions inaccurately indicated that no foot problems or open lesions were present. This discrepancy was confirmed during interviews with the Infection Preventionist and the Director of Nursing, who acknowledged the error and its potential impact on the resident's care plan. The resident's medical records, including discharge summaries and wound evaluations, consistently documented the presence of an open wound on the right foot. Observations and interviews with the resident and staff further confirmed the existence of the wound, contradicting the MDS documentation. The facility's policy emphasized the importance of accurate assessments, yet the MDS failed to reflect the resident's actual condition, potentially affecting the care and interventions provided to the resident.
Failure to Timely Schedule Podiatry Consultation
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for a resident when a referral to a podiatrist was not ordered and carried out upon admission. The resident was admitted with diagnoses including right ankle and foot acute osteomyelitis, cellulitis of the right lower limb, and Type 2 Diabetes Mellitus. The discharge summary from the hospital indicated a need for an outpatient podiatry consultation as soon as possible, but this was not scheduled until almost a month after admission. Interviews with facility staff, including a Licensed Nurse, the Social Services Director, the Director of Nursing, and the Infection Preventionist, confirmed that there were no orders for a podiatry referral upon admission. The staff acknowledged the oversight and the delay in scheduling the necessary podiatry consultation. The facility's policies and procedures required that orders for immediate care and needs be provided upon admission, but this was not adhered to in this case, resulting in a delay in the resident receiving necessary care.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. This incident involved two residents, where one resident, who was cognitively intact with a BIMS score of 13, physically assaulted another resident, who was moderately impaired with a BIMS score of 11. The assault occurred in the hallway outside the victim's room, where the aggressor, in a wheelchair, self-propelled towards the victim and struck him in the face, resulting in swelling and pain in the victim's left eye. The incident was witnessed by a CNA who intervened to separate the residents and redirect the aggressor, who then became belligerent towards the staff. The facility's report indicated that the incident was substantiated, and a nursing assessment was completed with no injuries initially noted. However, the victim did experience swelling and pain following the assault. The facility's policy on abuse, neglect, and exploitation was reviewed, which outlines the protection of residents' health, welfare, and rights by prohibiting and preventing abuse. Despite these policies, the incident occurred, highlighting a failure in protecting the resident from physical abuse.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident's rights to be free from abuse when another resident threw urine and feces at him. This incident was witnessed by the victim's daughter and occurred after the aggressor became frustrated, believing the victim was intentionally smearing feces on a shared toilet. The aggressor admitted to his actions and expressed regret, acknowledging that he should have sought assistance to clean the mess instead of retaliating. The victim, who was cognitively intact and had a history of chronic osteomyelitis, expressed feelings of anger and embarrassment due to the incident, which was also witnessed by his daughter. The incident was reported by the victim's daughter to a Licensed Nurse, who confirmed the presence of urine and feces on the floor and the victim's wet clothing. A Certified Nursing Assistant also observed the aftermath, noting the victim's wet clothes and the aggressor's verbal aggression. The facility's Infection Preventionist Nurse confirmed the occurrence of the incident and emphasized that all residents should be free from abuse. The facility's policy on abuse prevention, revised in December 2016, states that residents have the right to be free from various forms of abuse, including physical and verbal abuse by other residents.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a staff member witnessed an altercation between two residents, where one resident physically assaulted another. Resident 1, who has dementia, cognitive communication deficit, and major depression, was identified as the aggressor in a physical altercation with Resident 2, who has a history of stroke, anxiety, depression, and muscle weakness. The incident occurred when Resident 1 charged at Resident 2, yelling obscenities and hitting Resident 2 on the arms, resulting in bruising. This incident was confirmed by the Activity Director, who witnessed the event and intervened. Resident 2 expressed fear and discomfort following the incident, stating that they felt unsafe and were considering moving to another facility. The Director of Nursing confirmed that the bruising on Resident 2's arms was caused by Resident 1's actions and acknowledged the incident as abuse. The facility's policy on abuse reporting was reviewed, indicating that resident-to-resident altercations are considered abuse, yet the facility failed to prevent this incident, compromising Resident 2's right to be free from abuse.
Failure to Provide Consistent Wound Care Leads to Infection
Penalty
Summary
The facility failed to provide consistent treatment for a resident with existing pressure ulcers, leading to an infection and subsequent hospitalization. The resident, admitted with multiple diagnoses including osteomyelitis and pressure ulcers on both buttocks, had wound care orders that were not followed. The Treatment Administration Record indicated multiple instances where the resident refused wound care, and there were days when care was not provided. Despite these refusals, there was no documentation that the physician was notified, as required by the facility's policy. Interviews with facility staff revealed that the physician should have been informed of the resident's refusal of care, and that wound care orders should have been adhered to. The facility's policy on wound treatment management emphasized the importance of following physician orders and monitoring the effectiveness of treatments. However, the lack of communication with the physician and failure to provide wound care as ordered resulted in the resident's condition worsening, ultimately leading to hospitalization due to wound infections.
Violation of Resident Privacy in LTC Facility
Penalty
Summary
The facility failed to ensure the privacy of a resident, identified as Resident 1, when an individual entered her room without permission. Resident 1, who was admitted with diagnoses of hemiplegia and epilepsy, had a BIMS score indicating no cognitive impairment. On the morning of June 20, 2024, a Licensed Nurse (LN 1) heard yelling from Resident 1's room. Upon investigation, Resident 1 reported that someone attempted to get into her bed, which she perceived as an invasion of her personal space. Further inquiry revealed that another resident, identified as Resident 5, admitted to trying to get into Resident 1's bed. Resident 5 was admitted with cerebrovascular disease and a cognitive communication deficit but was noted to be alert and oriented. The Director of Nursing confirmed that the incident was a violation of Resident 1's right to privacy, as outlined in the facility's policy on resident rights. The policy emphasizes the resident's right to personal privacy, which was not upheld in this instance.
Violation of Resident Privacy
Penalty
Summary
The facility failed to ensure the privacy of a resident, identified as Resident 1, when an individual entered her room without permission. Resident 1, who was admitted in early 2016 with hemiplegia and epilepsy, was assessed to have no cognitive impairment as per her Minimum Data Set (MDS) dated 4/27/24. On 6/20/2024, a Licensed Vocational Nurse (LN 1) heard yelling from Resident 1's room and discovered that Resident 5, another resident admitted in mid-2024 with cerebrovascular disease and a cognitive communication deficit, had attempted to get into Resident 1's bed. During interviews conducted on 6/26/2024, Resident 1 expressed that her personal space was invaded, and the Director of Nursing (DON) confirmed that the incident was a violation of Resident 1's privacy. The facility's policy on Resident Rights, which was reviewed and found to be undated, states that residents have a right to personal privacy. This incident highlights a breach in maintaining the privacy and personal space of residents within the facility.
Controlled Medication Reconciliation and Administration Failures
Penalty
Summary
The facility failed to ensure accurate reconciliation and accountability of controlled medications and proper medication administration for a census of 92 residents. Random controlled medication use audits for two residents revealed discrepancies where medications were signed out of the Controlled Drug Record (CDR) but were not documented on the Medication Administration Record (MAR) on multiple occasions. Specifically, for one resident, Norco was not documented on the MAR on three occasions, and for another resident, oxycodone was not documented on the MAR on seven occasions. The Desk Nurse and Director of Nursing confirmed these discrepancies, acknowledging the risk for controlled substance diversion and the importance of reconciling CDR and MAR records accurately as per facility policy and procedure (P&P). Additionally, one resident's controlled pain medication was administered less than two hours apart, contrary to the physician's order of every four hours, posing a risk for overdose. The Director of Nursing confirmed that the physician's order should be followed precisely to avoid such risks. Furthermore, another resident's medications were found unattended and unsupervised on their bedside table, which was against the facility's policy of not leaving medications at the bedside. The Licensed Nurse and Director of Nursing acknowledged this oversight, emphasizing that no patient in the facility was authorized to self-medicate. The facility's P&P on medication administration clearly stated that medications should be administered as ordered and observed during consumption by the resident.
Failure to Adhere to Physician's Orders for Pain Medication
Penalty
Summary
The facility failed to ensure that two residents, Resident 3 and Resident 59, did not receive unnecessary narcotic pain medication. Resident 3, who had diagnoses including fibromyalgia and a fracture of the left leg, was administered oxycodone 15 mg on multiple occasions despite having pain ratings below the physician-ordered threshold of 8. This was confirmed by the Desk Nurse and the Director of Nursing, who both acknowledged that the medication should not have been administered if the pain rating was less than 8. Instances of administration included pain ratings as low as 0 and 4, which were not in accordance with the physician's order. Similarly, Resident 59, who had diagnoses including bullous pemphigoid and pain in the right knee, was administered Norco 10-325 mg on several occasions despite having a pain rating of 0. The Desk Nurse confirmed that Norco should only be given for breakthrough pain and not when the pain rating is zero. The Director of Nursing also confirmed that the medication should not have been administered if there was no pain. The facility's policy on medication administration, which requires medications to be administered as ordered by the physician, was not followed in these instances.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure medications and supplies were properly labeled and stored according to the facility's policies and accepted professional principles. During an observation, 22 loose pills were found in two medication carts, with one nurse confirming that the loose pills should not be there and acknowledging the risks of infection control and resident safety. Another nurse also confirmed the presence of loose pills and highlighted the risk of wrong patient administration. The Director of Nursing (DON) confirmed that loose pills should not be in the medication carts and emphasized the risks of running out of medication, diversion, and resident safety. The facility's policy indicated that medications should be stored in their original containers and that medication storage areas should be kept clean and safe. Additionally, an opened vial of Tuberculin purified protein derivative (PPD) was found in the medication refrigerator without an opened date label. The Desk Nurse confirmed that the vial should have been labeled when opened and discarded after a maximum of one month. The DON also confirmed that the opened vial of PPD should have been labeled and was not supposed to be in the refrigerator without a date. The facility's policy stated that multi-dose vials should be dated when opened and discarded within 28 days.
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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