Rinaldi Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Granada Hills, California.
- Location
- 16553 Rinaldi St, Granada Hills, California 91344
- CMS Provider Number
- 055906
- Inspections on file
- 75
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Rinaldi Convalescent Hospital during CMS and state inspections, most recent first.
The facility failed to follow its Abuse, Neglect, Exploitation, and Misappropriation Prevention Program and Hiring policies by not properly completing and documenting pre-employment reference and background checks for a CNA. The CNA’s personnel file contained an incomplete Pre-Employment Reference Check List, including a reference from a staff member in a non-qualifying role and missing dates and verification details for prior employment. The DON and ADM acknowledged that pre-employment checks are intended to identify any history of abuse or related disciplinary actions and that it was unclear whether appropriate checks had been performed for this CNA, despite policy requirements to conduct such background investigations.
A resident with a G-tube and indwelling catheter did not have weekly weights obtained as ordered, and staff failed to monitor and document intake and output according to facility policy and professional standards. The resident, who was dependent on staff and had multiple complex medical conditions, did not receive required I/O monitoring from admission through hospitalization, and the omission was confirmed by interviews with nursing staff and leadership.
A resident with severe cognitive impairment and multiple complex medical conditions experienced significant unplanned weight loss and developed new and worsening pressure ulcers. Despite these major changes in health status, the facility failed to complete a required Significant Change in Status Assessment (SCSA) MDS, instead performing only a quarterly assessment, contrary to facility policy and staff acknowledgment.
A resident with severe cognitive impairment and multiple medical conditions did not receive physician-ordered lab tests, including CBC, CMP, and magnesium, due to staff failing to process the requisition and notify the physician of the missed tests.
A resident with hypertension and congestive heart failure, who was cognitively intact, exhibited a sudden change in behavior by refusing care, screaming, laughing inappropriately, and kicking a staff member. Despite staff involvement and facility policy requiring physician notification for such changes, the physician was not informed of the incident.
Two residents did not receive their prescribed medications on time, and staff failed to notify the physician prior to administering the late doses. In both cases, medications scheduled for the morning were given several hours late without prior physician input, and documentation of physician notification or assessment for adverse effects was lacking. Nursing staff and the DON confirmed that the required process for physician notification was not followed.
A nurse failed to ensure that a resident with multiple medical conditions received medications according to physician orders, including not providing required food or fluids with certain medications, not instructing the resident to rinse her mouth after inhaler use, and allowing self-administration without a physician's order or proper supervision.
A resident did not receive multiple scheduled morning medications within the required timeframe, with doses administered over three hours late and subsequent doses given in close succession. Nursing staff did not notify the physician of the missed doses or document any monitoring for adverse reactions, resulting in a failure to follow medication administration protocols.
A nurse failed to sign the treatment administration record for a resident's wound care and pleural catheter treatments, leaving uncertainty about whether care was provided. In a separate case, a nurse documented that a resident's morning medications were given before actual administration, which occurred later in the day after the resident initially refused. These actions resulted in incomplete and inaccurate medication and treatment records, as confirmed by staff interviews and policy review.
A resident with severe cognitive impairment was found with pillows placed on both sides of their body, restricting movement, without a physician's order for restraints. A CNA admitted to placing the pillows and forgetting to remove them, despite being aware that this could be considered a restraint. The LVN and DON confirmed that such use of pillows is not permitted without proper authorization, and facility policy prohibits restraints for staff convenience or fall prevention.
Surveyors found that a resident with COVID-19 did not have the required droplet precaution signage posted, another resident receiving IV antibiotics lacked enhanced barrier precaution signage and supplies, and two nurses failed to perform hand hygiene before administering medications, with one also not wearing gloves for eye drop administration. These actions were inconsistent with the facility's infection control policies.
A bottle of Pepto-Bismol was found at the bedside of a resident without a physician's order or proper labeling. The medication, brought in by the resident's family, was not listed on the Medication Administration Record and had not been assessed for self-administration. Facility staff confirmed that medications should not be left at the bedside without following required procedures.
Expired blood glucose (BG) control solutions were found in a medication cart and had been used for quality control checks after their expiration date. An LVN confirmed the solutions should have been replaced, and the DON acknowledged the risk of inaccurate readings. Facility policy required outdated medications to be returned or destroyed, but this was not followed.
The facility did not include required performance evaluations in the personnel files of four CNAs, as confirmed by record review and staff interviews. Facility policy mandates evaluations after probation and annually, but these were missing, resulting in incomplete personnel records.
Several CNAs and LVNs did not have required health exam documentation in their personnel files, including exams prior to or shortly after hire and annual health exams thereafter. The DSD and DON confirmed the lack of medical clearance for these staff, and facility policies requiring such documentation were not followed.
The facility did not provide or document required behavioral health in-service training for two CNAs, despite having residents with psychiatric and mood disorders and a scheduled training on the in-service calendar. Interviews confirmed that the CNAs had not received formal training, and the Director of Staff Development acknowledged the training was not conducted as scheduled. Facility policies require annual behavioral health training for all staff, but no evidence of such training was found in the CNAs' personnel files.
The facility failed to develop comprehensive care plans for two residents, one with severe cognitive impairment and another with a history of falls. The absence of care plans for a Restorative Nursing Assistant exercise program and a floor mat intervention led to potential inadequate care and risk of injury. Staff interviews confirmed the lack of person-centered care plans, despite facility policies emphasizing their importance.
The facility failed to update care plans for residents after changes in medication and ADL needs. A resident's anticoagulation therapy care plan was not revised after medication changes, another resident's care plan lacked specific ADL interventions, and a third resident's care plan inaccurately reflected discontinued anti-anxiety medication. These deficiencies were identified during interviews and record reviews, highlighting a lack of adherence to facility policies on care plan updates.
Two residents in an LTC facility did not receive appropriate pain management due to failures in assessing pain and documenting medication administration. Tramadol and Percocet were administered without prior pain assessment or entries in the MAR, violating facility policies. This lack of documentation hindered effective pain management and risked unmanaged pain for the residents.
Two residents in an LTC facility did not have their controlled medications properly documented in the MAR, despite being removed from the blister pack as per the CDR. This failure to document involved Xanax and Tramadol for one resident and Percocet for another, leading to potential medication errors and drug diversion. The facility's policy requires immediate documentation in both the CDR and MAR, which was not followed.
A LTC facility failed to administer Morphine Sulfate Contin to a resident as ordered, potentially increasing their pain. Additionally, two residents received midodrine despite having systolic blood pressure readings above the physician-ordered threshold, risking elevated blood pressure. The facility's medication administration policy was not followed.
The facility failed to maintain sanitary food storage practices when a scoop was left inside a bin of thickener powder used for pureed diets. This was observed during an inspection with the Dietary Supervisor, who confirmed that the scoop should not have been left in the bin to avoid contamination. This practice risked exposing five residents on pureed diets to foodborne illnesses.
A long-term care facility failed to implement proper infection control measures, including the absence of trash cans for PPE disposal, improper use of isolation gowns by an LVN, and unlabeled urinals, leading to potential cross-contamination. Additionally, personal belongings were found in a medication room, violating infection control policies.
A facility failed to ensure staff knocked and requested permission before entering the rooms of two residents, violating their rights to dignity and privacy. Both residents had intact cognitive skills and required assistance with personal care. A CNA entered their rooms without knocking, which was against the facility's policy on dignity.
A facility failed to maintain a current copy of a resident's advance directive in their medical record, as required by policy. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was admitted with conditions including hemiplegia and encephalopathy. The absence of the advance directive in the chart was confirmed by the DSS and DON, posing a risk of not honoring the resident's medical decisions.
A resident requiring moderate assistance with personal hygiene was not provided with necessary nail trimming services, despite having long and curvy fingernails. The resident, who has intact cognitive skills and medical conditions including hypertension and type 2 diabetes, expressed a desire for her nails to be trimmed but reported that no staff had offered assistance. This failure to adhere to the facility's ADL policy resulted in a deficiency in maintaining the resident's personal hygiene.
A facility failed to provide a resident-centered activities program by not meeting a resident's spiritual needs. The resident, with dementia and schizophrenia, had an MDS indicating the importance of religious services, but their care plan lacked interventions for such activities. The resident did not participate in religious activities or receive visits from religious representatives, contrary to the facility's policy.
A resident with multiple diagnoses, including dementia and malnutrition, did not receive a prescribed RNA exercise program due to lack of clarification and implementation by facility staff. The order lacked specifics on exercise type, frequency, and affected area, and the resident's restorative treatment records showed no entries, indicating a failure to provide necessary care to prevent ROM decline.
A facility failed to communicate a resident's nutritional intake and meal refusals to the RD and physician, risking weight loss. The resident, with severe cognitive impairment and malnutrition, consistently refused meals, yet staff did not document or report these refusals as required by policy.
The facility did not post the actual hours worked by nursing staff as required, instead displaying projected hours or leaving the actual hours section blank. This occurred due to a misunderstanding by the DSD, who believed actual hours were only needed at the end of the day, contrary to the facility's policy.
A facility failed to monitor a resident for side effects of Trazadone and Xanax, as required by physician orders. The resident, with various medical conditions, was prescribed these medications for depression and anxiety. Documentation was missing for the monitoring of side effects, indicating non-compliance with facility policy and physician orders. The DON highlighted the importance of monitoring to adjust dosages and prevent unnecessary medication use.
A resident with intact cognition threw water at another resident, making contact with their face, chest, and clothes, after a disagreement over television volume. The incident was substantiated as abuse, with both residents confirming the altercation. The facility's administrator acknowledged the event but felt it was a spontaneous action that could not have been prevented.
A resident with multiple diagnoses, including atrial fibrillation, experienced hematuria, leading to a physician's order to hold Xarelto. The facility failed to monitor the resident for signs of bleeding every shift as required, with no specific documentation of monitoring on several shifts. This lack of adherence to the facility's policy on acute condition changes could have led to confusion in care and services.
A facility failed to implement contact precautions for a resident diagnosed with scabies upon their return from a hospital. The resident's room lacked appropriate signage, and staff were not informed to use isolation gowns, leading to inadequate infection control measures for several days. The DON confirmed the resident should have been placed on contact precautions immediately.
The facility failed to develop a comprehensive care plan for a resident diagnosed with dermatitis consistent with scabies. The resident was transferred to a hospital for skin rashes and itching but returned without specific interventions in the care plan or contact precaution signage. Interviews confirmed the care plan was not updated as required by facility policies.
Failure to Complete and Document Pre-Employment Screening for CNA
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse, Neglect, Exploitation, and Misappropriation Prevention Program and Hiring policies by not conducting and documenting required pre-employment screening for a certified nursing assistant (CNA 1). Review of CNA 1’s personnel file, including the Personnel Action Form, showed prior employment at another skilled nursing facility. The Pre-Employment Reference Check List (PERCL) for CNA 1 contained only a name of a former employee as the first reference, with no title documented, and a second reference listing only the prior facility’s company name and the current Director of Staff Development’s (DSD) name, without an interview date, employment verification dates, or other required information. The DSD confirmed CNA 1’s date of hire and that the PERCL lacked complete documentation. During interviews, the DON stated that pre-employment reference checks are part of ensuring safety, confirming qualifications, and determining whether an applicant has any history of resident abuse, and clarified that RNA or CNA staff are not permitted to provide professional employment references or verify employment history. The DON further stated that the reference from the restorative nursing assistant appeared to be a personal reference and that the former DSD had not completed CNA 1’s PERCL prior to hire. In a separate interview, the Administrator acknowledged that the purpose of pre-employment checks is to identify any negative history and that it was difficult to determine whether such checks had been completed for CNA 1. Review of the facility’s Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy showed a requirement to conduct employee background checks and not knowingly employ individuals with disciplinary actions related to abuse or misappropriation, and the Hiring policy allowed for background investigations for applicants and current employees, which were not properly carried out or documented for CNA 1.
Failure to Monitor Weekly Weights and Intake/Output for Resident with G-Tube and Catheter
Penalty
Summary
The facility failed to obtain weekly weights as ordered for one resident who had significant medical needs, including a gastrostomy tube (G-tube) and an indwelling catheter. The resident was admitted with diagnoses such as traumatic subarachnoid hemorrhage, type 2 diabetes mellitus, and neuromuscular dysfunction of the bladder, and was dependent on staff for most activities of daily living. Physician's orders specified weekly weights for four weeks, but documentation showed that the weight for the third week was not obtained or recorded. Staff interviews confirmed that the weekly weight was missed, and facility policy required monitoring weights to detect undesirable or unintended weight loss or gain. Additionally, the facility did not ensure that staff monitored and documented the resident's intake and output (I/O) in accordance with professional standards and facility policy. Despite the resident having a G-tube and an indwelling catheter, there was no documented evidence of I/O monitoring from admission through the resident's most recent hospitalization. Staff interviews revealed that I/O monitoring was not included in the admission orders, and as a result, staff did not perform or document I/O in the Medication Administration Record. Facility policy required I/O monitoring for at least one month for residents with a G-tube and/or indwelling catheter, but this was not done for the resident in question. Interviews with nursing staff and facility leadership confirmed that the omission of I/O monitoring was due to a failure to include it in the admission orders and a lack of subsequent identification of this omission by clinical staff. The Director of Nursing stated that I/O monitoring should have been initiated upon admission and continued for the first four weeks, especially given the resident's history of pulling out the G-tube. Facility policies reviewed indicated that I/O monitoring is required for residents with urinary catheters and should be documented and evaluated weekly, but these procedures were not followed in this case.
Failure to Complete Timely SCSA MDS for Resident with Significant Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe for one resident who experienced notable changes in health status. The resident, who had diagnoses including traumatic subarachnoid hemorrhage, G-tube dependence, mood disorder, and neuromuscular bladder dysfunction, was readmitted and subsequently experienced severe cognitive impairment. Despite these complex medical needs, the facility only completed a quarterly MDS assessment rather than the required comprehensive SCSA. Record reviews revealed that the resident underwent significant, unplanned weight loss over a short period, losing 57 pounds (29.4%) in 92 days. Additionally, the resident developed new and worsening pressure ulcers, including an unstageable ulcer on the sacrococcyx and a stage II pressure ulcer on the right foot. These changes represented a major decline in more than one area of the resident's health status, meeting the criteria for a significant change that would require a comprehensive reassessment and potential revision of the care plan by the interdisciplinary team (IDT). Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that a SCSA should have been completed in response to the resident's significant weight loss and the development and worsening of pressure ulcers. The facility's own policy also indicated that a SCSA is required when there is a major decline or improvement in a resident's status affecting multiple health areas and requiring IDT review. However, the facility did not complete the SCSA as required, instead performing only a quarterly assessment.
Failure to Complete Ordered Laboratory Tests for Resident
Penalty
Summary
The facility failed to follow a physician's order dated 8/26/2025 to obtain laboratory tests for one resident. The resident, who had a history of traumatic subarachnoid hemorrhage with loss of consciousness, a gastrostomy tube, and neuromuscular dysfunction of the bladder, was severely cognitively impaired and dependent on staff for most activities of daily living. The physician's order required a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and magnesium level to be performed. However, review of records and interviews with staff confirmed that these laboratory tests were not completed as ordered. Further investigation revealed that the requisition slip for the lab tests was folded, indicating that the phlebotomist did not collect the required blood samples. Staff interviews confirmed that the missed laboratory tests were not communicated to the physician. The facility's policy required staff to process test requisitions and arrange for tests as ordered by the physician, but this protocol was not followed in this instance.
Failure to Notify Physician of Resident's Sudden Behavioral Change
Penalty
Summary
The facility failed to notify the attending physician of a sudden and marked change in a patient's behavior, as required by regulation. Patient 4, who had diagnoses of hypertension and congestive heart failure and was cognitively intact, refused a shower and began screaming when staff attempted to change her soiled incontinence briefs. The situation escalated to the point where the patient was yelling, laughing inappropriately, and ultimately kicked a staff member. Multiple staff, including the Administrator and Director of Social Services, were present and attempted to address the situation, but the physician was not notified of this significant behavioral change. Interviews with staff, including the CNA, Administrator, Director of Staff Development, LVN, and Director of Nursing, confirmed that the physician should have been informed of the change in the patient's condition. The facility's own policy also required prompt notification of the physician and resident representative in the event of a change in the resident's medical or mental condition. The failure to report this incident represented a lapse in following both regulatory and facility policy requirements.
Plan Of Correction
A) IMMEDIATE CORRECTIVE ACTION: On 10/7/2025, the RN supervisor assessed Patient 4 for any signs of adverse outcome regarding refusals to showers/bed bath. Upon explanation and discussing the importance of showers, Patient 4 was still not convinced to allow the CNA to continue with the hygienic and care procedure. CNA was relieved from her care and another CNA was assigned immediately with no further issues. Change of Condition was initiated and completed by the Charge Nurse to reflect Patient 4's behavior. MD and responsible party (RP) were made aware of patient 4's refusals. Patient 4's care plan was updated by the MDS nurse to signify her behavior change. Patient 4 will be monitored for 72-hours for any other changes. On 10/7/2025, the Director of Nursing Services (DON) and Director of Staff Development (DSD) completed an in-service to nursing staff on how to handle patient refusals of showers and notification requirements and processes for changes of condition. A policy and procedure titled, "CHANGE of CONDITION," was reviewed and discussed followed by question-and-answer evaluation. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, DSD interviewed all CNAs on shift to identify additional patients with episodes of care needs refusals, included them on a "Special Care Needs" list to ensure proper monitoring and appropriate interventions as individualized as possible. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025, DON held an in-service with all licensed nurses on P/P: Change of Condition, with an emphasis on MD/RP notification. On 10/29/2025, two additional systematic changes were implemented: 1. "Resident Special Care Needs" worksheet was modified to include patients with episodes of refusals of care needs. The list will be generally updated weekly and as changes occur by the Desk Nurse, to be shared on both nursing units. 2. "Huddle" every shift to review patients with special needs such as giving detailed attention to the patients who would tend to refuse care. Discussed with the team huddle the importance of reporting any incident of refusals to immediately implement interventions as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Weekly audits on refusals based on Change of Condition reports will be reviewed by the DON/Designee. The DON/Designee will present any findings to the QAPI/QAA Committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025
Failure to Notify Physician of Late Medication Administration
Penalty
Summary
The facility failed to notify the attending physician when medications were not administered on a timely basis as prescribed for two patients. For one patient, who had diagnoses including muscle weakness, GERD, depression, and cerebral infarction, multiple scheduled morning medications were not administered at the prescribed time. The medications, which included pregabalin, duloxetine, famotidine, fenofibrate, and several supplements, were given three and a half hours late without prior notification to the physician. The patient confirmed not receiving the medications on time, and the nurse acknowledged that the physician was not notified of the missed doses or the late administration. The subsequent dose was administered only a few hours after the late dose, again without physician input, and there was no documentation of assessment for adverse reactions due to the close timing of doses. For the second patient, who had paraplegia and was cognitively intact, the morning medications were not administered at the scheduled time due to the patient's refusal, except for pain medication. The nurse waited for the patient to request the medications and eventually administered them several hours late. The physician was only notified about the late administration after the survey team inquired, and not before the medications were given. The nurse stated that the physician should be notified in such situations to avoid potential double dosing, especially for medications scheduled twice daily. The facility's policy required contacting the physician if a dose was believed to be inappropriate or excessive, but this was not followed prior to the late administration. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not have a specific policy for late medication administration, but acknowledged the importance of notifying the physician before giving late doses. The staff recognized that failing to notify the physician and document instructions could lead to inappropriate medication timing and potential adverse effects. The deficiency was identified through interviews, record reviews, and direct observation, showing a lack of timely physician notification and documentation when medications were not administered as ordered.
Plan Of Correction
C 0875 - NURSING SERVICE - GENERAL Medication Administration IMMEDIATE CORRECTIVE ACTION: 1. The RN supervisor assessed Patient 10 on any signs of adverse outcome regarding medications that were not administered on time per MD orders. Vital signs were taken and recorded as follows: BP =124/74, P = 76, R = 19, O2 Sat = 96% and Pain level = 2/10. Patient 10 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. 2. The RN supervisor assessed Patient 5 for any abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96% & Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. 3. A one-on-one in-service was initiated and completed with LVN 2 and LVN 4 respectively to discuss the P/P on timely medication administration. The emphasis was to be very careful in following the guidelines for patients' health and well-being under their care. Discussed also the potential of unwanted effects from medications being administered too close of the time of the next ordered dose to be given. Reiterated in the discussion on the importance for the patients' MD be notified of circumstances that may lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring would be done to ensure patient safety, followed by accurate timely documentation. An in-service was done by the DON on 10/28/2025 on all nursing staff on how to handle patients with medications that are delayed in administration. A policy and procedure titled, "Medication Administration" was reviewed and discussed. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: All alert/oriented patients are with the potential to have set ways of taking their medications, these identified patients must be properly assessed by the RN supervisor as to the need of time adjustments on their medications to be administered. Patients with special requests or needs must be communicated to their respective MDs for proper orders to ensure ultimate safety, health and well-being of identified patients. The Medical Records Department will continue to do daily audits on both eMARs and eTARs to ensure proper charting and documentation as required. Any deviations must be reported to the DON/Designee for immediate resolutions/corrections. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: The facility had implemented a Weekly Medication Pass Audit by the DON, ADON and DSD to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations must be corrected immediately, and continued mentoring with performance improvement must be done with the specific charge nurses. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report and discuss with the QAPI/QAA committee the outcomes of Weekly Medication Administration audits including issues observed during medication pass and immediate actions done to prevent deficient practice from occurring. This will be reviewed for 3 months. E) COMPLETION DATE: 10/31/2025
Failure to Administer Medications as Prescribed
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications to a patient as prescribed by the physician. The patient, who had diagnoses including dysphagia, asthma, chronic respiratory failure with hypoxia, COPD, and lack of coordination, required specific administration instructions for several medications. During a medication pass, the nurse prepared and provided the medications to the patient but did not ensure that the medications were taken according to the physician's orders. Specifically, the patient did not take Metoprolol with food, did not take Potassium Chloride with the prescribed four to six ounces of water, and did not rinse her mouth after using the Pulmicort inhaler. The nurse also did not provide instructions or directions for the use of these medications and left the room before confirming that the patient had followed the required steps. The patient's care plan included interventions for swallowing problems, asthma/COPD, and nutritional risk, all of which required staff to monitor and assist with medication administration and hydration. Despite these documented needs, the nurse allowed the patient to self-administer medications without a physician's order for self-administration and without providing the necessary assistance or supervision. The nurse also failed to notify the physician when medications were not administered as prescribed, such as when Metoprolol was given more than two hours after the scheduled time and without food. Facility policy required medications to be administered as prescribed, within the appropriate time frame, and with adherence to any special instructions, such as taking medications with food or fluids and rinsing the mouth after inhaler use. The policy also specified that self-administration of medications must be authorized by the physician and documented in the care plan. In this case, the nurse did not follow these policies, resulting in the patient not receiving medications in accordance with physician orders.
Plan Of Correction
C 0900 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025 the RN supervisor immediately assessed patient 9 for any signs of adverse outcome regarding medications that were not administered per MD orders. Vital signs were taken and recorded as follows: BP=139/76, P=68, R=16, O2 Sat=96% and Pain level=0/10. Patient 9 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. MD and responsible party were notified. RN supervisor provided patient 9 with education on proper method of taking her medication. Patient verbalized understanding. 2. On 10/7/2025 DON initiated and completed a one-on-one in-service with LVN 4 respectively to discuss the policy and procedure (P/P) on medication administration. The emphasis was on accurately following MD orders for specific medications as per MD order and/or pharmaceutical recommendation (i.e. with food with sufficient fluids, rinsing mouth between medications, etc.) DON also discussed the potential of unwanted effects from medications being administered incorrection. DON reiterated the importance of "pour, pass, and sign" medication administration procedure. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025 upon identification of deficient practice, DON, ADON, and RN Supervisor immediately completed a facility round to observe all other charge nurses during medication pass to ensure residents' medications are being administered as ordered. No additional residents were affected by the deficient practice. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025 DON completed an in-service for all nursing staff on "Medication Administration" P/P, how to handle patients with medication refusals, importance of "pour, pass, sign," and MD/RP notification prior to administration of any additional doses. The discussion was followed by question-and-answer evaluation. On 10/30/2025 facility implemented a medication pass audit that will be completed weekly at random selection by the DON, ADON and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately and continued mentoring and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C0900
Failure to Administer Medications on Time and Notify Physician
Penalty
Summary
A deficiency occurred when a resident did not receive their scheduled 9 a.m. medications within the required timeframe. The medications, which included Pregabalin, Duloxetine, Famotidine, Fenofibrate, and several others, were not administered within one hour of the prescribed time as required by regulation and facility policy. The delay was confirmed during a medication area inspection and through interviews with nursing staff, who acknowledged that the medications were not given as ordered and that there was no documentation of administration on the Medication Administration Record (MAR) within the required window. Further review revealed that the resident had not received any of their scheduled morning medications by the time of the inspection, and the medications were ultimately administered at 12:29 p.m., more than three hours after the scheduled time. The resident confirmed in an interview that she had not received her morning medications and stated that she does not refuse medication when woken up. Nursing staff also confirmed that the physician was not notified of the missed doses, and no reason for the omission was documented in the resident's records. Additionally, the administration of the next scheduled doses occurred at 4:10 p.m., resulting in two sets of medications being given in close succession. There was no documentation that the resident was monitored or assessed for adverse reactions following the late administration of multiple medications, including anti-constipation and seizure medications. The facility's policy requires medications to be administered within one hour of the prescribed time, and the failure to do so, along with the lack of physician notification and monitoring, constituted the deficiency.
Plan Of Correction
C 0945 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025, the RN supervisor immediately assessed Patient 10 for any signs of adverse outcome regarding medications that were not administered on time per MD orders. Vital signs were taken and recorded as follows: BP=124/74, P=76, R=19, O2 Sat=96%, and Pain level=2/10. Patient 10 was deemed stable with no issues and remained verbally responsive, alert, and oriented x 4 with no apparent complaint at this time. MD and responsible party were notified. 2. On 10/7/2025, DON completed a one-on-one in-service with LVN 2 to discuss the P/P on timely medication administration. The emphasis was to be very careful in following the guidelines for patients' health and well-being under their care. DON also discussed the importance of "pour, pass, sign." DON reiterated that MD be notified of circumstances that lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring would be done to ensure patient safety, followed by accurate timely documentation. C) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, upon identification of deficient practice, DON, ADON, and RN Supervisor immediately interviewed all other charge nurses regarding any other medication administration delays that took place that day. No additional delays were identified, and no other residents were identified as being affected. MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: An in-service was completed by the DON on 10/28/2025 for all nursing staff on "Medication Administration" policy and procedures. The facility had implemented a Medication Pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations will be corrected immediately, and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C 0965 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 4. On 10/07/2025, RN Supervisor immediately assessed patient 2 for any change of condition or abnormality of wounds - no redness, no discharge observed from affected sights (right thigh scab, right pleur x site, and spine suture site). MD was notified. LVN 4, who
Failure to Document and Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure proper documentation and administration of medications and treatments for two patients, resulting in deficiencies related to medication and treatment records. For one patient with chronic respiratory failure, asthma, and pleural effusion, the treatment nurse did not sign the electronic Treatment Administration Record (eTAR) for three ordered treatments on a specific date. The treatments included care for a right thigh scab, a right Pleur X catheter, and a post-surgical spine site. The eTAR was left blank for these treatments, while other dates were properly signed, indicating a lapse in documentation and uncertainty about whether the treatments were administered as ordered. In another instance, a cognitively intact patient with paraplegia and multiple medication orders did not receive their scheduled morning medications at the prescribed time due to refusal. The nurse documented the medications as given before actually administering them, which did not occur until later in the afternoon. This premature documentation could have led to confusion for the oncoming shift and the risk of medications being administered too close together. The nurse acknowledged documenting before administration and recognized the potential for confusion and medication errors. Both deficiencies were confirmed through interviews with nursing staff and review of facility policies, which require that medications and treatments be documented immediately after administration. The facility's policies also emphasize the importance of accurate and timely documentation to ensure continuity of care and adherence to physician orders. The failure to follow these procedures resulted in incomplete records and the potential for missed or improperly timed treatments and medications.
Plan Of Correction
Completed patient 2's treatment on 10/04/2025, immediately completed late entry documentation. On 10/07/2025, the RN supervisor immediately assessed Patient 5 for any change of condition or abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96%, and Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. MD was notified. On 10/7/2025, the DON initiated and completed a one-on-one in-service with LVN 4 to discuss the policy and procedure (P/P) on charting and documentation and timely medication administration. The emphasis was on signing eTAR immediately upon completion of treatment. DON also discussed the potential of unwanted effects from medications being administered too close to the time of the next ordered dose to be given. DON reiterated the importance of notifying the patient's MD of circumstances that lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring period would be done to ensure patient safety, followed by accurate timely documentation. **B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE:** 1. On 10/7/2025, upon identification of deficient practice, DON, ADON, and Treatment Nurse immediately reviewed all eTARS for the last 30 days to ensure that no additional gaps in documentation were identified. No additional residents were affected by the deficient practice. 2. On 10/7/2025, DON, ADON, and RN Supervisor immediately interviewed all the licensed nurses on shift to identify any other delayed medication administration. No further residents were identified to be affected by the deficient practice. 3. The Medical Records Department will continue to do daily treatment audits to ensure that any potential deficient practice does not occur by notifying the DON/Designee immediately. Further, the DON has in-services scheduled for licensed nurses for continuous education and training. **C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR:** 1. On 10/28/2025, DON completed an in-service for all nursing staff on "Charting and Documentation" policies and procedures. The discussion was followed by a question-and-answer evaluation. On 10/30/2025, the facility implemented a weekly eTAR audit to be completed by the Medical Records Department to ensure accuracy and completion of treatment documentation. Audit findings will be provided to DON and/or Designee. 2. On 10/30/2025, the facility implemented a medication pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately, and continued mentoring and performance improvement plans will be implemented as needed. **D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED:** The DON/Designee will report weekly findings for eTAR audits and medication pass audits to the QAPI/QAA committee monthly for three months for recommendations. **E) COMPLETION DATE:** 10/31/2025
Improper Use of Physical Restraints Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of dementia and failure to thrive was found with pillows placed on both sides of their body, restricting their movement. The resident was dependent on staff for activities of daily living and lacked the capacity to make decisions. During an observation, a CNA admitted to placing the pillows during breakfast and forgetting to remove them, acknowledging awareness that such use of pillows could constitute a restraint. Further interviews revealed that the LVN had previously instructed the CNA not to use pillows in this manner to restrict the resident's movement, and confirmed that there were no physician orders for restraints for this resident. The DON also stated that pillows placed in a way that restricts movement and cannot be removed by the resident are considered restraints. Review of facility policy confirmed that restraints should only be used with a physician's order and not for staff convenience or fall prevention, and that any material restricting movement and not easily removed by the resident is considered a physical restraint.
Plan Of Correction
C 1130-Nursing Service - Restraints and Postural Support A) IMMEDIATE CORRECTIVE ACTION: 7. On 10/06/2025, CNA #2 immediately removed patient 4's bilateral pillows. RN Supervisor immediately assessed patient 4 for any change of condition (COC) or adverse effects that may have been caused by the bilateral pillows. No COC noted. MD and RP were notified. 8. On 10/06/2025, DSD completed a one-on-one in-service with CNA 2 on facility's restraint-free environment policies and procedures. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: 4. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that no additional residents have pillows by their sides that may be used as restraints. No further residents were identified to be affected by the deficient practice. 5. The Medical Records Department continues to do daily audits on Change of Condition that reflects any incident requiring the use of restraints. At this time, no resident was identified and observed to have any form of restraint at all. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: 3. On 10/28/2025, DON completed an in-service for all nursing staff on a P/P: "Restraint Usage." The discussion was followed by question-and-answer evaluation with all participants. On 10/30/2025, Social Services Director and DSD completed additional in-services on a "Restraint Free Environment." The discussion was followed by question-and-answer evaluation. 4. On 10/29/2025, Administrator updated the form "Resident Centered Care Room Rounds Report" to include "Does resident have any objects that may be a restraint?" question on daily rounds to be completed daily by assigned ambassadors and/or Manager on Duty (MOD). Any noted deviations will be corrected immediately, and surveillance tools will be submitted to the DON and/or Designee for monitoring. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Time, no resident was identified and observed to have any form of restraint at all.
Infection Control Lapses in Signage, Precautions, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection control practices. In one instance, a patient with a confirmed diagnosis of COVID-19 was not properly identified with a droplet transmission-based precaution sign outside her room. Although the patient's care plan required standard, contact, and droplet isolation with eye protection and a closed door, only an enhanced barrier precaution sign was posted. The Assistant Director of Nursing and the Infection Preventionist both acknowledged that the correct signage was not in place, which could have led to unintentional exposure of staff, visitors, and other patients to COVID-19. Another deficiency was observed with a patient who had a surgical site infection and was receiving intravenous antibiotics. Despite facility policy requiring enhanced barrier precautions for residents with indwelling medical devices or wounds, there was no EBP sign or PPE supply cart outside the patient's room. Both the Director of Staff Development and the Director of Nursing confirmed that the appropriate signage and precautions were not implemented, contrary to facility policy and infection control standards. Additional lapses in infection control were noted during medication administration. Two nurses failed to perform hand hygiene before administering medications to two patients, and one nurse did not wear gloves while administering eye drops. The soap dispenser in one patient's room was also found to be empty. These actions were inconsistent with the facility's policies on hand hygiene, medication administration, and the instillation of eye drops, as confirmed by the Director of Nursing and review of facility procedures.
Plan Of Correction
The DON/Designee will report daily findings of Room Rounds to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C 1270- Nursing Service - Patients with Infectious Disease A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/06/2025, facility Infection Preventionist (IP) immediately replaced the door signage with the appropriate Droplet Precautions signage on patient 1's door to reflect the appropriate isolation precautions. All assigned staff who worked in patient 1's room were tested with a Rapid Antigen Test - all results were negative, and staff were notified to test again on days 3 and 5 and monitor themselves for any signs or symptoms of possible Covid-19. To date, no additional staff have tested positive for Covid-19, and the facility outbreak has been closed. 2. On 10/6/2025, upon identification of deficient practice, CNA 6 immediately donned the correct PPE, and IP immediately placed an EBP sign on the door of patient 6. CNA was immediately provided with a one-on-one in-service by the DSD on Enhanced Barrier Precautions. RN Supervisor immediately assessed patient 6 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. 3. On 10/7/2025, LVN 5 immediately completed the required hand hygiene protocols upon the identification of deficient practice. RN Supervisor immediately assessed patient 11 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. DON immediately completed a one-on-one in-service with LVN 5 on the importance of hand hygiene and hand hygiene protocols during medication administration. 4. On 10/7/2025, LVN 4 immediately completed the required hand hygiene protocols upon the identification of deficient practice. RN Supervisor immediately assessed patient 9 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. DON immediately completed a one-on-one in-service with LVN 4 on the importance of hand hygiene and hand hygiene protocols during medication administration. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: 1. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that all other isolation signage has been posted appropriately and corresponded with the ordered isolation precautions. No additional deficient practices were identified. 2. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that all other staff providing care to residents on EBP were donning appropriate PPE when providing care. No additional deficient practices were identified. 3. & 4. On 10/7/2025, upon identification of deficient practice, DON, ADON, and IP immediately rounded the facility to ensure that all other charge nurses are completing hand hygiene timely and appropriately during medication administration. No additional deficient practices were identified. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: 1. On 10/14/2025, clinical resource consultant completed a one-on-one in-service for the IP on Standard, Enhanced, and Transmission-based Precautions, hand hygiene, PPE use, L.A. County DPH - IPCP Guidelines for SNFs, EBP program, and assessment of all residents for EBP eligibility. 2.-4. On 10/20/2025, DSD completed an in-service for all nursing staff on infection control and types of isolations, EBP, donning and doffing PPE, and hand hygiene. On 10/28/2025, DON completed an in-service for all nursing staff on infection control and types of isolations and signage, EBP, and hand hygiene during medication administration. The discussion was followed by a question-and-answer evaluation. 3. Effective 10/30/2025, IP and/or designee will monitor EBP and other isolation signage during daily facility rounds and document performance on surveillance checklist. 4. Effective 10/30/2025, facility implemented a medication pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor charge nurses' medication administration performance on proper and accurate medication administration and hand hygiene. Any noted deviations will be corrected immediately, and continued mentoring and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The IP/Designee will report Infection Control Surveillance results to the QAPI/QAA committee monthly for three months for recommendations, if any. DON/Designee will report weekly medication pass audits to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025
Unlabeled Nonlegend Medication Found at Bedside Without Physician Order
Penalty
Summary
A deficiency was identified when a bottle of Pepto-Bismol, a nonlegend medication, was found at the bedside of a patient without a physician's order. The medication was observed on the patient's nightstand, unopened and without a label. The patient stated that her daughter had brought the medication for her to use if needed, and that it had been on her nightstand for some time. Review of the patient's records showed no order for Pepto-Bismol, and the medication was not listed on the Medication Administration Record. The patient had multiple diagnoses, including end stage renal disease, type 2 diabetes mellitus, and congestive heart failure, and required moderate assistance with activities of daily living. During interviews, facility staff, including a Licensed Vocational Nurse and the Assistant Director of Nursing, confirmed that medications should not be left at the bedside without a physician's order and an assessment for self-administration. The facility's policy requires that any medication brought in by family must be given to licensed staff for labeling, verification of an order, and assessment before being left at the bedside. The presence of the medication at the bedside without following these procedures constituted a failure to prevent unauthorized access to medication and to ensure proper medication management as required by facility policy and regulation.
Plan Of Correction
C2000 - Pharmaceutical Services - Labeling & Storage A) IMMEDIATE CORRECTIVE ACTION: On 10/06/2025, the Charge Nurse immediately removed the Pepto-Bismol from the resident's bedside. RN supervisor immediately assessed Patient 7, who is alert and oriented x 4, for any changes of condition and/or adverse effects of having non-prescribed medications at bedside. None were noted. When the RN asked the patient about the medication, she indicated that her daughter brought it for her to use when she needs it. MD and RP were notified. The Charge Nurse obtained an order from the MD for the medication to be given as needed, medication secured in the medication cart, and the RN supervisor explained to the patient about no medications being allowed at bedside until a proper assessment is accomplished. The resident agreed to have the medication stored in the medication cart and to ask the Charge Nurse for it if she ever needed it. The DON completed a one-on-one in-service with LVN 2 regarding policies and procedures for self-administration of medications. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/6/2025, DON, ADON, and DSD immediately rounded the facility to identify any additional medications at residents' bedsides. No additional medications were noted at bedsides. Ongoing daily rounds by the RN supervisor, ADON, DON, and Ambassadors will continue to focus on the presence of medications at bedside. Any presence of medications will be dealt with accordingly. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/29/2025, the Administrator updated the Resident Centered Care Room Rounds Report to ensure room ambassadors are checking resident bedsides for any OTC and/or prescription medications. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Room ambassadors will provide Room Rounds Reports to DON/Designee upon completion, and audit results will be presented and discussed with the QAPI/QAA committee for the next three months to ensure compliance.
Expired Blood Glucose Control Solutions Used for Quality Control
Penalty
Summary
A package containing two bottles of expired blood glucose (BG) control solutions was found stored inside one of the facility's medication carts. The bottles were labeled with a handwritten open date, and according to the manufacturer's instructions, the solutions expired 90 days after opening. Despite this, the expired solutions remained in the cart and were documented as being used for quality control checks after their expiration date. The Licensed Vocational Nurse (LVN) confirmed that the solutions should have been replaced once expired. The Director of Nursing (DON) acknowledged that expired blood sugar control solutions could result in inaccurate blood sugar readings. Facility policy required that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, but this procedure was not followed in this instance. The expired solutions were available for use and had been used for quality control checks beyond their expiration date.
Plan Of Correction
C2030 COMPLETION DATE: 10/31/2025 C2030-Pharmaceutical Services - Labeling & Storage A) IMMEDIATE CORRECTIVE ACTION: On 10/07/2025, the Charge Nurse immediately removed the expired Control Solution from Medication Cart 1. The DON immediately completed a one-on-one in-service with LVN 2 regarding p/p regarding viability of expired medications and biologicals, with an emphasis on the importance of possible effects on patient's safety and well-being. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, upon identification of the expired Assure Dose Control Solution, DON, ADON, and RN Supervisor checked all medication carts and medication rooms for any additional expired medications and/or biologicals. No other expired products were identified. Ongoing random monitoring of medication cart reviews are done weekly by the RN supervisor, ADON, and DON while medication pass is in progress to ensure that no biologicals are present in medication cart. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, weekly random medication cart audits will be initiated and completed by the ADON and RN supervisor. Any observed issue will be corrected immediately, and findings will be reported to DON/Designee. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report to the QAPI/QAA committee and discuss findings of random weekly medication cart audits. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025
Missing Performance Evaluations in CNA Personnel Files
Penalty
Summary
The facility failed to maintain current, complete, and accurate personnel records by not including required performance evaluations for four of eight Certified Nursing Assistants (CNAs). During a review of employee records and interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), it was confirmed that there was no documentation of current performance evaluations for these CNAs. The DSD, responsible for completing CNA evaluations, stated that the evaluations were not done and could not provide a reason, noting that the evaluations were due before her employment at the facility. The DON confirmed that performance evaluations are typically conducted after the probationary period and annually, and that these evaluations are essential for identifying staff training and education needs. A review of the facility's policies and procedures indicated that performance evaluations are required at the end of the 90-day probationary period, annually, and after promotions or transfers. The policies also specify that personnel files must include performance appraisals or evaluations. The absence of these evaluations in the personnel files for the identified CNAs was verified through record review and staff interviews, demonstrating noncompliance with both regulatory requirements and the facility's own policies.
Plan Of Correction
C4860-Employee Personnel Records A) IMMEDIATE CORRECTIVE ACTION: On 10/08/2025, DSD immediately completed performance evaluations for CNA 1, CNA 2, CNA 3, and CNA 4. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/8/2025, DSD and Assistant DSD reviewed all current CNA files to ensure the presence of an evaluation within the last 12 months. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, DSD will review all CNA anniversary dates monthly to ensure annual evaluations are completed timely and as per facility protocol. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DSD/Designee will present monthly evaluation completion reports to the QAPI/QAA committee monthly. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025 C4905-Employee Personnel Records
Missing Staff Health Exam Documentation
Penalty
Summary
The facility failed to ensure that the personnel files for several certified nursing assistants (CNAs) and licensed vocational nurses (LVNs) contained documentation of required health examinations either 90 days prior to or within seven days after hire, as well as annual health exams thereafter. Specifically, the records for five CNAs and two LVNs did not include evidence of a health exam completed within the required timeframe upon hire. Additionally, the files for two LVNs lacked documentation of annual health exams after their initial employment. During interviews, both the Director of Staff Development (DSD) and the Director of Nursing (DON) acknowledged the absence of medical clearance for these staff members. The DSD confirmed that it is now her practice to ensure compliance with health exam requirements for new hires and annual reviews. The facility's policies and procedures require maintenance of personnel records in accordance with state and federal regulations, including documentation of the ability to perform essential job functions, but these were not followed in the cited cases.
Plan Of Correction
A) IMMEDIATE CORRECTIVE ACTION: On 10/09/2025, DSD immediately contacted CNA 1, CNA 2, CNA 3, CNA 4, CNA 5, LVN 1, and LVN 2 to notify them that they may not return to work until a physical exam is completed. She referred them to a clinic that completed their physicals and provided the facility with their clearance and ability to work. Staff were returned to work upon providing their physical exams to the DSD and/or Administrator. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/8/2025, DSD and Assistant DSD reviewed all other CNA and LVN files to ensure the presence of a health exam within the last 12 months. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, DSD will review all CNA and LVN anniversary dates monthly to ensure annual health exams are completed timely and as per facility protocol. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DSD/Designee will present monthly health exam completion reports to the QAPI/QAA committee monthly. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025
Failure to Provide Required Behavioral Health Training to CNAs
Penalty
Summary
The facility failed to provide required in-service training on behavioral health for Certified Nursing Assistants (CNAs), as indicated by the facility's own in-service calendar and policies. A review of the facility assessment showed that residents commonly have psychiatric and mood disorders, including psychosis, impaired cognition, depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, and other mental health conditions. The facility's annual in-service calendar scheduled behavioral health training for March, covering care of residents with dementia, mental and psychosocial disorders, substance abuse, PTSD, trauma, and trigger management for all staff. Interviews with two CNAs revealed that neither had received formal in-service or training on behavior management, and one CNA expressed a desire for such education to better handle residents' behaviors. The Director of Staff Development (DSD), who started employment in March, confirmed that the scheduled behavioral health training was not provided and was unsure if the previous DSD had conducted it. Review of personnel files for the two CNAs showed no documented evidence of behavioral health training. Facility policies require annual in-service training for nurse aides and all staff on behavioral health, with training to be completed prior to providing services, annually, and as necessary based on the facility assessment. The policies also specify that training curricula should include learning objectives, performance standards, and evaluation criteria, and that competency may be demonstrated through written exams or consistent application of interventions. Despite these requirements, the facility did not provide or document the required behavioral health training for the sampled CNAs.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential inadequate care and risk of injury. For Resident 27, who was admitted with conditions including dysphasia, dementia, seizures, severe protein-calorie malnutrition, and repeated falls, the facility did not create a care plan addressing the resident's Restorative Nursing Assistant (RNA) exercise program. Despite the resident's severe cognitive impairment and need for substantial assistance in daily activities, the care plan lacked specific interventions and goals for the RNA program, which was crucial for maintaining the resident's function and joint mobility. Similarly, the facility did not develop a comprehensive care plan for Resident 12, who was admitted with dementia, lack of coordination, a subtrochanteric fracture of the right femur, and a history of falls. The resident required maximal assistance for daily activities and had a floor mat placed next to the bed to prevent injury from falls. However, there was no documented evidence of a care plan addressing the use of the floor mat, which was necessary for consistent staff intervention and monitoring of its effectiveness in preventing falls. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed the absence of person-centered care plans for both residents. The facility's policies and procedures emphasized the importance of developing comprehensive care plans based on thorough assessments, yet these were not followed, resulting in a lack of structured care and monitoring for the residents' specific needs.
Failure to Update Care Plans for Medication Changes and ADL Needs
Penalty
Summary
The facility failed to update and revise the care plan for a resident undergoing anticoagulation therapy after changes were made to the prescribed medications. Resident 29, who was readmitted to the facility with diagnoses including end-stage renal disease and paroxysmal atrial fibrillation, had their anticoagulant medications changed from Plavix and Aspirin to Eliquis. Despite this change, the care plan was not updated to reflect the new medication regimen, which was confirmed during interviews with the MDS Coordinator and the Director of Nursing. The facility's policy requires care plans to be updated with current medications, but this was not adhered to, resulting in an inaccurate medical record. Another deficiency was identified in the care plan for a resident with severe cognitive impairment and total dependence on staff for activities of daily living (ADLs). Resident 70's care plan lacked specific interventions for grooming, oral hygiene, toileting, showering, and personal hygiene needs. During a review, the MDS Coordinator acknowledged that the care plan should have included specific interventions to ensure the resident's ADL care was tailored to their needs. The absence of detailed interventions in the care plan could lead to inadequate care provision. Additionally, the facility did not update the care plan for a resident who had been prescribed anti-anxiety medication. Resident 12, who had a history of dementia and a recent femur fracture, was prescribed Xanax for anxiety, which was later discontinued. However, the care plan continued to reflect the use of Xanax, leading to potential confusion among staff. The Assistant Director of Nursing confirmed that the care plan was not updated to reflect the discontinuation of the medication, which is contrary to the facility's policy requiring accurate and complete documentation in the medical record.
Inadequate Pain Management Due to Documentation Failures
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, Resident 22 and Resident 10, by not assessing their pain before and after administering controlled medications. For Resident 22, tramadol was administered on February 9, 2025, without prior pain assessment or documentation in the Medication Administration Record (MAR). The Licensed Vocational Nurse (LVN) responsible for administering the medication did not sign the MAR, which is crucial for tracking medication administration and ensuring proper pain management. The Assistant Director of Nurses confirmed the lack of documentation and emphasized the importance of signing both the Controlled Drug Record (CDR) and MAR to prevent medication errors and ensure effective pain management. Resident 10 experienced a similar issue with the administration of oxycodone with acetaminophen (Percocet) on multiple occasions. The medication was removed from the blister pack and administered without prior pain assessment or documentation in the MAR. The Director of Nurses and LVN involved confirmed the absence of corresponding entries in the MAR, which is necessary for tracking medication administration and assessing the effectiveness of pain interventions. The facility's policy requires immediate documentation of controlled medication administration, including date, time, and nurse's signature, to ensure accurate medical records and effective pain management. The facility's failure to adhere to its policies and procedures for controlled medication administration resulted in inadequate pain management for both residents. The lack of documentation in the MAR and CDR prevented proper tracking of medication administration and pain assessment, potentially leading to unmanaged pain and diminished quality of life for the residents. The facility's policies emphasize the importance of accurate documentation to prevent medication errors and ensure effective pain relief, which was not followed in these cases.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, leading to a deficiency in medication administration documentation. Resident 22, who was admitted with diagnoses including repeated falls, depression, and anxiety disorder, had orders for Xanax and Tramadol. On a specific date, these medications were removed from the blister pack, as indicated in the Controlled Drug Record (CDR), but were not documented in the Medication Administration Record (MAR). This omission was confirmed by the Director of Staff Development and the Assistant Director of Nurses, who noted the importance of signing both the CDR and MAR to prevent medication errors and ensure proper reassessment of the medications' effectiveness. Similarly, Resident 10, who was admitted with chronic pain syndrome, had orders for Percocet. The CDR showed that Percocet was removed on three separate occasions, but these administrations were not recorded in the MAR. This discrepancy was confirmed during a medication cart observation and record review with a Licensed Vocational Nurse and the Director of Nurses. The failure to document in the MAR could lead to issues such as medication errors and drug diversion, as the MAR is crucial for tracking medication administration and assessing pain relief. The facility's policy and procedure for controlled medications require that the licensed nurse immediately document the administration details in both the CDR and MAR. However, in these cases, the nurses failed to follow this protocol, resulting in incomplete records. The lack of documentation in the MAR for both residents' medications highlights a significant lapse in the facility's adherence to its own policies, potentially compromising resident care and safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer Morphine Sulfate Contin to Resident 72 as ordered by the physician on February 1, 2025. Resident 72, who was admitted with diagnoses including infection and inflammatory reaction to prosthetic devices, acute hematogenous osteomyelitis, cellulitis, and chronic pain syndrome, did not receive the prescribed 30 mg dose of Morphine Sulfate Contin. The Minimum Data Set Nurse confirmed that the medication was not administered, and the Licensed Vocational Nurse assigned to Resident 72 on that day was unavailable for comment. The Director of Nursing acknowledged that the failure to administer the medication as ordered placed Resident 72 at risk for increased pain. The facility also failed to adhere to physician orders regarding the administration of midodrine for Residents 70 and 83. Resident 83, who was admitted with hypertension and heart failure, was given midodrine despite having systolic blood pressure readings above the physician-ordered threshold of 120 mm Hg on multiple occasions in January and February 2025. Licensed Vocational Nurses 3 and 4 confirmed that they signed off on administering the medication even when the blood pressure parameters were not met, potentially putting Resident 83 at risk for elevated blood pressure and complications. Similarly, Resident 70, who was admitted with hypertension and hypotension, received midodrine when their systolic blood pressure exceeded 120 mm Hg on several occasions in January 2025. The Director of Nursing confirmed that the medication should not have been administered under these conditions, as it could lead to elevated blood pressure and associated complications. The facility's policy on medication administration, which requires adherence to physician orders, was not followed in these instances.
Improper Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. During an observation and interview with the Dietary Supervisor, a container bin with a transparent cover containing a whitish powder, identified as a thickener used for pureed diets, was found with a stainless steel scoop inside. The handle of the scoop was buried in the thickener powder, which is against the facility's policy. The Dietary Supervisor acknowledged that the scoop should not have been left inside the bin to prevent contamination of the thickener powder. This practice had the potential to place five residents on pureed diets at risk for foodborne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by several deficiencies observed during the survey. In one instance, a resident's room lacked a trash can for disposing of used Personal Protective Equipment (PPE), which is crucial for maintaining transmission-based precautions. This oversight was acknowledged by the Assistant Director of Nursing, who confirmed that the absence of a trash can could lead to the spread of infection to other residents. Another deficiency was observed when a Licensed Vocational Nurse (LVN) exited a resident's room while still wearing an isolation gown, which is against the facility's Enhanced Barrier Precautions (EBP) policy. The LVN's failure to remove the gown before leaving the room resulted in potential contamination of the medication cart. The Infection Preventionist confirmed that the LVN should have removed the gown to prevent the spread of infection, as per the facility's guidelines. Additionally, the facility did not ensure that urinals were properly labeled with resident identifiers, which could lead to cross-contamination. Two residents had unlabeled urinals, one of which was improperly hung on a trash bin. The Director of Nursing acknowledged that this practice could result in the inadvertent use of urinals by other residents, increasing the risk of infection. Furthermore, a medication room was found to contain personal belongings, which is against infection control policies, as confirmed by the Assistant Director of Nursing and the LVN involved.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure that staff knocked and requested permission before entering the rooms of two residents, which violated the residents' rights to dignity and privacy. Resident 40, who was admitted with diagnoses including hypertension and type 2 diabetes mellitus, had intact cognitive skills for daily decision-making and required partial assistance with personal care. During an observation, a Certified Nurse Assistant (CNA) entered Resident 40's room without knocking or asking for permission, which the CNA later acknowledged as disrespectful. Similarly, Resident 188, who was admitted with hypertension and depression, also had intact cognitive skills and required substantial assistance with personal care. The same CNA entered Resident 188's room without knocking or asking for permission. The facility's policy on dignity, which was last reviewed in January 2025, mandates that staff must knock and request permission before entering residents' rooms to promote their well-being and self-esteem. The Minimum Data Set Coordinator confirmed that this practice is essential to respect residents' rights and privacy.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives for one resident, identified as Resident 16. The deficiency was identified during a review of Resident 16's clinical records, which revealed that the facility did not maintain a current copy of the resident's advance directives in the resident's chart. This oversight was confirmed during interviews with the Director of Social Services (DSS) and the Director of Nursing (DON), both of whom acknowledged that the advance directive should have been included in the resident's medical record to guide staff in honoring the resident's medical decisions. Resident 16 was initially admitted to the facility with diagnoses including hemiplegia, hemiparesis, gastrostomy, and encephalopathy, and was noted to have severely impaired cognition and total dependence on staff for activities of daily living. The Minimum Data Set (MDS) and History and Physical (H&P) assessments indicated that Resident 16 lacked the capacity to understand and make decisions. Despite this, the facility's failure to maintain the advance directive in the resident's chart posed a risk of not honoring the resident's end-of-life treatment preferences, as outlined in the facility's revised policy on advance directives.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene for a resident, specifically in trimming fingernails, which is a part of Activities of Daily Living (ADLs). The resident, who was admitted with diagnoses including hypertension and type 2 diabetes mellitus, was noted to have intact cognitive skills but required moderate assistance for personal hygiene. Despite this, the resident was observed with long and curvy fingernails and expressed a desire for them to be trimmed, indicating that no staff had offered to assist with this task. The facility's policy on Activities of Daily Living, which was last reviewed in January 2025, mandates that residents unable to independently perform ADLs should receive necessary services to maintain personal hygiene. However, during observations and interviews, it was revealed that the resident had not been offered assistance with nail trimming, which could potentially lead to skin tears if the resident scratched herself. This oversight in care was identified as a deficiency in maintaining the resident's personal hygiene and overall well-being.
Failure to Provide Resident-Centered Religious Activities
Penalty
Summary
The facility failed to implement a resident-centered activities program by not providing activities that met the spiritual or religious needs of a resident diagnosed with dementia and schizophrenia. The resident's Admission Minimum Data Set (MDS) indicated that participating in religious services was important to them. However, the care plan for activity preferences did not include any interventions to provide religious services, and the resident was not listed as having participated in any religious activities or received room visitation by a religious representative during the months reviewed. The Activity Director acknowledged that the care plan should have included an intervention to address the resident's preference for religious services. The facility's policy on spiritual and religious activities, which was last reviewed shortly before the survey, stated that such activities should be provided in accordance with residents' preferences and religious affiliations. Despite this policy, the facility failed to arrange for the resident to be visited by a religious provider, thus violating the resident's right to receive religious services.
Failure to Implement RNA Exercise Program for Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to prevent a decrease in range of motion (ROM). The resident, who was admitted with multiple diagnoses including dysphasia, unspecified dementia, seizures, severe protein-calorie malnutrition, and repeated falls, had a physician order for a Restorative Nursing Assistant (RNA) exercise program. However, the order was not clarified or implemented, as it did not specify the type of exercises, frequency, or the location of the affected area for partial weight bearing. Interviews and record reviews revealed that the resident's RNA exercise program was not carried out. A Certified Nursing Assistant (CNA) who sometimes worked as an RNA stated that she had never provided RNA exercises to the resident. The Minimum Data Set (MDS) Coordinator and the Director of Rehabilitation confirmed that the resident was enrolled in a hospice program, and as such, was not evaluated by the rehabilitation department. They acknowledged that the physician's order for the RNA exercise program required clarification, which was not done by the licensed staff. The facility's policies and procedures indicated that residents with limited ROM should receive treatment to prevent further decline, with care plans developed by the interdisciplinary team. However, the resident's restorative treatment records showed no entries for the months reviewed, indicating a lack of implementation of the RNA exercise program. This deficiency had the potential to place the resident at risk for further ROM decline.
Failure to Communicate Nutritional Intake and Meal Refusals
Penalty
Summary
The facility failed to provide appropriate care and services to maintain acceptable parameters of nutritional status for a resident, identified as Resident 27. The deficiency involved a lack of communication with the facility's Registered Dietician (RD) regarding the resident's nutritional intake percentage and failure to inform the resident's physician about the resident's refusal to eat, as indicated in her care plan. This oversight had the potential to place the resident at risk for weight loss. Resident 27 was admitted to the facility with diagnoses including dysphasia, unspecified dementia, seizure, and severe protein-calorie malnutrition. The resident's Minimum Data Set (MDS) indicated severely impaired cognitive skills for daily decision-making and required staff supervision or assistance when eating. Despite a stable weight, the resident's meal intake log showed consistently low intake percentages, ranging from 0-25%, with multiple instances of meal refusals. Interviews with facility staff, including Certified Nursing Assistants (CNAs) and the MDS Coordinator, revealed that the resident frequently refused meals, yet there was no documentation of notifying the physician or the RD about these refusals. The facility's policy required such notifications to ensure timely assessments and interventions, but this was not followed, leading to the deficiency.
Failure to Post Actual Nursing Staff Hours
Penalty
Summary
The facility failed to ensure that staffing information, specifically the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, was posted daily as required by their policy and procedure on Staffing, Sufficient and Competent Nursing. On multiple occasions, the Director of Staff Development (DSD) was observed posting projected hours instead of actual hours, with the explanation that actual hours would only be available after payroll calculations the following day. This practice was observed on 2/11/2025 and 2/13/2025, where the posted documents at the nursing station contained either projected hours or were missing actual hours entirely. The Director of Nurses (DON) confirmed that the actual hours should be documented and posted by 11 a.m. after the stand-up meeting, once the DSD knows which staff is present. However, the DSD misunderstood the requirement, believing that only projected hours needed to be posted initially, with actual hours to be completed at the end of each 24-hour patient day. This misunderstanding led to the failure to post accurate staffing information, potentially keeping residents and visitors unaware of the actual staffing levels in the facility.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor a resident for side effects of Trazadone and Xanax, which are psychotropic medications. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who had been readmitted to the facility with various medical conditions including infection and inflammatory reaction to prosthetic devices, was prescribed Trazadone for depression and Xanax for anxiety. The physician orders required monitoring for side effects of these medications every shift. However, documentation was missing for the monitoring of side effects on a specific date, indicating that the licensed nurses did not perform this required task. During interviews, the Director of Nursing emphasized the importance of monitoring for side effects to determine if medication dosages needed adjustment and to prevent the resident from receiving unnecessary medication. The facility's policy on psychotherapeutic medication use also required monitoring for adverse consequences and documentation of the prescriber's rationale if medications were continued despite potential adverse effects. The lack of documentation and monitoring for side effects constituted a failure to adhere to these policies, potentially placing the resident at risk of adverse side effects from unnecessary medication.
Resident-to-Resident Altercation Involving Water Throwing
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident threw water at another resident, resulting in physical contact with the resident's face, chest, and clothes. This incident involved Resident 1, who had been admitted to the facility with diagnoses including congestive heart failure, ventricular tachycardia, and hypertension. Resident 1 was noted to have fully intact cognition and the ability to understand and make decisions. The altercation occurred when Resident 1 became frustrated after being asked to turn down the television and subsequently threw water at Resident 2. Resident 2, who had been admitted with diagnoses including metabolic encephalopathy, major depressive disorder, and generalized anxiety disorder, was subjected to this act of aggression. The facility's investigation substantiated the abuse, confirming that Resident 1 intentionally threw water at Resident 2. Interviews with both residents corroborated the event, with Resident 1 admitting to the action and Resident 2 confirming the incident. The facility's administrator acknowledged the altercation but believed it was a spontaneous action that could not have been prevented.
Failure to Monitor Acute Condition Changes
Penalty
Summary
The facility failed to implement its policy on monitoring acute condition changes for a resident who experienced hematuria. The resident, admitted with multiple diagnoses including metabolic encephalopathy, hereditary deficiency of clotting factors, unspecified dementia, paroxysmal atrial fibrillation, and heart failure, was prescribed Xarelto, a blood thinner. Following a change in condition where the resident was found to have blood in her urine, the physician ordered the Xarelto to be held for three days. However, the facility did not monitor the resident for signs and symptoms of bleeding every shift as required by the order. The MDS Nurse confirmed that there was no specific documentation of monitoring for hematuria on several shifts following the change in condition. The facility's policy on acute condition changes requires staff to monitor and document the resident's progress and responses to treatment, which was not adhered to in this case. The lack of documentation and monitoring could have led to confusion in care and services for the resident, as the facility's policy also emphasizes the importance of communication between the interdisciplinary team regarding the resident's condition and response to care.
Failure to Implement Contact Precautions for Resident with Scabies
Penalty
Summary
The facility failed to implement infection control practices by not ensuring contact precautions were in place for a resident diagnosed with dermatitis consistent with scabies upon their return to the facility. The resident, who had a history of cervical spondylosis and actinic keratosis, was readmitted to the facility after being transferred to a general acute care hospital for a skin wound or ulcers. The hospital discharge instructions indicated the resident had a rash and was diagnosed with scabies, requiring treatment with permethrin cream. However, upon the resident's return, no contact precaution signage was posted, and staff were not informed to use isolation gowns, leading to inadequate infection control measures for several days. During an interview, the CNA assigned to the resident for two days stated she was unaware of the need for contact precautions and only used gloves while providing care. The Director of Nursing confirmed that the resident should have been placed on contact precautions immediately upon return to the facility but was not until several days later. The facility's policies on infection control and scabies treatment were reviewed, indicating that residents with scabies should be on contact precautions during the treatment period. The failure to follow these policies resulted in a potential risk of spreading scabies and cross-contamination among staff and other residents.
Failure to Develop Comprehensive Care Plan for Resident with Scabies
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident diagnosed with dermatitis consistent with scabies. The resident, who had intact cognition and was dependent on staff for various activities, was transferred to a general acute care hospital for evaluation of skin rashes and itching. Upon return, the resident's care plan did not include specific interventions for the scabies diagnosis, and there was no contact precaution signage posted in the resident's room. The resident had been experiencing on and off skin itchiness for months and had been diagnosed with scabies by his physician. During a review of the resident's care plans and interviews with the Director of Nursing and the Infection Preventionist, it was confirmed that the facility did not develop a comprehensive care plan upon identification of the resident's skin rashes and scabies diagnosis. The facility's policies and procedures indicated that care plans should reflect currently recognized standards of practice and be revised as the resident's condition changes. However, this was not done in this case, leading to a potential delay or lack of necessary care and services for the resident.
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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