River View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Modesto, California.
- Location
- 1611 Scenic Drive, Modesto, California 95355
- CMS Provider Number
- 055011
- Inspections on file
- 40
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at River View Post Acute during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including a stage 4 left ankle pressure ulcer and hemiparesis, developed a twisted, purple, cold left foot, prompting a STAT x‑ray of the left lower extremity. The STAT x‑ray later showed a distal leg fracture and osteomyelitis, and the results were transmitted to the facility the same evening. The nurse on duty did not re‑check for results after an initial review, did not contact the x‑ray provider to verify timing, and, once the abnormal report was received, notified the physician only by text without follow‑up phone calls or direct confirmation, despite facility policies requiring immediate, voice communication of new fracture findings and STAT results. This failure to follow established notification policies delayed physician awareness and subsequent hospital transfer orders.
A resident with hemiplegia, a stage 4 ankle pressure ulcer, DM2, PVD, and anemia was noted by staff to have a twisted left foot that was purple and cold, prompting a STAT x-ray of the left lower extremity. The x-ray later showed a fracture and acute osteomyelitis of the distal lower leg, and the physician was notified of these abnormal results. However, nursing staff did not complete or document a comprehensive reassessment of the resident’s left leg and foot, including pain and circulatory status, before or after notifying the physician, despite facility policy and job descriptions requiring detailed assessment and use of SBAR for significant changes in condition.
A resident with multiple complex medical conditions experienced a severe, unrecognized weight loss over several weeks. Facility staff failed to weigh the resident as required, did not notify the physician or implement interventions in a timely manner, and did not document the change of condition, despite facility policy requiring prompt action for significant weight changes.
A resident with a history of stroke and colon cancer, experiencing sadness and depression, did not receive a timely psychiatric evaluation after a referral order was entered. The Social Services Department failed to process the referral, and the resident reported not being offered counseling or therapy. Interviews confirmed the referral was not completed as required by facility policy.
A resident with anxiety and depression was administered PRN lorazepam without the required 14-day stop date or physician documentation explaining the omission. Facility staff and policy confirm that such medications must have a stop date to ensure ongoing evaluation, but the medication was given on multiple occasions without this safeguard.
A resident with documented intellectual disability and cerebral palsy was admitted without these conditions being accurately reflected on the PASRR Level I screening. The screening incorrectly indicated no need for further evaluation, and staff did not review the PASRR for accuracy, resulting in the resident not being properly evaluated for specialized services as required by facility policy.
A resident with adjustment disorder and anxiety did not receive two scheduled psychotherapy sessions as ordered, and facility staff failed to ensure timely follow-up or alternative interventions. Interviews confirmed that the missed visits were not communicated or addressed according to facility procedures.
A resident who required a mechanical lift and sling for transfers was unable to attend preferred activities on multiple occasions due to the facility's failure to provide an available sling. Staff confirmed that equipment shortages and uncharged lift batteries delayed care, and the resident had to use an inappropriate shower sling, resulting in skin irritation. The DON acknowledged the lack of equipment and its impact on the resident's ability to participate in activities, contrary to facility policy on resident autonomy and dignity.
A resident with bipolar disorder and intact cognition alleged that a CNA forcefully grabbed her legs, causing pain and bruising. Although two LNs and the CNA were aware of the allegation on the day it occurred, the incident was not documented or reported to the Department until five days later, contrary to facility policy requiring immediate reporting of suspected abuse. This delay resulted in a late investigation and reduced the facility's ability to protect residents from harm.
A resident with schizophrenia reported being hit on the head, but the facility did not notify the responsible party (RP) of this abuse allegation as required. The incident was documented in the resident's records and care plan, but the DON confirmed there was no evidence that the RP was informed, contrary to facility policy.
Two residents did not receive required alert charting following incidents—one after an allegation of physical harm and another after a verbal altercation. Despite care plans and facility policy mandating 72 hours of monitoring and documentation for psychosocial effects, licensed nurses did not complete the necessary charting for either resident.
Two residents with depression were unable to enjoy a safe and comfortable environment due to another resident's ongoing disruptive behavior, including yelling and cussing in hallways and activity areas. Staff confirmed that the disruptive resident, who has bipolar disorder, frequently caused distress, leading the affected residents to keep their doors closed and avoid activities. The facility's policy on maintaining comfortable sound levels was not met.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident was not provided with scheduled showers and instead had to use disposable wipes for hygiene, as staff did not accommodate the resident's preference for a female CNA. The care plan was not updated to reflect these preferences, and documentation did not indicate that the resident refused care. This failure to honor the resident's choices and provide routine care led to the resident's needs not being met and caused distress.
Two residents sharing a bathroom were exposed to an unsanitary environment when a toilet seat remained contaminated with fecal matter and urine for an extended period. A housekeeper confirmed the bathroom had not been cleaned during her shift, and the Director of Staff Development acknowledged the lapse, which was inconsistent with facility policies on cleanliness and infection control.
A resident with a history of repeated falls was found to have multiple wheelchairs, a recliner, and an overbed table stored in their room for several days, obstructing access and creating a potential fall hazard. The DSD confirmed these items should not have been stored in the room, as this violated facility policies on safety and a homelike environment.
The facility failed to maintain infection control practices, as personal care items like urinals, wash basins, and toothbrushes were found unlabeled and improperly stored in shared bathrooms. This increased the risk of cross-contamination among residents. Interviews with staff revealed that the facility's process required labeling and proper storage of these items, which was not followed, posing a significant infection control risk.
A resident discharged from the hospital with instructions for follow-up care with a podiatrist and interventional radiology did not receive these appointments from the facility. The resident, who had undergone a partial foot amputation due to gangrene, also required a surgical evaluation that was not communicated to the primary physician. This lack of follow-up and communication may have contributed to the resident's wound infection and subsequent leg amputation.
A CNA in an LTC facility failed to maintain infection control standards by wearing a loosened gauze dressing on her hand while caring for nine residents. The dressing, used to cover a burn, was not properly secured and was washed with the CNA's hands, posing a risk of infection spread. The facility's policies require strict hand hygiene to prevent such risks.
A facility failed to provide proper respiratory care for three residents receiving oxygen therapy. One resident received oxygen without a physician's order, and two residents lacked care plans for their oxygen use. Additionally, a resident's nasal cannula was expired, and the oxygen humidifier bottle was not labeled with a change date, posing an infection risk.
The facility failed to ensure safe medication storage practices, with expired, unlabeled, and undated medications found in two medication carts and two storage rooms. Observations included expired Atropine Sulfate and Latanoprost Ophthalmic Solutions, undated Ipratropium Bromide and Albuterol Sulfate inhalation solution, and a vial of Lorazepam belonging to a discharged resident. Over-the-counter medications with debris were also noted. Licensed nurses and the DON confirmed the need for proper labeling and disposal of medications.
The facility failed to ensure food safety and sanitation, affecting 91 residents. Opened food packages were unlabeled, spoiled and expired food was not removed, and kitchen equipment was not cleaned. A partially consumed water bottle was found in the dry food storage area, violating FDA guidelines.
A resident with physical limitations was denied the use of a personal device for communication and entertainment, despite it being important for their well-being. The facility unplugged the device due to concerns about the roommate, without providing alternatives, contrary to their policies on personal property and a homelike environment.
A resident with spastic diplegic cerebral palsy and adjustment disorder was unable to reach her call light due to contractures in her arms and hands, placing her at risk of falls and unmet care needs. A nurse confirmed the call light was out of reach, and the resident's care plan emphasized the importance of having the call light accessible. The DON expected call lights to be within reach, aligning with the facility's policy for timely responses to residents' needs.
A resident with a history of falls and fractures was observed in a Geri chair with the footrest elevated, preventing free movement and acting as a restraint. The DSD confirmed the chair should be upright when the resident is awake. The facility's policy states that restraints should only be used for medical symptoms, not for convenience or fall prevention.
The facility failed to develop and implement care plans for three residents, leading to potential unmet care needs. A resident with end-stage renal disease lacked a dialysis care plan, another with a splint had no care plan for its management, and a third involved in altercations had no behavioral care plan. These omissions were confirmed by staff and violated facility policies requiring comprehensive, person-centered care plans.
The facility failed to update care plans for two residents, one with new skin wounds and another who switched from smoking tobacco to vaping. The DON acknowledged the lack of a care plan for the resident with wounds, while the AD admitted to not updating the smoking care plan in a timely manner. This oversight could lead to inadequate care, as staff may not be aware of necessary interventions or changes in residents' conditions.
A resident with a left arm injury and chronic pain was not seen by an orthopedist for six months despite a referral from the facility's MD. The resident's splint, worn since admission, showed signs of neglect, and transportation issues were cited as the reason for the delay. Interviews with staff confirmed the oversight, and the MD emphasized the need for the referral.
A resident with worsening eyesight and specific symptoms was not assisted by the facility in obtaining an ophthalmology appointment, despite repeated requests and a care plan intervention. The Social Services Director acknowledged the oversight, and the Director of Nursing confirmed the lack of documentation and emphasized the risk of vision decline affecting mobility and fall risk.
A resident with pressure ulcers did not receive consistent treatment as ordered by their physician, specifically the use of heel protectors every shift. Observations confirmed the resident's heels were bare, and facility staff acknowledged the oversight, which was contrary to the facility's wound care policy.
A resident with quadriplegia did not receive ordered Restorative Nurse Assistant (RNA) services, including the use of orthotics and passive range of motion (PROM) exercises, due to a lack of communication and awareness among staff. Additionally, the facility failed to develop a care plan for the resident's arm and hand contractures, increasing the risk of further decline in range of motion.
A resident at high risk for falls did not have appropriate fall precautions in place, as fall mats were not positioned correctly and were not included in the care plan. Staff confirmed the mats were sometimes moved and not returned, and the resident's bedside table was out of reach, increasing fall risk. The need for fall mats was not documented, highlighting a lapse in care planning and staff education.
A facility failed to obtain a physician's order for a resident's indwelling foley catheter, despite the resident's diagnoses of urinary tract infection and acute kidney failure. The care plan required regular catheter care and infection monitoring, but the absence of a physician's order meant staff were not properly informed of the resident's needs, placing the resident at risk for complications.
A resident receiving IV therapy for MRSA had their IV tubing lying on the floor, and the infusion bag was not labeled with the date, time, or staff initials. The ADON confirmed these issues, acknowledging the risk of infection and physical hazards. The DON expected proper labeling and tubing management, as outlined in facility policies, but these standards were not met, resulting in a deficiency.
A resident's unlabeled urinal was found on the bedside table, posing a risk of infection if used by another resident. The CNA, LN, IP, and DON all confirmed that urinals should be labeled to prevent mix-ups. The facility's infection control policy requires maintaining a safe and sanitary environment, which was not followed in this case.
A resident with severe cognitive impairment was physically assaulted by another resident with a history of aggression in a common area. The incident was witnessed by a CNA who was unable to intervene due to attending to another resident. The facility's policies on monitoring and preventing abuse were not effectively implemented, leading to a deficiency.
A resident with osteoarthritis and osteoporosis fell and sustained fractures when a blanket caught in the wheel of a shower chair during transport, causing the chair to tip forward. The incident, witnessed by a CNA, resulted in severe pain and decreased mobility for the resident. The facility's policy required blankets to be secured during transport, which was not adhered to, leading to the preventable accident.
A resident with epilepsy did not receive his prescribed seizure medication for several days due to an insurance issue, and the physician was not informed. The resident experienced multiple seizures and was hospitalized. The facility's policy required notifying the physician and taking further steps if medication was unavailable, which was not followed.
Failure to Immediately Notify Physician of STAT X‑Ray Showing Fracture and Osteomyelitis
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician of significant STAT x‑ray results showing a fracture and osteomyelitis. The resident had multiple serious diagnoses, including hemiplegia/hemiparesis after stroke, a stage 4 pressure ulcer of the left ankle, type 2 diabetes mellitus, peripheral vascular disease, and anemia. On the morning in question, a CNA alerted a nurse to check the resident’s left foot; the nurse and supervisor observed the left foot twisted downward from the ankle, with purple, cold skin and an existing stage 4 wound. A physician gave a verbal order for a STAT x‑ray of the left ankle, foot, and knee, which was entered into the record at 12:34 PM. The STAT x‑ray was completed and the radiology report, indicating a fracture and osteomyelitis of the distal left lower leg, was transmitted to the facility at 10:20 PM that same day. The facility’s process was that STAT x‑ray results would be uploaded into the electronic health record and faxed to a designated nurse’s station. The nurse on duty (LN 3) stated that during shift handoff, the pending x‑ray was discussed and that she checked the electronic record and fax machine around 8 PM but did not see results at that time. LN 3 did not check again for the remainder of the shift and did not call the x‑ray company to verify when results would be available. At approximately 1 AM, another nurse brought the faxed x‑ray report to LN 3, confirming the abnormal findings. Upon receiving the abnormal STAT x‑ray results, LN 3 notified the resident’s physician by text message at 1:40 AM and sent a picture of the report but did not make any additional attempts to contact the physician for the rest of the shift. LN 3 acknowledged that facility procedure required immediate reporting of abnormal x‑ray results and that notification several hours after the results were available did not meet the expectation of “immediate.” LN 3 also confirmed that no follow‑up phone call was made when the physician did not respond to the text message, and there was no direct confirmation that the physician had received the results. The DON stated that the nurse who received the STAT x‑ray results should have immediately notified the physician and, if there was no response within 30 minutes, should have called again, and that the lack of timely, direct voice communication delayed the order to transfer the resident to the hospital by approximately twelve hours, placing the resident at risk for pain and complications. Facility policies titled “Guidelines for Notifying Physician of Clinical Problems,” “General Guidelines for Reporting Abnormal Test Results to Physicians,” and “Lab and Diagnostic Test Results – Clinical Protocol” required immediate notification of physicians for sudden or marked changes in condition and for new or unsuspected x‑ray findings such as fractures, with direct voice communication identified as the preferred method for results requiring immediate notification. These policies specified that immediate notification meant contacting the physician as soon as possible, especially for STAT results and problematic abnormal findings. The events described show that the facility did not follow its own policies for immediate physician notification of a STAT x‑ray result revealing a fracture and osteomyelitis, resulting in delayed communication of critical diagnostic information.
Failure to Complete Comprehensive Assessment After Abnormal X-Ray Findings
Penalty
Summary
The deficiency involves the facility’s failure to complete and document a comprehensive assessment for a resident who experienced a significant change in condition involving the left lower extremity. The resident was admitted with multiple serious diagnoses, including hemiplegia/hemiparesis after a cerebral infarction affecting the left side, a stage 4 pressure ulcer of the left ankle, type 2 diabetes mellitus, peripheral vascular disease, and anemia. The resident’s BIMS score indicated moderate cognitive impairment. On the morning of 2/8/26, a CNA notified nursing staff that the resident’s left foot appeared twisted. A nurse’s note documented that the left foot was in a twisted position, with a stage 4 wound, purple skin color, and skin cold to touch. A physician was contacted and a STAT x-ray of the left ankle, foot, and knee was ordered and carried out. Later that day, radiology results were reported to the facility, indicating a fracture and acute osteomyelitis of the distal lower leg. The clinical record shows that the physician was notified of the abnormal x-ray results in the early morning hours of 2/9/26. However, there is no documentation that the resident’s left leg and foot were reassessed for changes in condition or for pain after the initial assessment at approximately 11:00 AM on 2/8/26 and before or after the physician was notified of the x-ray findings. During interview, the nurse who received the handoff report acknowledged that although she and another nurse viewed the resident’s foot, she did not complete a comprehensive assessment at that time. The DON’s review of the x-ray results and nursing progress notes confirmed that the assigned RN should have completed and documented a comprehensive assessment using the SBAR Communication Form in response to the significant change in the resident’s condition. The DON stated that the assessment should have included a detailed description of the leg and foot, circulation status, presence of bleeding, necrosis, or further twisting, and whether the resident expressed pain or discomfort. The facility’s policy on change in a resident’s condition requires nurses to make detailed observations and gather relevant information, prompted by the Interact SBAR form, prior to notifying the physician. Job descriptions for LVNs, RNs, and the Nursing Supervisor also require assessment and observation of residents with changes in condition. Despite these requirements, a comprehensive reassessment was not completed or documented around the time the abnormal x-ray results were obtained and communicated, constituting the cited deficiency.
Failure to Recognize and Address Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutrition for a resident who experienced a significant, unrecognized weight loss. The resident, admitted with multiple diagnoses including colon cancer, dehydration, post-surgical aftercare, anemia, vitamin D deficiency, and muscle weakness, lost 21.4 pounds (15.7% of body weight) over a 10-day period, and a total of 31.8 pounds (23.3% of body weight) over five weeks. This weight loss was not identified, addressed, or reported to the physician in a timely manner, as required by facility policy. Observations and interviews revealed that the Restorative Nursing Assistant (RNA) was responsible for weighing residents and documenting the results, with the expectation to notify the DON or ADON of any weight change of 3 pounds or more. However, the RNA did not recall notifying anyone about the resident's severe weight loss. Licensed nursing staff and the DON confirmed that there was no documentation of physician notification or change of condition related to the weight loss during the critical period. The resident was not weighed weekly as required, and the significant weight loss was not recognized until more than four weeks after it occurred. Further review with the Registered Dietician (RD) and Medical Director (MD) confirmed that the resident met the criteria for severe weight loss, but interventions were not implemented until more than a month after the initial documented loss. The facility's own policies required prompt notification of significant changes in condition and unplanned weight loss, but these procedures were not followed. The delay in recognition and intervention was attributed in part to staff transitions, including changes in DON and RD positions during the period in question.
Failure to Process Psychiatric Referral for Resident with Depression
Penalty
Summary
A deficiency occurred when the facility failed to ensure the psychosocial well-being of a resident by not processing a psychiatric referral in a timely manner. The resident, who had a history of hemiplegia, hemiparesis following a stroke, malignant neoplasm of the colon, and recent colon surgery, was admitted with significant medical and emotional needs. An order for a psychiatric referral was entered by a Nurse Practitioner after the resident was observed with tears in her eyes and refusing therapy. However, the Social Services Department did not process this referral as required, and the resident did not receive the intended psychiatric evaluation. During interviews, the resident expressed feelings of sadness, loneliness, and depression related to her medical condition and stay at the facility, stating she had not been offered counseling or therapy. The Social Services Director confirmed that the referral process was not completed, and the DON acknowledged the importance of timely referrals for residents' mental health. The Nurse Practitioner who ordered the referral was unaware it had not been completed, and facility policy required social services to coordinate and document such referrals in collaboration with nursing staff.
Failure to Ensure Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including anxiety disorder and depression was prescribed lorazepam, an anti-anxiety medication, on an as-needed basis without the required 14-day stop date or a documented rationale from the physician for omitting the stop date. The medication order, signed by the physician, instructed administration of lorazepam 0.5 mg every 6 hours as needed for anxiety or restlessness. Facility staff, including a licensed nurse and the Assistant Director of Nursing, confirmed that as-needed psychotropic medications are expected to have a 14-day stop date to ensure periodic evaluation of the medication's necessity and safety. However, the order for lorazepam did not include this stop date, and there was no documentation from the physician explaining the omission. Record review showed that the resident received lorazepam on three consecutive days without a stop date in place. The Minimum Data Set Coordinator and the facility pharmacist both confirmed that as-needed anti-anxiety medications require a specified duration or stop date to prompt re-evaluation before continuation. The facility's policy also states that PRN psychotropic drug orders, except for antipsychotics, are limited to 14 days unless the attending physician documents a rationale and indicates a duration for the order. In this case, the required documentation and stop date were missing, resulting in the administration of lorazepam without proper oversight.
Failure to Accurately Complete PASRR Screening for Resident with Intellectual Disability
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) for one resident who had documented diagnoses of mild intellectual disabilities and cerebral palsy. Upon review, the PASRR Level I screening did not indicate the presence or suspicion of intellectual or developmental disability or related conditions, despite these diagnoses being present in the resident's admission record. The Minimum Data Set Coordinator (MDSC) confirmed that the PASRR did not match the resident's diagnoses and stated that, had the intellectual disability been identified, it would have triggered a Level II evaluation. The PASRR was completed at the facility but was never reviewed for accuracy. Interviews with facility staff, including the MDSC and Assistant Director of Nursing (ADON), revealed that staff were expected to review completed PASRRs for accuracy, but this was not done in this case. The facility's policy required all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders, and to refer individuals for Level II evaluation if indicated. The failure to accurately complete and review the PASRR resulted in the resident not being properly evaluated for specialized services as required by policy.
Failure to Provide Scheduled Psychotherapy and Timely Follow-Up
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with adjustment disorder with depressed mood and anxiety disorder. The resident had a physician's order for psychotherapy sessions twice a week, as documented in the psychologist's progress notes and the doctor's order summary. However, both scheduled psychotherapy sessions during a specific week were missed, with no documentation indicating that services were provided or that alternative interventions were implemented. Licensed nursing staff confirmed the missed visits and acknowledged the absence of follow-up or backup plans. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed that the process for handling missed psychotherapy appointments required communication and timely follow-up, which did not occur in this instance. The Social Services Department was responsible for managing psychology referrals and appointments, and staff were expected to notify appropriate personnel if a visit was missed. Despite these expectations, there was no evidence that the missed psychotherapy sessions were addressed, placing the resident at risk for negative psychosocial outcomes.
Failure to Provide Mechanical Lift Sling Prevents Resident Participation in Activities
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident who required a mechanical lift and sling for transfers, as documented in her care plan due to an ADL self-care deficit. On multiple occasions, the resident was unable to attend morning activities of her choice because the facility did not have a mechanical lift sling available. Documentation showed that transfers out of bed occurred at irregular times, often after scheduled activities, and staff interviews confirmed that a lack of available slings and uncharged lift batteries delayed care. On one occasion, the resident had to use a shower sling, which caused skin irritation, due to the shortage of regular slings. Interviews with staff and the resident confirmed that the absence of appropriate equipment directly prevented the resident from participating in preferred activities. The DON acknowledged that the facility should have the necessary equipment to meet the resident's needs and that missing activities could negatively affect the resident's psychosocial well-being. Facility policies reviewed emphasized the importance of resident autonomy, participation in activities, and dignity, all of which were not upheld in this instance due to the equipment shortage.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported to the Department in a timely manner. A resident with a diagnosis of bipolar disorder and intact cognitive function alleged that a certified nursing assistant (CNA) forcefully grabbed her legs, causing pain and bruising. The incident was initially reported by the resident to licensed nurses, who assessed her but did not observe visible marks and failed to document or report the allegation as required. Both nurses later acknowledged that they should have documented and reported the incident for the safety of the resident and others. The incident occurred on a Saturday evening, but the administrator did not become aware of the allegation until five days later, resulting in a delayed report to the Department. Interviews confirmed that two licensed nurses and the CNA involved were aware of the resident's allegations on the day of the incident, but no immediate action was taken to notify the administration or authorities. Facility policy required immediate reporting of suspected abuse within two hours, but this protocol was not followed, leading to a delay in the investigation process and a failure to protect the resident and others from potential harm.
Failure to Notify Responsible Party of Abuse Allegation
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's allegation of abuse. The resident, who had a diagnosis of schizophrenia, reported to staff that she had been hit on the head by a tall man with a stick during the early morning hours. This allegation was documented in the resident's progress notes, and the care plan was updated to address a potential psychosocial well-being problem related to the claim. The care plan included an intervention to increase communication between the resident, family, and caregivers. During an interview and record review with the Director of Nursing (DON), it was confirmed that there was no documentation indicating the RP had been informed of the abuse allegation. The DON acknowledged that the RP should have been notified and kept updated about the resident's situation. Facility policy requires that all reports of resident abuse be reported and that the resident's representative be notified immediately upon conclusion of the investigation, but this was not done in this case.
Failure to Implement and Document Required Alert Charting After Incidents
Penalty
Summary
The facility failed to implement care plan interventions for two residents following incidents that required monitoring for potential psychosocial effects. One resident, admitted with schizophrenia, reported being hit on the head and claimed to have lumps and bumps. The care plan for this resident included alert charting for 72 hours to monitor for possible psychosocial effects of the reported incident. However, documentation confirmed that alert charting was not completed by licensed nurses on two subsequent days as required. Another resident was involved in a verbal altercation with a peer, after which staff were instructed to monitor both individuals for behavioral changes. The care plan for this resident also required alert charting for 72 hours to assess for any adverse psychosocial effects. Record review and staff interviews confirmed that no alert charting was completed for this resident during the specified period. Facility policy mandates documentation of such incidents and subsequent care every shift for at least 72 hours, which was not followed in these cases.
Failure to Maintain Homelike Environment Due to Resident's Disruptive Behavior
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents who were negatively affected by the disruptive behavior of another resident diagnosed with bipolar disorder. Both affected residents, who had diagnoses including depression, requested that their room doors be kept closed due to the noise and verbal aggression occurring in the hallway outside their rooms. One of these residents also avoided participating in activities because the disruptive resident was present, yelling and cussing at others in the activities room. Multiple staff members, including CNAs and licensed nurses, confirmed that the disruptive resident frequently yelled and used profanities toward other residents, causing discomfort and distress among those exposed to the behavior. Review of the disruptive resident's care plan and progress notes revealed a history of sudden and abrupt episodes of verbal and physical aggression without warning, with documented incidents of yelling at both staff and residents. Staff interviews indicated that the behavior was ongoing and had a negative impact on the environment, with staff expressing concern and empathy for the affected residents. The facility's policy on maintaining a homelike environment emphasized the importance of comfortable sound levels, which was not upheld in this situation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Scheduled Showers and Honor Resident Preferences
Penalty
Summary
A deficiency occurred when a resident was not provided with routine showers as scheduled, despite being cognitively intact and having a care plan that required assistance with bathing and shower transfers. The resident was scheduled to receive showers twice weekly, but documentation and interviews confirmed that showers were not provided on multiple scheduled dates. Instead, the resident resorted to using disposable wipes for personal hygiene, as staff did not offer showers outside of the assigned days and there was no documentation of refusal by the resident. Further investigation revealed that the resident preferred a female CNA to assist with showers and would decline when a male CNA offered assistance. This preference was reported to the licensed nurse several times, but the care plan was not updated to reflect the resident's needs or preferences. The facility's own policies and job descriptions emphasized the importance of honoring resident choices and promoting dignity, but these were not followed in this case, resulting in the resident's care needs not being met and causing distress.
Failure to Maintain Sanitary Shared Bathroom Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and sanitary environment for two residents who shared a bathroom. During an observation, a clump of brown bowel movement was found smeared on the toilet seat in the shared bathroom. The housekeeper assigned to clean the area confirmed that she had cleaned one of the resident's rooms earlier in her shift but had not yet cleaned the bathroom, stating she planned to do so later. At the time of the interview, the toilet remained soiled with both smeared feces and urine in the bowl. The Director of Staff Development acknowledged that the toilet should not have been left in such a condition and emphasized that it should have been cleaned to prevent injury or transmission of infection. Facility policies reviewed indicated that residents are to be provided with a safe, clean, and homelike environment, and that infection control practices are intended to maintain a sanitary environment and prevent disease transmission. The failure to promptly clean the soiled toilet created an unsanitary environment for the residents using the shared bathroom.
Unsafe Storage of Equipment in Resident Room Creates Fall Hazard
Penalty
Summary
The facility failed to provide a safe and hazard-free environment for one of three sampled residents when multiple items, including three standard wheelchairs, a high back wheelchair, an overbed table, and a reclining medical chair, were stored in the resident's bedroom. These items were placed on the side of the room closest to the door, while the resident's bed and personal belongings were on the opposite side. The resident reported that the items had been in the room for several days to clear the hallway. The resident involved had a history of repeated falls and was identified in the care plan as being at risk for falls due to poor safety awareness, with fall risk precautions indicated. During an interview, the Director of Staff Development confirmed that the items should not have been stored in the resident's room and acknowledged that their presence could create a trip or fall hazard. Facility policies reviewed emphasized the importance of maintaining a safe, clean, and homelike environment, free from accident hazards.
Inadequate Infection Control Practices in Shared Bathrooms
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for its 91 residents. During multiple observations of shared bathrooms, various personal care items such as urinals, wash basins, kidney basins, toothbrushes, and bedpans were found unlabeled and stored in unsanitary conditions. These items were often placed on the floor or on top of paper towel dispensers, increasing the risk of cross-contamination among residents. Certified Nurses Assistants (CNAs) confirmed that the items were not labeled and acknowledged the risk of cross-contamination due to improper labeling and storage. Interviews with the Infection Preventionist (IP), Director of Nursing (DON), and Administrator (ADM) revealed that the facility's process required staff to label personal care items with the resident's room number, first name, and last initial before use. After use, items were to be cleaned, dried, and stored in a bag in the resident's personal area, not in shared bathroom spaces. The IP, DON, and ADM all expressed that the condition of the bathrooms and the improper handling of personal care items did not meet the facility's expectations and posed a significant infection control risk.
Failure to Arrange Follow-Up Care Leads to Resident's Amputation
Penalty
Summary
The facility failed to provide necessary follow-up care for a resident who was discharged from the hospital with specific instructions for follow-up with a podiatrist and interventional radiology within 1-2 weeks. Despite these clear instructions, the facility did not arrange for these appointments, which were crucial for the resident's ongoing care following a partial amputation of the right foot due to gangrene. The resident's medical records indicated a lack of documentation regarding the condition of the surgical wound upon admission to the facility, and there was no evidence that the facility consulted with the physician about the removal of the surgical sutures. Additionally, the facility did not act on a recommendation from the wound care physician for a surgical evaluation of the resident's right foot. The wound care physician noted the need for a surgical examination for revision of the right TMA stump, but this recommendation was not communicated to the resident's primary physician or nurse practitioner. The facility's staff, including the Assistant Director of Nurses and the Social Services Director, acknowledged that the necessary follow-up appointments were not scheduled, and the resident was discharged without these critical consultations being arranged. The failure to ensure proper follow-up care and communication among the facility's staff and external healthcare providers may have contributed to the resident's wound infection and subsequent amputation of the right leg below the knee. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's follow-up needs, highlighting deficiencies in the facility's processes for managing and coordinating care for residents with complex medical needs.
Infection Control Breach Due to Improper Dressing Use
Penalty
Summary
The facility failed to maintain proper infection prevention and control standards for nine residents when a Certified Nursing Assistant (CNA) wore a loosened gauze dressing on her right hand. The CNA had burned her hand at home and chose to cover it with a dressing rather than call in sick. During her shift, she washed her hands with the dressing on and changed it three times, which was observed to be dislodged near the thumb and top of the hand. This action posed a risk of spreading infection to the residents under her care and potentially to others she assisted. The Director of Staff Development (DSD) confirmed that the dressing was only partially covered with an occlusive dressing and was peeling away, which was against the facility's infection control policies. The facility's policy emphasized hand hygiene as the primary means to prevent infection spread, requiring all personnel to follow handwashing procedures. The Administrator also acknowledged that the CNA should have changed the dressing every time she washed her hands to prevent the risk of infection spread.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for three residents receiving oxygen therapy. Resident 53 was observed receiving oxygen therapy without a physician's order, which is necessary to determine the correct flow rate and monitor oxygen saturation levels. The Licensed Nurse confirmed the absence of an order and was unsure why the resident was receiving oxygen therapy. The Director of Nursing stated that a physician's order is expected for oxygen administration. Additionally, both Resident 53 and Resident 90 did not have care plans developed for their oxygen use. Resident 53's care plan was missing, which should have informed staff of the need for oxygen therapy. Similarly, Resident 90, who was diagnosed with chronic obstructive pulmonary disease, was observed using oxygen without a corresponding care plan. The Director of Nursing and the Director of Staff Development emphasized the importance of care plans to ensure staff are aware of and can meet the residents' needs. Resident 30's nasal cannula was found to be expired, and the oxygen humidifier bottle was not labeled with a change date. The Licensed Nurse confirmed that the nasal cannula was nine days old, exceeding the recommended seven-day change interval, which poses a risk of infection. The Director of Nursing and the Infection Preventionist both stated that oxygen tubing and humidification water should be changed weekly to prevent infection and ensure proper function.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure safe medication storage practices in two out of four medication carts and two medication storage rooms. Observations revealed expired, unlabeled, and undated prescription medications in the active storage areas of medication cart 2, including vials of Atropine Sulfate and Latanoprost Ophthalmic Solutions. Medication cart 4 contained an undated foil package of Ipratropium Bromide and Albuterol Sulfate inhalation solution. Additionally, the Station 1 medication room had an undated open foil package of Albuterol Sulfate Inhalation Solution, and the Station 2 medication room contained a vial of liquid Lorazepam belonging to a discharged resident. Over-the-counter liquid medications with dry, crusty debris were also found in medication carts 2 and 4. Licensed nurses confirmed that medications should be labeled, dated when opened, and disposed of after a specified period. The Director of Nursing stated that medications should be pulled for destruction when expired, undated, unlabeled, or belonging to discharged residents. The facility's policy indicated that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary manner, and that the dispensing pharmacy should be contacted for instructions regarding the return or destruction of discontinued, outdated, or improperly labeled medications.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure safe food production in accordance with professional standards for food safety, affecting 91 residents who received facility-prepared meals. During an inspection, it was observed that opened food packages and containers were not labeled with an open date. Specific instances included unlabeled containers of ground mustard, rubbed sage spice, baking powder, parsley flakes, oregano leaves, cream of wheat dry cereal, and a bin containing a white substance. The facility's policy required all food items to be labeled and dated, but this was not adhered to. Additionally, the facility did not remove spoiled and expired food products. An opened container of Italian seasoning was found to be expired, a red onion with mold growth was noted, and loaves of bread were expired. In the walk-in refrigerator, a flat of eggs contained a cracked egg. These observations were contrary to the facility's policy, which required produce to be fresh and free of spoilage, and bread to be used in the order delivered to ensure freshness. The facility also failed to maintain cleanliness of kitchen equipment and food contact surfaces. A can opener had a dried grayish substance on the blade, and the walk-in refrigerator had rust and substances on the walls. The oven had black, grimy build-up, and a metal strainer had a dried brownish substance. Other equipment, such as a toaster oven, commercial mixer, muffin tin, and metal rack, were also found with various residues. Furthermore, a partially consumed bottle of drinking water was found on a shelf with food items in the dry food storage area, which was against the FDA Food Code that requires designated areas for employee consumption to prevent contamination.
Failure to Provide Communication and Entertainment Alternatives
Penalty
Summary
The facility failed to provide a resident with alternative methods of communication and entertainment, despite the resident's physical limitations that prevented the use of a cell phone or tablet device. The resident, who was readmitted to the facility with spastic diplegic cerebral palsy and adjustment disorder with mixed anxiety and depressed mood, was provided with a device by their family to receive phone calls and listen to music. However, the facility repeatedly unplugged the device, citing concerns about it bothering the roommate and the potential for the family to overhear the roommate's conversations. Interviews with staff and family members revealed that the resident enjoyed listening to music and white noise, which helped them relax and feel less lonely. Despite this, the staff were instructed to unplug the device, and no alternative was provided. The facility's policies on personal property and creating a homelike environment emphasize the importance of allowing residents to use personal belongings to maintain comfort and independence, yet these policies were not adhered to in this case.
Resident's Call Light Inaccessible, Risking Unmet Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident when the resident's call light was not within reach, placing the resident at risk of falls and unmet care needs. The resident, who was readmitted to the facility with spastic diplegic cerebral palsy and adjustment disorder with mixed anxiety and depressed mood, was observed with contractures of both arms and hands, which were held against her chest. During an observation, the resident attempted to reach her call light but was unable to extend her arms enough to access it. The resident stated that if she could not reach the call light, she would yell for help. A licensed nurse confirmed that the resident was unable to reach her call light and stated that it should be within reach. The resident's care plan indicated that the resident was at risk for falls and required the call light to be within reach to request assistance. The Director of Nursing stated that it was her expectation that residents' call lights would be in reach at all times. A review of the facility's policy on answering call lights indicated that the call light should be accessible to the resident when in bed and that the resident call system should be answered immediately.
Improper Use of Geri Chair as Restraint
Penalty
Summary
The facility failed to ensure that Resident 19 was free from the use of physical restraints. Resident 19, who was admitted in 2023 with a history of falling, fractures, and altered mental status, was observed on multiple occasions sitting in a Geri chair that was reclined with the footrest elevated. This positioning prevented Resident 19 from freely getting out of the chair, effectively acting as a restraint. The Director of Staff Development (DSD) confirmed that the Geri chair should be upright with the footrest down when the resident is awake to avoid it being considered a restraint. Observations and interviews revealed that Resident 19 was awake and attempting to get out of the Geri chair, which was reclined and had the footrest elevated. The Director of Nursing (DON) stated that the expectation was for the footrest to be down to allow residents to get in and out of the chair easily. The facility's policy on the use of restraints indicated that restraints should only be used to treat medical symptoms and not for staff convenience or fall prevention. The policy also defined physical restraints as any device that restricts freedom of movement, which includes Geri chairs that residents cannot remove themselves.
Failure to Develop Resident-Specific Care Plans
Penalty
Summary
The facility failed to develop and implement resident-specific care plans for three residents, leading to potential unmet care needs. Resident 32, who was admitted with end-stage renal disease and dependent on dialysis, did not have a care plan addressing her dialysis treatment. Despite receiving dialysis three times a week, there was no documented care plan to guide staff in meeting her dialysis needs, as confirmed by a licensed nurse. This oversight was contrary to the facility's policy, which mandates a comprehensive care plan for residents with end-stage renal disease. Resident 197, admitted with chronic pain syndrome and a splint on her left arm, also lacked a care plan for her splint care. The Director of Nursing confirmed the absence of a care plan, which should have included interventions for monitoring the splint and preventing skin problems. The facility's policy requires regular review and management of splints as part of the resident's care plan, which was not adhered to in this case. Resident 46, involved in an altercation with another resident, did not have a behavioral care plan addressing her conflict with Resident 23. Despite multiple incidents and ongoing tension between the two residents, there was no care plan to guide staff in managing these behaviors. The Social Services Director and the Director of Nursing acknowledged the lack of a behavioral care plan, which was necessary to prevent escalation and ensure appropriate interventions were in place. This was in violation of the facility's policy on resident-to-resident altercations, which requires care plan updates following such incidents.
Failure to Update Care Plans for Residents with Changing Conditions
Penalty
Summary
The facility failed to update or revise the comprehensive care plan for two residents, leading to potential inadequacies in their care. Resident 83 experienced a change in condition due to the development of multiple skin wounds or ulcers, as documented in the SBAR Summary for Providers Record. Despite the physician being notified and a wound care consult being ordered, the Director of Nursing (DON) acknowledged that no care plan was initiated for this change in condition. The facility's policy requires care plans to be updated with any significant change in a resident's condition, which was not adhered to in this case. Resident 71's care plan was also not updated in a timely manner regarding her smoking habits. Initially admitted with chronic obstructive pulmonary disease and centrilobular emphysema, Resident 71's smoking care plan was not revised to reflect her switch from tobacco to vape products until much later. The Activity Director (AD) admitted to not updating the care plan when Resident 71 began vaping, which led to confusion among staff about her smoking privileges and preferences. The Director of Staff Development (DSD) and Licensed Nurse (LN) 8 emphasized the importance of having updated smoking care plans to ensure staff are aware of residents' smoking preferences and necessary precautions. The facility's policy mandates that comprehensive, person-centered care plans be developed within seven days of a significant change in status and be revised as residents' conditions change. The failure to update the care plans for Residents 83 and 71 as required by the facility's policy and procedure potentially compromised their care and well-being, as staff may not have been aware of the necessary interventions or changes in their conditions.
Failure to Execute Orthopedic Referral for Resident
Penalty
Summary
The facility failed to follow a physician's order for a resident, identified as Resident 197, who was admitted with a splint on her left arm due to an injury. Despite a referral from the facility's Medical Director to see an orthopedist for persistent pain, the resident had not been seen by a specialist for six months. The resident's clinical records indicated a history of chronic pain syndrome and a previous injury requiring a splint, with multiple orders and notes confirming the need for an orthopedic consultation. However, the referral was not executed, and the resident continued to wear the same splint since admission. Interviews with facility staff, including a licensed nurse and the Director of Nursing, revealed that the referral was not carried out due to transportation issues, as the resident's wheelchair exceeded transport capacity, and the clinic could not accommodate her in a gurney. The splint was observed to have brown spots and a foul odor, indicating potential skin issues. The Medical Director confirmed the need for the referral and suggested that the resident should have been sent to the ER if transportation to the orthopedic clinic was not feasible. The facility's job description for Licensed Vocational Nurses emphasized the importance of following physician orders and meeting residents' individualized care needs.
Failure to Provide Vision Care for Resident
Penalty
Summary
The facility failed to provide necessary vision care for a resident who complained of worsening eyesight and requested to see an ophthalmologist. Despite the resident's repeated requests and the presence of a care plan intervention indicating the need for an ophthalmology referral, the facility did not assist in scheduling the required appointment. The resident, who had been admitted in 2022 with diagnoses including palliative care, history of falling, major depressive disorder, and anxiety disorder, expressed concerns about her vision deteriorating and reported specific symptoms such as her right eye fading to black and experiencing lightening flicks. The Social Services Director (SSD) acknowledged the responsibility for arranging ancillary care, including vision appointments, and confirmed that an appointment should have been made shortly after the care plan was created. However, there was no documentation in the resident's clinical record regarding her vision concerns or any follow-up appointments. The Director of Nursing (DON) also confirmed the lack of documentation and emphasized the risk of continued vision decline, which could affect the resident's mobility and increase the risk of falls. The facility's policy on visually impaired residents highlighted the responsibility to assist with scheduling appointments and arranging transportation, which was not fulfilled in this case.
Failure to Follow Heel Protector Order for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident received consistent treatment to promote the healing and prevention of pressure ulcers. The resident, who was admitted with diagnoses including pressure ulcers to the sacral region and left heel, had a physician's order for heel protectors to be worn on both feet every shift for pressure ulcer prevention. However, during observations and interviews, it was confirmed that the resident's feet and heels were bare and without protection, indicating that the treatment order was not followed. The Director of Staff Development and the Director of Nursing both acknowledged that the treatment order for heel protectors was not adhered to. The facility's policy and procedure for wound care, which includes applying treatments as indicated and using supportive devices as instructed, was not followed in this case. This oversight placed the resident at risk for worsening their current pressure ulcer and increased the chance for the development of new pressure ulcers.
Failure to Implement Restorative Services and Care Plan for Resident with Quadriplegia
Penalty
Summary
The facility failed to provide appropriate care and services to maintain the highest level of range of motion (ROM) for a resident diagnosed with quadriplegia. The resident, identified as Resident 74, had an order for Restorative Nurse Assistant (RNA) services, which included donning and doffing bilateral orthotics and performing passive range of motion (PROM) exercises. However, these services were not implemented, as confirmed by the RNA staff who were unaware of the resident's needs. The Occupational Therapy Director also did not know what happened to the referral for the resident, and the Certified Nurse Assistants (CNA) and Licensed Nurse (LN) caring for the resident were not informed about the hand splints or the need for ROM exercises. Additionally, the facility did not develop a care plan for Resident 74's arm and hand contractures, which are conditions that could lead to deformity and rigidity of joints. The Medical Records staff confirmed the absence of a care plan, and the Director of Nursing (DON) acknowledged that a care plan was necessary to communicate the resident's care needs and ensure staff awareness. The lack of a care plan and the failure to implement RNA services placed Resident 74 at risk of a decline in ROM and worsening contractures.
Failure to Implement Fall Precautions for High-Risk Resident
Penalty
Summary
The facility failed to ensure appropriate fall precaution measures were in place for one resident, identified as Resident 12, who was at high risk for falls. During an observation, it was noted that Resident 12's bedside table was out of reach, and two fall mats intended to cushion falls were not properly positioned next to the resident's bed. One mat was found folded against the wall, and the other was under the bed. A Certified Nurse Assistant (CNA) confirmed that the fall mats were sometimes moved during feeding assistance and should have been placed back correctly. The CNA also noted that the resident might attempt to reach the table and fall, indicating a lack of adequate supervision and safety measures. Interviews with nursing staff revealed that Resident 12 was at risk for falls and should have had fall mats and padded side rails due to a risk of seizures. However, the need for fall mats was not documented in the resident's care plan or medical record, which was confirmed by a Licensed Nurse (LN) and the Director of Nurses (DON). The DON acknowledged that the resident's fall risk evaluation indicated a high fall risk, yet the care plan did not include fall mats as an intervention. This oversight in care planning and staff education contributed to the deficiency, as the necessary interventions to prevent falls were not implemented or communicated effectively.
Failure to Obtain Physician's Order for Indwelling Catheter
Penalty
Summary
The facility failed to obtain a physician's order for an indwelling foley catheter for a resident who was admitted with diagnoses including urinary tract infection, acute kidney failure, and urine retention. The resident's care plan indicated the presence of an indwelling catheter and the need for regular catheter care and monitoring for signs of infection. However, the resident's nurses' weekly summaries did not reflect the presence of a catheter, and there was no physician order documented in the clinical record for its use. During interviews, both the Assistant Director of Nurses and the Director of Nursing confirmed the absence of a physician's order for the catheter, which is necessary to ensure proper care and monitoring by the nursing staff. The lack of an order meant that the staff was not adequately informed about the resident's catheter care needs, including monitoring for urine characteristics and signs of infection. This oversight placed the resident at risk for catheter-associated urinary tract infections and other complications.
Deficiency in IV Therapy Administration
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) therapy for a resident, identified as Resident 297, who was receiving treatment for a methicillin-resistant Staphylococcus aureus (MRSA) infection. During an observation, it was noted that the IV tubing connected to Resident 297's access site was lying on the floor, and the IV infusion bag was not labeled with the date, time, or initials of the staff who administered the medication. The Assistant Director of Nurses (ADON) confirmed these observations and acknowledged the importance of labeling the IV bag to track administration details and prevent expiration. The ADON also recognized the risk of infection and potential physical hazards posed by the tubing lying on the floor. The Director of Nursing (DON) stated that it was her expectation for IV infusion bags to be properly labeled and for IV tubing to be kept off the floor to prevent infection. The facility's policies and procedures, including those on preventing intravenous catheter-related infections and ensuring resident safety, were reviewed and indicated the importance of maintaining a safe environment and adhering to current standards of care. However, these standards were not met in the case of Resident 297, leading to a deficiency in the administration of IV therapy.
Unlabeled Urinal Poses Infection Risk
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures when a resident's urinal was found unlabeled. This incident involved a resident who was admitted with multiple diagnoses, including end-stage renal disease, dependence on renal dialysis, and anemia in chronic kidney disease. During an observation, the resident was seen resting in bed with an unlabeled urinal on the bedside table. Both a Certified Nurse Assistant (CNA) and a Licensed Nurse (LN) confirmed the presence of the unlabeled urinal and acknowledged that urinals should be labeled to prevent confusion and potential misuse by other residents. The Infection Preventionist (IP) and the Director of Nursing (DON) both stated that urinals should be labeled with at least the resident's room number, last name, or initials to prevent mix-ups that could lead to infections. The facility's policy on infection control, dated October 2018, emphasized maintaining a safe and sanitary environment, which was not adhered to in this instance. The failure to label the urinal posed a risk of infection spread if it were used by another resident.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as Resident 33, from physical abuse by another resident, identified as Resident 20. On August 3, 2024, Resident 20 pinched and hit Resident 33, an incident witnessed by CNA 7. Resident 33, who has severe cognitive impairment due to Alzheimer's Disease, was assaulted in a common area known as the Circle. Resident 20, who also has severe cognitive impairment and a history of physical aggression, was not adequately monitored despite existing care plans and interdisciplinary team notes indicating the need for close supervision due to her aggressive behavior. The incident occurred while CNA 7 was attending to another resident, and the licensed nurse was at the nurses' station, indicating a lapse in supervision. The Director of Nursing acknowledged that the interventions to monitor Resident 20's whereabouts were not followed as expected. The facility's policies on resident rights, resident-to-resident altercations, and abuse prevention emphasize the need to protect residents from abuse, yet these policies were not effectively implemented in this case, leading to the deficiency.
Resident Fall Due to Improper Transport Procedure
Penalty
Summary
The facility failed to provide a safe environment for a resident when a blanket became caught in the wheel of a shower chair during transport, causing the chair to stop abruptly and tip forward. This incident resulted in the resident falling and sustaining a fracture to her left medial malleolus and left fibula, leading to increased pain and decreased mobility. The resident was admitted to the facility in 2022 with diagnoses including bilateral osteoarthritis of the knee and age-related osteoporosis, conditions that made her more vulnerable to falls and fractures. The incident occurred when a CNA was transporting the resident from the shower room to her bedroom. The CNA had placed bath blankets over the resident, and during transport, one of the blankets became entangled in the wheel of the shower chair. This caused the chair to tilt forward, and despite the CNA's attempt to catch the resident, she fell onto her knees and hands. The fall was witnessed, and the resident immediately complained of severe pain in her left knee, with a pain score of 8 out of 10. The facility's policy on safety and supervision for residents emphasizes making the environment as free from accident hazards as possible. However, the Director of Nurses confirmed that the fall was due to the blanket becoming caught in the wheel, and it was expected that staff would ensure blankets were tucked in and not hanging below the resident's knees during transport. The Medical Director acknowledged that the fall was preventable and that the initial pain management was inadequate, leading to further complications for the resident.
Failure to Administer Medication and Notify Physician
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for one resident when the resident did not receive his prescribed medication, and the physician was not informed that the medication was unavailable. The resident, who had a diagnosis of epilepsy, was admitted to the facility with a care plan that included administering seizure medication as ordered by the doctor. However, the medication administration record indicated that the resident did not receive his clobazam medication for several days due to an insurance issue, and the progress notes confirmed that the medication was pending delivery. Despite this, the nursing staff did not notify the physician about the unavailability of the medication. On the fifth day without the medication, the resident experienced multiple seizures and had to be hospitalized. Interviews with the licensed nurse and the Director of Nurses confirmed that the physician was not contacted about the medication issue, which was against the facility's policy. The policy required nursing staff to notify the physician and take further steps if the medication was unavailable. The failure to follow these procedures may have contributed to the resident's increased seizure activity and subsequent hospitalization.
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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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