Rose Villa Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellflower, California.
- Location
- 9028 Rose Street, Bellflower, California 90706
- CMS Provider Number
- 056104
- Inspections on file
- 23
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Rose Villa Health Care Center during CMS and state inspections, most recent first.
Staff failed to accurately document I&O for a resident with urinary retention and an indwelling catheter. The resident’s care plan required monitoring and documenting I&Os and observing for urinary symptoms, but over multiple days and shifts, nurses recorded urine output on the MAR only as "x2" instead of in measured cc amounts. An RN and the DON confirmed that catheter bags should be emptied, measured, and documented in cc, and the facility’s I&O policy required licensed nurses to record intake and output each shift for residents with indwelling catheters.
A continent resident with spinal stenosis and type 2 DM, who required assistance with transfers but was able to make his own decisions, was placed in an adult brief and told by staff to urinate in it instead of being assisted to a toilet, bedpan, or bedside commode. A CNA reported routinely putting briefs on all residents unless told otherwise, while an RN confirmed the resident was continent and did not need briefs. The resident reported feeling like a baby and having difficulty urinating in the brief. This practice conflicted with the resident’s care plan, which called for assisted toilet transfers and maximal resident participation, and with facility policy requiring residents be treated with dignity and respect.
A resident with HTN, a-fib, and anemia had multiple morning medications documented as given on the MAR, but surveyors later observed a cup with six pills still on the bedside table, showing the medications were not ingested. An LVN reported placing the medication cup at the bedside and leaving to assist another resident, despite facility policy requiring missed medications to be flagged on the MAR and the nurse to return and directly observe administration. The DON confirmed that staff are not to leave medications unattended at the bedside.
An LVN poured multiple morning medications for a resident with HTN, a-fib, CHF, and anemia, left the medication cup with six pills on the bedside table, and left the room to assist another resident. The pills remained untouched on subsequent observations, yet the LVN documented on the MAR that several of the medications had been administered. In an interview, the LVN admitted leaving the medications unattended and acknowledged that signing the MAR before actual administration was incorrect, while the DON confirmed that facility policy requires a pour-pass-chart process and immediate documentation only after medications are given.
Two cognitively impaired, high fall-risk residents experienced unwitnessed falls after the facility relied on care plan interventions that required them to use call lights for assistance, despite their severe cognitive deficits and documented history of not using call lights. One resident, with hemiplegia, hemiparesis, and dependence on staff for mobility and toileting, had repeated falls in his room and bathroom while attempting tasks independently, even though his care plan focused on call light use and staff reported he never used it. The other resident, with encephalopathy, dementia, and visual impairment, was care planned to use a call light and required CGA for ambulation, yet staff believed he could ambulate alone except to the restroom, and he sustained an unwitnessed fall in his room while attempting to sit. The DON and DOR confirmed that the residents’ ability to follow call light instructions had not been clearly assessed, that the call light intervention was ineffective, that rehab did not evaluate one resident after a repeat fall, and that required IDT post-fall investigations and documentation to determine causal factors were not completed for either resident’s fall, contrary to facility policies on comprehensive care planning and fall management.
The facility failed to accurately complete MDS assessments for several residents, resulting in incorrect documentation of continence status, active diagnoses, and use of safety devices. For example, a resident was incorrectly coded as incontinent, another's mood disorder diagnosis was omitted despite psychiatric documentation and antidepressant use, and the use of bed and chair alarms was not recorded for a resident with mobility issues. Additionally, a resident's MDS listed schizophrenia instead of the correct diagnosis of bipolar disorder, as supported by psychiatric evaluations and medication orders.
Two residents with significant care needs did not have comprehensive care plans addressing their specific issues. One resident with severe cognitive impairment and orders for bed and chair sensor alarms lacked a care plan for the use and monitoring of these devices. Another resident, dependent for most activities and refusing to get out of bed for several days, did not have a care plan addressing this refusal. Staff confirmed the omissions, and facility policy requires such care plans to be in place.
Two residents received antibiotics without proper monitoring or reassessment as required by the facility's antibiotic stewardship program. One resident was given Zosyn for pneumonia without documentation of indication or infection surveillance, and another received daptomycin for a MRSA wound infection but was not tracked in the antibiotic stewardship binder or reassessed during therapy. Facility policy requiring ongoing monitoring, assessment, and tracking of antibiotic use was not followed.
A facility did not have a policy or procedure for the use of bed and chair sensor alarm pads and failed to consistently monitor and document their use for a resident with severe cognitive impairment and high fall risk. Staff interviews confirmed the lack of policy and missing documentation in the MAR, resulting in unmonitored use of the sensor alarm pads.
A resident with intact cognition and a history of incontinence was not provided with a bowel and bladder retraining program, despite being identified as a candidate through assessments. Staff interviews and record reviews confirmed the absence of a care plan, physician's order, and structured retraining program, in violation of facility policy.
A nurse failed to administer a prescribed multivitamin with minerals to a resident with multiple medical conditions and cognitive impairment, despite a physician order and facility policy requiring its administration. The omission was confirmed by review of records and staff interview.
A resident's liquid multivitamin, brought from home and stored in the medication refrigerator, lacked a manufacturer expiration date on its label. Staff, including an LVN and the DON, were unable to locate the expiration date despite attempts to remove facility-applied labels. The medication was administered multiple times per physician order, but its packaging did not meet facility policy or regulatory requirements for verification and labeling of medications brought in by residents or family members.
A resident with a history of major depressive disorder and a diagnosis of adjustment disorder with depressed mood did not have this diagnosis accurately reflected in their medical records or MDS, despite being prescribed antidepressant medication and having supporting psychiatric and psychologist notes. Staff interviews confirmed the omission and emphasized the importance of accurate documentation for care planning and monitoring.
A resident with pneumonia, diabetes, and dementia was not properly protected by infection control measures when a visitor assisted with care without PPE, and staff failed to provide visible EBP signage or education. Additionally, after the resident developed multiple episodes of diarrhea and was suspected of C. diff infection, staff did not initiate contact isolation or follow proper hand hygiene protocols, and the care plan lacked appropriate isolation interventions.
The facility failed to provide consistent Restorative Nursing Aide (RNA) treatment for four residents, as required by their care plans. This deficiency was observed through gaps in RNA Treatment Flow Sheets and confirmed by resident interviews, placing the residents at risk for further decline in mobility and joint function.
The facility failed to provide RNA treatments as ordered for four residents, leading to missed treatments and potential decline in mobility. Residents with various diagnoses, including dementia, muscle weakness, and arthritis, did not receive the prescribed exercises and splint applications, as documented in the RNA Treatment Flow Sheets.
The facility failed to communicate the pharmacist's recommendations to the physician for two residents, leading to the continued use of unnecessary medications. For one resident, a GDR of Escitalopram was not attempted, and for another, Pantoprazole was not gradually discontinued as recommended. The facility did not follow its policies and procedures, putting the residents at risk for adverse drug reactions.
The facility failed to act on a pharmacist's recommendation for a gradual dose reduction of Escitalopram Oxalate for a resident with depression. Despite the recommendation, no action was taken, and the physician's response was not documented, as confirmed by the DON. This failure had the potential to place other residents at risk for unnecessary medication use.
The facility failed to obtain informed consent before administering psychotropic drugs to a resident and did not perform Gradual Dose Reductions (GDR) for two other residents. One resident received Lorazepam without consent or notifying the daughter, while two other residents did not have documented GDR attempts for their prescribed medications.
The facility failed to monitor the medication refrigerator temperature and properly label opened medications, including insulin and Tuberculin, increasing the risk of administering ineffective or expired medications to residents.
The facility failed to ensure that the call lights for two residents, who had cognitive impairments and required assistance with daily activities, were within their reach. This deficiency was confirmed during an observation and interview with an LVN and acknowledged by the DON.
The facility failed to honor a 7-day bed hold for a resident transferred to a hospital, admitting a new resident to the bed on the fifth day of the hold. This violated the resident's right to return to their guaranteed bed and was against facility policy.
An LVN failed to check a resident's gastrostomy tube (G-tube) placement and patency before administering medications, as required by physician's orders. The resident, with severe cognitive impairments and multiple diagnoses, received medications without the necessary checks, which the LVN admitted to forgetting. The DON confirmed the requirement for these checks to prevent complications, and the facility's policy mandates verifying tube placement and patency.
The facility failed to provide timely nutritional interventions and monitoring for a resident who experienced severe weight loss. Delays in notifying the physician and RD, implementing IDT recommendations, and updating the care plan contributed to the resident's continued weight loss. Additionally, meal intake was inconsistently monitored and documented, and the resident was served an incorrect diet.
The facility failed to ensure the enteral feeding administration set and piston syringe were signed and dated per policy, risking infection for a resident with acute respiratory failure, pneumonia, and hypotension. The set and syringe were found undated and unsigned, and staff interviews confirmed the oversight.
The facility failed to ensure timely physician visits and assessments for two residents. One resident did not receive a required visit and history and physical (H&P) within 72 hours of admission, while another resident missed a monthly physician visit. These lapses could lead to missed medical interventions and unaddressed concerns.
The facility failed to complete a CT scan with IV contrast ordered for a resident to rule out a Clostridioides difficile/Colitis relapse diagnosis. Despite the physician's order and the facility's policy for radiology services, the scan was not performed, as confirmed by interviews and record reviews with LVN 1 and the DON.
A resident with severe cognitive impairment and significant weight loss was served an incorrect diet, contrary to the physician's orders. The error was confirmed by the RD, DS, and DON, who acknowledged the importance of serving the correct therapeutic diet to prevent malnutrition.
The facility's QAA and QAPI committee failed to ensure the administrator attended monthly meetings, as required. The administrator, along with the Infection Preventionist (IP) and the Director of Nursing (DON), did not sign the attendance sheet, which is necessary to indicate physical presence. This deficiency could hinder the committee's ability to identify and respond to systemic problems.
The facility failed to offer and administer the influenza and pneumococcal vaccines to two residents. One resident, who was dependent on others for daily activities, did not receive the vaccines, and another resident, who had signed a consent form, also did not receive the vaccines. The IPN admitted to not administering the flu vaccine outside the flu season and was unsure about obtaining consent for the first resident. The DON confirmed that it was the IPN's responsibility to ensure vaccines were offered and administered within 72 hours of obtaining consent.
The facility failed to administer the COVID-19 vaccine to a resident who had signed the consent form. The resident, admitted with hypertension, falls, and spinal stenosis, did not receive the vaccine within the required 72-hour window. The IPN acknowledged the oversight, and the DON confirmed it was the IPN's responsibility to ensure timely vaccination as per facility policy.
Inaccurate I&O Documentation for Resident With Indwelling Catheter
Penalty
Summary
Facility staff failed to accurately document intake and output (I&O) for a resident admitted with an indwelling urinary catheter. The resident had a diagnosis of urinary retention and, per the History and Physical, did not have the capacity to understand and make decisions, with fluctuating capacity. The Minimum Data Set indicated the resident required supervision with toilet hygiene. The resident’s care plan, dated 1/7/2026, identified the presence of an indwelling urinary catheter due to urinary retention, with a goal for the resident to remain free from catheter-related trauma and show no signs or symptoms of urinary tract infection. The care plan interventions included monitoring and documenting I&Os and monitoring for signs and symptoms of discomfort and frequency of urination. Record review of the Medication Administration Record from 1/3/2026 showed that, for multiple consecutive days and shifts, the resident’s I&O was documented only as “x2” rather than in measured amounts. Specifically, from 1/4/2026 to 1/16/2026, day and evening shifts documented I&O as “x2,” and night shifts documented “x2” from 1/4/2026 to 1/8/2026 and 1/10/2026 to 1/16/2026. In interviews, an RN stated that documenting urine output as “x2” was not an appropriate way to measure urine output for a resident with an indwelling catheter, explaining that the urinary bag should be emptied, measured, and recorded. The DON stated that CNAs empty the urinary bags and report the amount to the licensed nurse, and that licensed nurses are expected to document the urine output on the MAR in cubic centimeters (cc), not as “x1” or “x2.” The facility’s policy on Intake and Output Documentation, revised 1/2015, required that fluid intake and output be recorded for each resident with an indwelling catheter, with intake and output information recorded at the end of each shift by a licensed nurse.
Failure to Honor Continent Resident’s Toileting Needs and Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a continent resident did not lose the ability to perform activities of daily living, specifically toileting, without a medical reason. The resident was admitted with diagnoses including essential HTN, spinal stenosis, and type 2 DM without complications, and the H&P documented that he had the capacity to understand and make decisions. An MDS assessment showed he required substantial/maximal assistance with sit-to-lying and was dependent for toilet and tub/shower transfers and sit-to-stand, while a bowel and bladder evaluation documented that he was continent. His care plan identified ADL deficits related to spinal stenosis and directed staff to provide two-person assistance with toilet transfers and to encourage him to participate to the fullest extent possible with each interaction. Despite these assessments and care plan directives, the resident was observed wearing an adult brief and reported that staff had placed him in the brief and told him to use the restroom in it. He stated that a nurse told him to urinate in the adult brief instead of using other options such as a bedpan or bedside commode, and he described difficulty urinating and feeling like a baby when made to wear the brief. A CNA reported that she put an adult brief on the resident because he urinated everywhere when using a urinal and stated she puts adult briefs on all her residents unless instructed otherwise. An RN confirmed that the resident was continent and did not need briefs and should be allowed to use a bedside commode if that was his preference. The DSD stated that continent residents should not be made to wear adult briefs and acknowledged that placing diapers on continent residents and telling them to go in them could cause them to lose the urge to control their bladder. The facility’s resident rights policy stated that all residents are to be treated with kindness, dignity, and respect.
Medications Left Unattended and Not Administered as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as prescribed and not left unattended, resulting in one resident not receiving ordered medications. The resident had diagnoses including essential primary HTN, unspecified a-fib, and anemia, and required supervision with toilet hygiene and showering/bathing, but was independent with eating and oral hygiene. The resident’s MAR for a specific date in February 2026 showed that multiple medications, including chlorthalidone, ferrous sulfate, memantine HCL, a multivitamin, docusate sodium, and hydrochlorothiazide, were documented as administered at 9:00 a.m. However, observation later that morning showed that a medication cup containing six pills remained on the resident’s bedside table at 10:00 a.m. and again at 11:29 a.m., indicating the medications had not been ingested. An LVN reported that she had placed the medication cup with pills on the bedside table and left the room because she was called to assist another resident, acknowledging that this was not her usual practice and that medications should not be left unattended. The DON confirmed that licensed nurses were not to leave medications unattended at the bedside. The facility’s medication administration policy stated that if a resident is unavailable to receive medications, the MAR should be flagged and the nurse should return after the medication pass to administer the dose and observe the resident to ensure it is completely ingested.
False MAR Documentation After Medications Left Unadministered at Bedside
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for one resident when an LVN signed the Medication Administration Record (MAR) indicating medications were given, although they were not administered. The resident, who had diagnoses including essential primary hypertension, unspecified atrial fibrillation, and anemia, was care planned as requiring supervision with toilet hygiene and bathing, and being independent with eating and oral hygiene. The resident’s February MAR showed that on 2/11/2026 at 9:00 a.m., multiple medications were scheduled, including chlorthalidone 50 mg (½ tablet) for CHF, ferrous sulfate 325 mg, memantine HCL 5 mg, a multivitamin, docusate sodium 100 mg, and hydrochlorothiazide 50 mg. The MAR for that date indicated that chlorthalidone, ferrous sulfate, memantine, docusate sodium, and hydrochlorothiazide were documented as administered at 9:55 a.m. However, surveyor observations on 2/11/2026 showed that at 9:45 a.m. LVN 1 entered the resident’s room with a medication cup and then left the room, and at 10:00 a.m. and again at 11:29 a.m. the same medication cup with six pills remained on the bedside table, indicating the medications had not been taken. In an interview, LVN 1 stated she had placed the medication cup with pills on the bedside table and left because she was called to assist another resident, acknowledged it was not her usual practice to leave medications unattended, and admitted she should not have signed the MAR indicating the resident received the medications when they had not been administered. The DON confirmed that the correct process is “pour-pass-chart,” and that signing the MAR before administering medications constitutes false documentation. The facility’s medication administration policy stated that missed medications should be flagged on the MAR and documented immediately after administration by the person who gives the dose.
Failure to Individualize Fall Prevention Care Plans and Investigate Falls for Cognitively Impaired High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement effective, measurable care plan interventions for two cognitively impaired residents at high risk for falls, and failure to investigate falls and causal factors as required. Resident 1 was admitted with multiple conditions including diabetes mellitus, speech and language deficits, repeated falls, hemiplegia and hemiparesis following a stroke, and was assessed on the MDS as having severe cognitive impairment. He was dependent on staff for toileting hygiene, required moderate assistance for personal hygiene, and maximum assistance for walking up to 10 feet. His fall risk assessment identified him as high risk for falls. His At Risk for Falls care plan, dated 10/5/2025, identified poor balance and gait as risk factors and included interventions such as ensuring the call light was within reach and encouraging him to use it for assistance. On 10/13/2025, Resident 1 fell in the restroom. The SBAR and Post-Event IDT Review documented that he was found on the restroom floor and reported that his foot became stuck between the wheelchair while trying to wash his hands, causing him to lose balance and fall. He also stated he did not want to use the call light because he did not want to bother anyone and thought he could manage by himself. An Actual Fall care plan dated 10/13/2025 identified the fall as due to poor balance and set a goal for him to resume usual activities without further incident, with interventions including educating him to call for assistance when needed. Despite this, a subsequent SBAR dated 10/28/2025 documented that he was found sitting on the floor mat after falling from the left side of the bed while turning. Staff interviews revealed that Resident 1 was sometimes confused, always needed assistance to walk, used a cane and wheelchair, and, according to CNA 1, had never used the call light. RN 1 stated that Resident 1 was a high fall risk who would get up unassisted even when encouraged to use the call light. Resident 2 was also identified as high risk for falls and severely cognitively impaired. His diagnoses included encephalopathy, dementia, altered mental status, and a history of unspecified fall. The MDS indicated severe cognitive impairment and a need for moderate assistance with ambulation up to 10 feet. His fall risk assessment also identified him as high risk. An At Risk for Falls care plan dated 11/13/2025 cited dementia, right eye cataract, and history of falls as contributing factors, with goals to minimize risk of injury and interventions including keeping the call light within reach and encouraging him to use it for assistance. A PT note dated 11/21/2025 documented that he required contact guard assistance for mobility. On 11/22/2025, a nursing note recorded that he had an unwitnessed fall and was found sitting on the floor in his room after stating he fell on his buttocks when attempting to sit down. An Actual Fall care plan dated 11/22/2025 set a goal for him to resume usual activities without further incident and included interventions to determine and address causative factors of the fall. Interviews with staff highlighted inconsistencies and failures in implementing appropriate, individualized interventions and in investigating falls. CNA 1 reported that Resident 1 never used the call light and that she checked on him at least once an hour if possible. CNA 2 stated that Resident 1 liked to be independent, ambulated in his room, and went to the bathroom by himself, and that due to a past fall they were told to keep an eye on him, which she interpreted as checking at least once an hour, though this was not specified. CNA 2 also stated that Resident 2 ambulated on his own and required assistance only to the restroom, while the Director of Rehabilitation stated Resident 2 was not allowed to walk alone and needed someone within arm’s reach when ambulating because of high fall risk, cognition, and need for moderate assistance. The DOR stated that rehab did not evaluate Resident 1 after his second fall on 10/28/2025 and therefore had not discussed this with the IDT. The DON acknowledged that both residents had cognitive impairment and was unsure if they had been assessed for their ability to understand and follow instructions on using the call light, and stated that because they had not used the call light when needing help, the intervention was ineffective and other interventions such as more frequent rounds and monitoring should have been in place. The DON also stated that Post-Event IDT notes and investigations were not completed after Resident 1’s second fall on 10/28/2025 or Resident 2’s fall on 11/22/2025, despite facility policies requiring comprehensive person-centered care planning with measurable interventions and IDT review of fall incidents to determine probable causal factors.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for four out of five sampled residents, resulting in inaccurate documentation of their health status and care needs. For one resident, the MDS was incorrectly coded as always incontinent with urinary continence, despite the resident being alert, oriented, and able to communicate the need to use the restroom. The MDS Coordinator acknowledged that the assessment was coded incorrectly and that this could lead to an inappropriate plan of care. Another resident's MDS did not accurately reflect an active diagnosis of a mood disorder, even though psychiatric and psychological evaluations documented major depressive disorder and adjustment disorder with depressed mood, and the resident was prescribed an antidepressant. The MDS Coordinator and the Director of Nursing both confirmed that the MDS should have included the mood disorder diagnosis to ensure care plans were based on accurate information. Additionally, the MDS for a third resident failed to document the use of bed and chair sensor alarms, which were ordered and in use as safety devices. The MDS Coordinator admitted to omitting this information, and the Director of Nursing stated that such alarms should be documented in the MDS to ensure appropriate monitoring and safety. For a fourth resident, the MDS listed schizophrenia and depression as diagnoses, but psychiatric evaluations and medication orders indicated bipolar disorder and depression, with no evidence of schizophrenia. Both the MDS Coordinator and the Director of Nursing recognized the inaccuracy, noting that it could affect the resident's treatment plan.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific needs. For one resident with severe cognitive impairment and multiple physical dependencies, there were physician orders for bed and chair sensor alarms to alert staff when the resident attempted to get up unassisted. Despite these orders and the presence of the devices, the resident's care plan did not address the use, monitoring, or effectiveness of the sensor alarms. Both the MDS Coordinator and the Director of Nursing confirmed that the care plan lacked necessary interventions and guidance for staff regarding the alarms. Another resident, who was dependent on staff for most activities of daily living and had a history of cerebral infarction and muscle weakness, refused to get out of bed and participate in activities for three consecutive days. Although the care plan included interventions for pressure ulcer prevention that required the resident to get out of bed unless contraindicated, there was no care plan developed to address the resident's ongoing refusal to get out of bed. Staff interviews confirmed that refusals were reported to nursing staff and the physician, but the care plan was not updated to reflect this issue or guide staff response. The facility's policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes based on the resident's assessment. In both cases, the facility did not ensure that the care plans addressed all identified needs and physician orders, resulting in a lack of individualized interventions and measurable actions for the residents involved.
Failure to Implement Antibiotic Stewardship Program and Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two residents, resulting in deficiencies related to the monitoring and assessment of antibiotic use. For one resident with pneumonia, diabetes, and dementia, Zosyn was administered intravenously following transfer from a hospital. Documentation revealed that the indication for use and infection surveillance assessment were not completed as required. The Infection Preventionist (IPN) admitted to not performing the necessary infection surveillance or reassessment (antibiotic time-out) to determine if the antibiotic was still indicated, and was unsure if the use met McGeer's Criteria. The Director of Nursing (DON) later confirmed that the criteria were not met, but the antibiotic course had already been completed without proper assessment or documentation. For another resident with a history of asthma, hypertension, atrial fibrillation, and hyperlipidemia, daptomycin was ordered and administered intravenously for a right hip wound MRSA infection. While an initial infection surveillance assessment was completed at the start of therapy, the resident was not included in the antibiotic stewardship binder, which tracks residents on antibiotics. No subsequent monitoring or reassessment was performed to determine the ongoing need or effectiveness of the antibiotic. Both the IPN and DON acknowledged that there was no follow-up or ongoing monitoring for this resident while on the antibiotic, and the resident was not tracked as required by facility policy. The facility's own policy and procedure for antibiotic stewardship requires that all antibiotic use be monitored, assessed for indication, dose, and duration, and that ongoing surveillance and reassessment (antibiotic time-out) be performed. The policy also mandates that all residents on antibiotics be tracked and reviewed for appropriate use. In both cases, these procedures were not followed, resulting in a failure to ensure appropriate and necessary use of antibiotics for the affected residents.
Failure to Develop Policy and Monitor Use of Sensor Alarm Pads
Penalty
Summary
The facility failed to develop and implement a policy for the use of sensor alarm pads and did not ensure consistent monitoring and documentation of their use for a resident identified as being at high risk for falls. The resident in question had significant cognitive impairment and required maximal assistance with mobility and self-care tasks. Medical records indicated that sensor alarm pads were ordered for both bed and wheelchair use, with informed consent obtained from the responsible party. However, documentation in the Medication Administration Record (MAR) showed missing entries for several shifts, indicating that monitoring of the sensor alarm pads was not consistently performed or recorded. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed that there was no existing policy or procedure for the use of bed and chair sensor alarm pads. Both staff members acknowledged that monitoring should occur every shift and be documented to ensure the devices were functioning and in place. The absence of a policy and inconsistent documentation of monitoring placed the resident at risk, as the intervention was not reliably implemented or tracked.
Failure to Provide Bowel and Bladder Retraining Program for Incontinent Resident
Penalty
Summary
A deficiency was identified when a resident with diagnoses including schizophrenia, overactive bladder, and depression, who was alert, oriented, and had intact cognition, was not provided with a bowel and bladder retraining or toileting program despite being incontinent of bowel and bladder. The resident's Minimum Data Set (MDS) assessments consistently indicated frequent urinary incontinence and occasional bowel incontinence, yet there was no evidence of a structured retraining program in place. Interviews with staff, including the MDS Coordinator, CNA, LVN, and DON, confirmed that the resident was a candidate for such a program and would benefit from it, but the facility did not have an active program at the time. Record reviews showed that the resident's Bowel and Bladder Evaluations scored the resident as a possible candidate for retraining on two separate occasions. Despite this, there was no care plan addressing bowel and bladder retraining, no physician's order for the program, and no documentation of a formal retraining program being initiated. The facility's policy required assessment and initiation of retraining for appropriate candidates, but the policy was outdated and not being followed. The lack of a retraining program was further corroborated by staff interviews, where it was acknowledged that the resident should have been placed in such a program. The DON admitted the policy was outdated and that staff had not been in-serviced on the retraining program. The absence of a care plan, physician's order, and structured approach to bowel and bladder retraining for the resident constituted the deficiency.
Failure to Administer Prescribed Multivitamin with Minerals
Penalty
Summary
A deficiency occurred when a licensed vocational nurse failed to administer a prescribed multivitamin with minerals to a resident during medication administration. The resident's physician order required the administration of a multivitamin with minerals, but this medication was omitted during the observed medication pass. Review of the Medication Administration Record for the month showed that the multivitamin with minerals was not documented as given. The nurse later confirmed in an interview that she forgot to administer the medication. The resident involved had a history of multiple medical conditions, including hypertension, arthritis, atrial fibrillation, and a recent fall with a mild anterior wedge compression fracture. The resident required maximal assistance with activities of daily living and had moderately impaired cognition. The facility's policy required medications to be administered as prescribed, but this was not followed in this instance, resulting in the resident not receiving the ordered supplement.
Failure to Ensure Proper Labeling and Storage of Resident's Multivitamin
Penalty
Summary
The facility failed to ensure that a resident's multivitamin liquid bottle was labeled with a manufacturer expiration date, as required by both manufacturer specifications and the facility's own policies and procedures. During an inspection of the medication room, surveyors observed a bottle of Marry Ruth's Liquid Morning Multivitamin Hair Growth stored in the medication refrigerator without a visible manufacturer expiration date. The bottle had a facility-applied handwritten label with the resident's information and an open date, but neither the LVN nor the DON could locate the manufacturer's expiration date, even after attempting to remove the facility label. The DON confirmed the importance of the expiration date for determining the safety and effectiveness of the medication and acknowledged that the multivitamin was a home medication brought in by the resident, but could not verify its source. Further review of the resident's records indicated that the resident had severe cognitive impairment and required significant assistance with activities of daily living. The multivitamin was being administered per physician order, and documentation showed it had been given multiple times. Interviews with staff confirmed that the medication was brought in sealed by the resident, but without an expiration date, staff could not determine how long the product had been in use. Facility policy required that medications brought in by residents or family members must have contents verified and packaging that meets state, federal, and pharmacy guidelines, and that medications be stored according to manufacturer recommendations to maintain integrity and safety. These requirements were not met in this instance.
Failure to Accurately Document Resident's Mood Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that an accurate medical diagnosis was documented for one of three sampled residents by not reflecting a diagnosis of adjustment disorder with depressed mood in the resident's records. The resident in question was admitted and readmitted with several medical diagnoses, including hypertension, hyperlipidemia, diabetes mellitus, and glaucoma. However, despite psychiatric and psychologist consultation notes indicating a diagnosis of adjustment disorder with depressed mood and a history of major depressive disorder, this diagnosis was not included in the resident's admission record or in the active diagnoses section of the Minimum Data Set (MDS). The MDS assessment indicated that the resident had moderate cognitive impairment and required varying levels of assistance with self-care activities. The resident was also taking an antidepressant medication, yet the corresponding mood disorder diagnosis was missing from the MDS. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the diagnosis should have been documented in the resident's medical records to ensure care planning, monitoring, and appropriate treatment. Both staff members acknowledged the importance of accurate and up-to-date diagnoses for effective care and to prevent confusion. A review of the facility's policy on resident assessment and documentation showed that comprehensive and accurate assessments are required, with findings to be documented in the clinical health record. The failure to document the resident's adjustment disorder with depressed mood resulted in an incomplete and inaccurate reflection of the resident's condition in the medical record, which could impact the provision of necessary care and services.
Failure to Implement Infection Control Measures for Resident on Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident with multiple health conditions, including pneumonia, diabetes mellitus, and dementia. During an observation, a visitor was seen assisting the resident with repositioning without wearing any personal protective equipment (PPE) such as a mask, gown, or gloves, despite the resident being on Enhanced Barrier Precautions (EBP). The EBP signage was not placed in a visible location, and neither staff nor signage provided adequate education or instruction to the visitor regarding the need for PPE. Staff members also acknowledged that the signage was not easily visible and that they had not educated the visitor about PPE requirements. Additionally, the facility did not place the resident on contact isolation after the resident experienced multiple episodes of diarrhea and while awaiting lab results for possible Clostridium difficile infection. There was no isolation signage or isolation cart present, and staff did not implement contact precautions as required by facility policy. A nurse performed hand hygiene with sanitizer instead of soap and water after providing care, contrary to policy for suspected C. diff cases. The care plan for the resident addressed diarrhea with medication and fluid intake but did not include interventions for contact isolation precautions. Interviews with staff, including the Infection Preventionist Nurse and Director of Nursing, confirmed that the required infection control measures were not followed. Staff acknowledged that both staff and visitors should have been educated and required to use PPE, and that the resident should have been placed on contact isolation while awaiting lab results. Facility policies reviewed indicated clear procedures for EBP and contact precautions, which were not implemented in this case.
Failure to Provide Consistent RNA Treatment
Penalty
Summary
The facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM) and/or mobility for four residents. Specifically, the facility did not ensure that these residents received Restorative Nursing Aide (RNA) treatment five times a week as indicated in their care plans. This failure was observed in the cases of Residents 11, 20, 30, and 43, who had various diagnoses including dementia, major depressive disorder, osteoarthritis, muscle wasting, Alzheimer's disease, rheumatoid arthritis, and abnormalities of gait and mobility. Resident 11's care plan required RNA assistance with bilateral upper and lower extremity exercises five times a week. However, the RNA Treatment Flow Sheet for April 2024 showed no documentation of RNA therapy on several days, indicating that the treatment was not completed as ordered. Similarly, Resident 12's care plan included RNA assistance with ROM and ambulation five times a week, but the RNA Treatment Flow Sheet also showed gaps in documentation, indicating non-compliance with the care plan. Resident 30's care plan included the use of bilateral upper extremity resting hand splints and bilateral upper and lower extremity exercises five times a week. However, the RNA Treatment Flow Sheet for March 2024 showed no documentation for several days, and Resident 30 confirmed in interviews that the therapy was not consistently provided. Resident 43's care plan required RNA assistance with bilateral upper and lower extremity exercises five times a week, but the RNA Treatment Flow Sheet for April 2024 also showed gaps in documentation. Interviews with the Director of Rehab and the Director of Nursing confirmed that the lack of RNA therapy placed residents at risk for further decline in mobility and joint function.
Failure to Provide Ordered RNA Treatments
Penalty
Summary
The facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM) and/or mobility for four residents. Specifically, Residents 11, 12, 30, and 43 did not receive Restorative Nursing Aide (RNA) treatment five times a week as ordered. This failure was observed through blank documentation in the RNA Treatment Flow Sheets for multiple days, indicating that the prescribed treatments were not administered as required. Resident 11, who has diagnoses including major depressive disorder, dementia, osteoarthritis, and muscle wasting, was supposed to receive RNA assistance with bilateral upper and lower extremity exercises five times a week. However, the RNA Treatment Flow Sheet for April 2024 showed blank sections on several days, indicating missed treatments. Similarly, Resident 12, diagnosed with difficulty in walking, muscle weakness, major depressive disorder, and Alzheimer's disease, also did not receive the ordered RNA treatments as documented in the RNA Treatment Flow Sheet. Resident 30, with diagnoses including rheumatoid arthritis, polyneuropathies, muscle weakness, and abnormal posture, was ordered to have bilateral upper extremity resting hand splints and active range of motion exercises five times a week. The RNA Treatment Flow Sheet indicated that these treatments were not completed on multiple days. Resident 43, diagnosed with a left femur fracture, abnormalities of gait and mobility, and dementia, also did not receive the ordered RNA treatments as documented. Interviews with the Director of Rehab and the Director of Nursing confirmed that the lack of RNA services placed residents at risk for further decline in mobility.
Failure to Communicate Pharmacist's Recommendations
Penalty
Summary
The facility failed to communicate the consultant pharmacist's recommendations to the physician for two residents, leading to the continued use of unnecessary medications. For Resident 20, the facility did not attempt a gradual dose reduction (GDR) of Escitalopram, a medication for depression, as recommended by the pharmacist. The Director of Nursing (DON) confirmed that there was no documentation indicating that the physician was notified of or responded to the pharmacist's recommendation for the GDR attempt, resulting in no GDR being performed for Resident 20. For Resident 13, the facility did not communicate the pharmacist's recommendation to gradually discontinue Pantoprazole, a medication that reduces stomach acid, to the physician. The pharmacist had recommended tapering the medication due to potential side effects and suggested an alternative medication. However, the section of the note for the physician's response was left blank, indicating that the recommendation was not relayed to the physician. The DON confirmed that the charge nurses were responsible for relaying the recommendations but failed to do so in this case. The facility's policies and procedures indicated that the consultant pharmacist's recommendations should be acted upon and documented by the facility staff and/or the prescriber. However, the facility did not follow these procedures, resulting in the residents' continued use of potentially harmful medications. The DON acknowledged that the failure to communicate the recommendations put the residents at risk for adverse drug reactions and negative health outcomes.
Failure to Act on Pharmacist's Recommendation for Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure that licensed nurses acted upon the Pharmacists' Consultation Report by notifying Resident 20's physician about the pharmacist's recommendation to attempt a gradual dose reduction (GDR) of Escitalopram Oxalate, a medication used to treat depression. Resident 20, who had diagnoses including diabetes mellitus, end-stage renal disease, and depression, was receiving Escitalopram Oxalate 5 mg daily. The Minimum Data Set (MDS) indicated that Resident 20 had intact cognition and was receiving both antianxiety and antidepressant medications during the assessment period. Despite the pharmacist's recommendation for a GDR on 2/5/2024, no action was taken, and the physician's response to the recommendation was not documented, as confirmed by the Director of Nursing (DON) during an interview and record review on 4/7/2024. The facility's policy and procedure required that the consultant pharmacist's recommendations be acted upon within a reasonable timeframe, but this was not followed in Resident 20's case. The failure to act on the pharmacist's recommendation resulted in the recommended GDR not being performed for Resident 20, which had the potential to place other residents receiving antidepressant medications at risk for unnecessary medication use. The facility's policies, including the Medication Regimen Review and Reporting policy and the Consultant Pharmacist Reports policy, emphasized the importance of acting on and documenting the consultant pharmacist's recommendations to prevent or minimize adverse consequences related to medication therapy. However, these policies were not adhered to, leading to the deficiency noted in the report.
Failure to Obtain Informed Consent and Perform Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic drugs to one resident and did not perform Gradual Dose Reductions (GDR) for two other residents. Resident 35 was administered Lorazepam multiple times without the required informed consent and without notifying the resident's daughter as specified in the physician's order. The resident's medical records indicated that the informed consent form was not signed or completed, and there was no documentation of the daughter being informed prior to medication administration. Resident 5, who had diagnoses including fibromyalgia, diabetes mellitus, and anxiety disorder, was prescribed Ativan for anxiety. However, there was no documentation of a GDR being attempted since the medication was ordered. The Director of Nursing (DON) confirmed that there was no record of a GDR being performed for Resident 5. Resident 20, diagnosed with diabetes mellitus, end-stage renal disease, and depression, was prescribed Escitalopram for depression. The facility's records showed that a pharmacist recommended a GDR, but there was no documentation of the physician's response or any GDR attempt. The DON acknowledged that no GDR was performed for Resident 20. The facility's policy required informed consent and GDRs for psychotropic medications, but these procedures were not followed in these cases.
Failure to Monitor and Label Medications Properly
Penalty
Summary
The facility failed to ensure proper monitoring and labeling of medications, leading to potential risks for residents. On 4/5/2024, the medication refrigerator temperature was not monitored as required by the facility's policy, which could result in medications being exposed to extreme temperatures and losing their effectiveness. This was confirmed during an interview with an LVN, who acknowledged the lapse in monitoring and the potential consequences of not knowing if the temperature was out of range for the stored medications. Additionally, the facility did not label opened medications with the required open dates. Specifically, Resident 52's Insulin Glargine and Insulin Lispro Kwikpen were found open but not labeled with an open date, contrary to the facility's policy and the manufacturer's requirements. This oversight increased the risk of administering ineffective or expired medications to Resident 52, who has a history of metabolic encephalopathy, diabetes mellitus type 2, and seizures. The LVN confirmed that these medications need to be labeled with an open date to ensure they are used within their effective period. Furthermore, a multi-dose vial of Tuberculin was found open but not labeled with an expiration date. According to the manufacturer's guidelines, Tuberculin must be stored in the refrigerator for up to 30 days once opened. The LVN and the DON both acknowledged that failing to label the medication with an open date could lead to the administration of expired medications, posing health risks to residents. The facility's policy clearly states that medications should include the date of opening on the container or vial, which was not followed in these instances.
Failure to Ensure Call Lights Within Residents' Reach
Penalty
Summary
The facility failed to ensure that the call lights for two residents, Resident 8 and Resident 155, were within their reach. Resident 8, who had severe cognitive impairment and required substantial assistance with daily activities, was observed with their call light hanging on the headboard, out of reach. Similarly, Resident 155, who had moderate cognitive impairment and was dependent on staff for various activities, had their call light hanging on the wall, also out of reach. This deficiency was confirmed during an observation and interview with LVN 4, who acknowledged the issue and moved the call lights within reach of the residents. The Director of Nursing (DON) confirmed that call lights need to be within residents' reach to ensure their needs are met. The facility's policy, revised in 2007, also indicated that call devices should be within residents' reach to provide a means of communication with nursing staff. The failure to adhere to this policy was identified through a review of the residents' admission records and Minimum Data Set (MDS) assessments, which highlighted their cognitive impairments and need for assistance with daily activities.
Failure to Honor 7-Day Bed Hold for Resident
Penalty
Summary
The facility failed to honor a 7-day bed hold for a resident (Resident 37) who was transferred to a General Acute Care Hospital (GACH) due to a critical laboratory result. Despite a physician's order for a 7-day bed hold, the facility admitted a new resident to Resident 37's bed on the fifth day of the bed hold. This action violated the resident's right to return to their guaranteed bed and was against the facility's policy and procedure for bed hold. The receptionist, responsible for updating the census, admitted to making beds on hold available for new admissions after consulting with the Director of Nursing (DON) or Administrator, despite being unsure if this practice was correct. The DON confirmed that the facility accommodates new admissions by giving away beds that are on hold, even though the Centers for Medicare and Medicaid Services (CMS) pays to reserve these beds for the residents' return within the 7-day period. Resident 37 had been admitted to the facility with diagnoses including acute respiratory failure with hypoxia and essential primary hypertension. The resident required maximal assistance for various activities of daily living and had the capacity to understand and be understood by staff. The facility's policy and procedure for bed hold, dated December 2023, clearly stated that residents or their representatives would be notified in writing of their right to a 7-day bed hold upon admission and before any transfer. However, this policy was not followed, resulting in the resident's bed being occupied by another individual, leaving no available bed for Resident 37 upon their potential return from the hospital.
Failure to Check G-Tube Placement and Patency Before Medication Administration
Penalty
Summary
Licensed Vocational Nurse (LVN) 3 failed to check for gastrostomy tube (G-tube) placement and patency per the physician's orders before administering medications to Resident 1. Resident 1, who has severe cognitive impairments and multiple diagnoses including cerebral palsy and seizure disorders, was observed receiving medications through the G-tube without the required checks for correct placement and patency. LVN 3 admitted to forgetting to perform these checks, which involve injecting air into the G-tube, listening for a whooshing sound, and withdrawing gastric residual to ensure the tube is correctly placed and open. The Director of Nursing (DON) confirmed that licensed nurses are required to check G-tube placement and patency before administering medications to prevent potential complications such as infection and unnecessary hospitalization. The facility's policy and procedure for medication administration via enteral tubes also mandates verifying tube placement by inserting air and listening for gurgling sounds, as well as aspirating stomach contents. The LVN's job description includes responsibilities for maintaining established procedures and administering services within the applicable scope of nursing practice, which encompasses tube feedings and other related tasks.
Failure to Provide Timely Nutritional Interventions and Monitoring
Penalty
Summary
The facility failed to provide quality care and services in accordance with professional standards for Resident 8, who experienced severe weight loss. The facility did not notify the physician and Registered Dietician (RD) immediately after identifying significant weight loss on two occasions. Specifically, a 9.73% weight loss was identified on 2/5/2024, but the physician and RD were not notified until 2/8/2024. Similarly, a 7.7% weight loss was identified on 4/5/2024, but the physician and RD were notified only on 4/6/2024. This delay in notification hindered timely intervention for Resident 8's nutritional needs. The Interdisciplinary Team (IDT) made recommendations on 2/8/2024, but these were not implemented until 2/17/2024, twelve days after the initial weight loss was identified. As a result, Resident 8 did not receive the prescribed nutritional supplement, Boost Glucose Control, or the appetite stimulant, Megestrol Acetate Suspension, in a timely manner. Additionally, the No Added Salt (NAS) portion of Resident 8's diet was not removed until 2/17/2024. This delay in implementing the IDT's recommendations contributed to Resident 8's continued weight loss. Furthermore, the facility failed to consistently monitor and document Resident 8's meal intake as required by the care plan. Out of 177 meals, 50 meals were not monitored, and the amount eaten was not recorded. Additionally, on 4/7/2024, Resident 8 was served an incorrect diet that included NAS, contrary to the ordered diet. The Nutrition care plan was also not updated in a timely manner, with a significant delay of one month after the severe weight loss was identified. These deficiencies resulted in Resident 8 experiencing a total weight loss of 37 lbs. from 1/5/2024 to 4/5/2024, placing the resident at higher risk for malnutrition and other health complications.
Failure to Adhere to Enteral Feeding Set Change Policy
Penalty
Summary
The facility failed to ensure the enteral feeding administration set and piston syringe were signed and dated per the facility's policy and procedure, which is crucial to prevent complications of gastrostomy tube use. This deficiency was observed in the case of a resident who was admitted with acute respiratory failure, pneumonia, and hypotension. The resident's Minimum Data Set indicated that they were rarely or never understood by others and were dependent on assistance for various activities of daily living. The physician's order required the enteral administration set to be changed with every formula bottle change, but during an observation, the set and syringe were found undated and unsigned. During an interview, an LVN confirmed that the administration set and syringe should be changed with each formula change and that the lack of dating and signing made it unsafe to determine when the last change occurred. The Director of Nursing also stated that LVN charge nurses are responsible for ensuring the administration set and syringe are changed daily to prevent contamination and infection. The facility's policy, revised in December 2023, indicated that all accessories, including syringes, should be cleaned after each use and replaced daily, which was not adhered to in this case.
Failure to Ensure Timely Physician Visits and Assessments
Penalty
Summary
The facility failed to ensure that the primary care physician visited Resident 37 to assess and continue admission orders from the hospital and complete a history and physical (H&P) within the required timeframe. Resident 37 was admitted with serious conditions including acute respiratory failure, hypertension, and benign prostatic hyperplasia. Despite the requirement for the physician to visit within 72 hours of admission, the H&P was not completed, and the physician's orders were not signed. The Corporate Medical Records staff acknowledged the oversight and stated it was their responsibility to audit and ensure timely physician visits, which did not occur in this case. The Director of Nursing (DON) also confirmed the lapse and emphasized the importance of timely physician evaluations to provide appropriate care and services to the resident. The facility also failed to ensure that Resident 29's physician conducted a monthly visit for the month of March 2024. Resident 29, who had diagnoses including a fracture of the left femur, osteoarthritis, and abnormalities of gait and mobility, had not seen her physician since February 2024. The resident expressed a desire to discuss her care with her physician but had not been able to do so. The facility's policy requires monthly physician visits, but there was no documentation indicating that the physician was notified of the missed visit. The DON confirmed that all residents are required to be seen by their physician monthly, and the facility's policy supports this requirement. These deficiencies highlight the facility's failure to adhere to regulatory requirements for timely physician visits and assessments, potentially impacting the quality of care provided to the residents. The lack of timely physician evaluations and documentation could lead to missed medical interventions and unaddressed concerns from the residents, as evidenced by the cases of Resident 37 and Resident 29.
Failure to Complete Ordered CT Scan for Resident
Penalty
Summary
The facility failed to ensure that a computed tomography (CT) scan with intravenous (IV) contrast, ordered on 3/14/2024, was completed for Resident 48. The CT scan was intended to rule out a Clostridioides difficile/Colitis relapse diagnosis with diarrhea. Resident 48, who was admitted with diagnoses including infectious gastroenteritis, colitis, and cystitis without hematuria, had moderate cognitive impairment and required various levels of assistance with daily activities. Despite the physician's order, there was no documented evidence that the CT scan was completed, as confirmed during interviews and record reviews with Licensed Vocational Nurse 1 (LVN 1) and the Director of Nursing (DON). Both LVN 1 and the DON acknowledged that the CT scan should have been completed to identify any acute problems. The facility's policy indicated that upon receiving an order for radiology services, a mobile unit would be dispatched to the facility. However, this procedure was not followed in the case of Resident 48. The facility's Facility Assessment Tool, updated on 8/10/2023, also indicated that radiology services were provided through contractual agreements for both routine and urgent needs. The failure to complete the CT scan as ordered had the potential to result in an undiagnosed problem, placing Resident 48 at higher risk for physical decline.
Failure to Provide Correct Therapeutic Diet
Penalty
Summary
The facility failed to ensure that Resident 8 received the ordered Consistent Carbohydrate Diet (CCHO) with regular texture, thin liquids consistency, fortified, and chopped meat. On the observed date, Resident 8 was served a breakfast tray that did not include a salt packet, which was part of the prescribed diet. The diet profile card on the tray indicated a CCHO no added salt (NAS) diet, which did not match the physician's order. This discrepancy was confirmed by the Registered Dietician (RD) and the Dietary Supervisor (DS), who acknowledged that the incorrect diet was served to Resident 8. The Director of Nursing (DON) also confirmed the error and emphasized the importance of serving the correct therapeutic diet to prevent malnutrition. Resident 8's medical history includes sepsis, muscle weakness, dysphagia, mild calorie protein-calorie malnutrition, schizophrenia, diabetes mellitus, and dementia. The resident had severe cognitive impairment and required substantial assistance with daily activities, including eating and oral hygiene. The Minimum Data Set (MDS) indicated that Resident 8 had experienced significant weight loss, losing more than 5 percent of body weight in the last month. The facility's policy and procedure titled Diet Orders, 2023, mandates that diet orders prescribed by the physician be provided by the Food and Nutrition Services Department, which was not adhered to in this instance.
Failure to Ensure Administrator Attendance at QAPI Meetings
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to ensure the facility's administrator attended the monthly meetings. During an entrance conference with the Director of Nursing (DON), it was revealed that the administrator was present during the meetings but did not sign the attendance sheet. Additionally, neither the Infection Preventionist (IP) nor the DON signed the attendance sheet, which is required to indicate physical presence at the meeting. A review of the facility's 2024 QAPI Plan indicated that the Administrator and the QA Committee of the governing body are responsible for integrating the QAPI plan. The Administrator has direct oversight for all functions of the QAPI committee and reports directly to the governing body. Despite receiving training on QAPI and using various resources for research, the Administrator did not fulfill the responsibility of ensuring proper documentation of attendance at the QAPI meetings. This deficiency has the potential to hinder the QAA committee's ability to identify and respond to systemic problems to improve services for the residents.
Failure to Administer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and administer the influenza and pneumococcal vaccines to two residents, Resident 1 and Resident 104. Resident 1 was admitted with acute respiratory failure, pneumonia, and hypotension, and was dependent on others for daily activities. The immunization record for Resident 1 did not indicate that the flu and pneumococcal vaccinations were administered. Resident 104, who had hypertension, falls, and spinal stenosis, had signed a consent form for the influenza, pneumococcal, and COVID-19 vaccines, but the vaccines were never administered. The Infection Preventionist Nurse (IPN) admitted to not administering the flu vaccine outside the flu season and was unsure about obtaining consent for Resident 1, who did not have a responsible party. The Director of Nursing (DON) confirmed that it was the IPN's responsibility to ensure vaccines were offered and administered within 72 hours of obtaining consent, and emphasized that if it is not documented, it is not done. The facility's policy and procedure on immunizations, revised in July 2023, stated that the facility would offer and administer flu and pneumococcal immunizations to eligible residents after providing education and obtaining consent. The policy also mentioned that if a resident was admitted outside the influenza season, the facility was not expected to offer the vaccine, and decisions would be made on a case-by-case basis. Despite this policy, the IPN failed to administer the vaccines to both residents, leading to a deficiency in the facility's vaccination protocol and potentially putting residents at risk for flu and pneumonia.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that Resident 104 received the COVID-19 vaccination despite the resident having signed the consent form on 4/1/2024. The resident was admitted with diagnoses including hypertension, falls, and spinal stenosis. During a review of the resident's immunization record, it was found that the COVID-19 vaccine had not been administered, even though the consent was signed. The Infection Preventionist Nurse (IPN) acknowledged the oversight and stated that she had not yet had the chance to administer the vaccine. The Director of Nursing (DON) confirmed that it is the IPN's responsibility to ensure all vaccines are offered and administered within 72 hours of consent. The facility's policy and procedure, revised in 7/2023, mandates that COVID-19 immunizations be offered and administered to eligible residents after obtaining consent and providing education on the risks and potential side effects. The failure to administer the vaccine as per the policy placed Resident 104 at risk of acquiring serious infections such as pneumonia and COVID-19.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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