Roseville Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Roseville, California.
- Location
- 1161 Cirby Way, Roseville, California 95661
- CMS Provider Number
- 055886
- Inspections on file
- 42
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Roseville Care Center during CMS and state inspections, most recent first.
The facility failed to protect a resident’s right to be free from abuse when one resident with dementia, agitation, and a history of behavioral symptoms, including physical aggression, struck another resident in the face during an altercation. The aggressor’s care plan already identified risks for striking out and being physically abusive, with a goal to prevent injury to self or others. The resident who was struck, who had bipolar disorder, anxiety, major depressive disorder, and parkinsonism, later expressed sadness and anger and appeared tearful. The DON acknowledged that residents are expected to be kept safe and free from abuse, consistent with the facility’s Resident Rights policy.
A resident with muscle weakness, gait abnormalities, and moderate memory impairment reported to an LN that she was injured during care by staff and felt unsafe, but the LN did not report this allegation to management as required. Clinical documentation noted trauma-related bruising and a skin tear on the leg, and a subsequent hospital wound care record reflected the resident’s report that a CNA rolled her in bed, nearly causing a fall and resulting in leg and foot injuries. The resident’s care plan identified impaired skin integrity related to trauma. The DSD and DON stated that staff are expected to immediately report new injuries, injuries of unknown source, and any resident report of injury during care as potential abuse, consistent with the facility’s abuse reporting policy, which mandates immediate reporting of suspected abuse or injury of unknown source to the administrator and appropriate authorities.
Two residents with cognitive impairments and mobility needs engaged in a physical altercation in a hallway after one resident bumped into the other's wheelchair and initiated hitting. Staff, including the DON and a nurse, witnessed the incident and intervened after both residents had exchanged blows. The facility's lack of effective supervision and monitoring allowed the altercation to occur, contrary to policy requirements to protect residents from abuse.
The facility did not ensure proper dishwashing and sanitary food service procedures, as evidenced by dirty pans stored as clean, staff unable to demonstrate or verbalize correct dishwashing temperatures and sanitizer use, and dishwashing machine logs showing temperatures below manufacturer guidelines. These failures affected all residents receiving food from the kitchen.
Two residents did not receive care according to professional standards when one was not provided with a physician-ordered low air loss mattress after being moved to a new room, and another did not have blood pressure medication administered or held in accordance with prescribed parameters, with vital signs not consistently checked as required. Staff documentation and interviews confirmed these failures to follow physician orders and facility policy.
Multiple deficiencies were identified in medication administration and management, including a resident receiving the wrong dose and timing of Flomax, another not receiving Valsartan due to unavailability, and a third missing several days of prescribed antifungal treatment. Additional issues included administration of expired medication, improper handling of controlled substances, and a loose pill found on the hallway floor. These events were confirmed through staff interviews, record reviews, and direct observation.
During a meal service, several residents did not receive meals consistent with their prescribed therapeutic diets. A resident on a low fat/low cholesterol diet was given tartar sauce instead of lemon, multiple residents on fortified diets did not receive the required margarine, and others on mechanical soft or dysphagia mechanical soft diets received fish not prepared according to the specified recipes. These deficiencies were confirmed by the RD and through review of facility menus and recipes.
Multiple staff failed to follow infection prevention protocols, including not using required PPE during high-contact care for residents with indwelling devices and wounds, improper storage of a nebulizer mask, and housekeeping not wearing a gown while cleaning an EBP room. These actions did not comply with facility policies for EBP and infection control.
Surveyors found that the laundry area was not maintained in a sanitary condition, with dust on supplies, racks, and window screens, and a damaged window screen with a hole. The Housekeeping and Laundry Supervisor confirmed the area should be clean at all times due to infection concerns, but cleaning logs were not available. The facility's policy requires all areas, including window screens, to be clean and in good repair.
Two residents were administered psychotropic medications without adequate documentation of specific target behaviors or appropriate indications for use. One resident received antipsychotics for bipolar disorder without clear behavioral manifestations noted, while another was given Depakote for dementia-related behaviors without specifying the behaviors being treated. Facility staff and leadership acknowledged the lack of detailed documentation and missed recommendations from the pharmacy review.
Two residents did not receive accurate MDS assessments: one resident's admission MDS failed to reflect the correct number of unstageable pressure injuries present on admission, and another resident's discharge MDS incorrectly documented the discharge status as transfer to an acute hospital instead of discharge home. Staff involved did not verify or accurately record assessment information as required by facility policy.
A resident with a history of fractures and skin tears experienced additional skin injuries when care plan interventions—such as keeping nails trimmed, using protective sleeves, and padding wheelchair arms—were not implemented. Observations and staff interviews confirmed that these measures were not in place, resulting in further skin tears during transfers.
A resident with urinary retention following joint replacement surgery was not provided care according to the physician's order, which required straight catheterization if certain criteria were met. Instead, staff inserted a Foley catheter for continuous drainage without a physician order, failed to document the intervention, and did not initiate a care plan for catheter care. The DON confirmed that the physician's order was not followed.
Two residents with significant weight loss were not properly assessed or provided with updated care plans, food preferences, or timely interventions. Staff failed to document or communicate the weight loss to the RD or physician, and interdisciplinary team meetings did not address the issue, resulting in continued weight loss and lack of appropriate nutritional support.
A resident with a G-tube and a history of dysphagia and paralysis was observed receiving tube feeding with the head of bed elevated below the physician-ordered 30-45 degrees. Nursing staff confirmed the resident could not adjust the bed independently, and the required elevation was not maintained during observation, despite clear orders and facility policy to prevent aspiration.
A resident with sleep apnea did not receive a functioning CPAP machine for over two months, despite a physician's order for replacement. Staff confirmed the absence of the device and no alternative interventions were implemented during this period, contrary to facility policy requiring timely repair or replacement of defective equipment.
A resident with multiple pain-related conditions received PRN pain medications in a manner inconsistent with physician orders and facility policy. Both oxycodone and Tylenol were administered at the same time for different pain levels, and oxycodone was given when the resident had no reported pain. The DON confirmed that staff did not follow the prescribed pain scale for medication administration.
Two residents with end stage renal disease and AV fistulas in their left arms had blood pressure measurements taken on the affected arms, despite care plans and posted signage indicating this should be avoided. In one case, a physician order to avoid the AVF arm was present but not followed; in the other, no such order was obtained. Nursing staff and facility leadership confirmed these practices were inconsistent with professional standards and facility policy.
A resident developed Stage 2 pressure ulcers due to the facility's failure to document daily skin checks and provide regular bowel and bladder care. Despite being at risk for skin breakdown, the resident did not receive the required care, leading to preventable pressure ulcers. The facility's policy on pressure ulcer prevention was not adhered to, resulting in this deficiency.
A facility failed to ensure a resident was seen by their physician as required, potentially delaying services and treatment. The resident, admitted with multiple diagnoses including dementia and epilepsy, had missing physician progress notes for two months. Interviews with staff confirmed the absence of required visits, contrary to the facility's policy of regular physician visits.
A resident in the facility received an incorrect dosage of Isavuconazonium Sulfate due to an error in entering the medication order into the EHR. The resident, with conditions including allergic bronchopulmonary aspergillosis and chronic kidney disease, was supposed to receive the medication once daily but was administered it every eight hours, resulting in 32 extra doses. The error was confirmed by the ADON and DON, and the facility's policies on medication reconciliation and monitoring were not followed.
A resident with dementia and diabetes had an indwelling urinary catheter without an active physician order or inclusion in their care plan. The facility failed to document catheter care and management, and the urine collection bag was observed on the floor without a privacy cover. Staff interviews confirmed the lack of proper documentation and handling, increasing the risk of infection.
A resident with PTSD and unspecified psychosis reported an alleged abuse incident to a nurse, but the facility delayed reporting it to the Department, Ombudsman, and Law Enforcement until the next day. The facility's policy requires immediate reporting within two hours, but the Director of Nursing believed the timeframe was within 24 hours, leading to a delay in the investigation and reduced protection for the resident.
The facility compromised the privacy of 179 residents by improperly disposing of meal tray tickets containing personal information in regular trash. A dietary aide was observed discarding these tickets, which included sensitive details such as names, medical record numbers, and dietary information. The assistant dietary services supervisor confirmed this as the standard disposal method, while the director of nursing stated that tickets should be shredded to maintain confidentiality.
The facility failed to maintain proper pharmacy services, including an unsealed emergency medication box not replaced within 72 hours, undocumented use of lorazepam from an E-kit, unavailable prescription medications for three residents, and a dose of lacosamide not signed out in the controlled medication binder.
The facility failed to properly store and label medications, including a multi-dose inhaler and glucose test strips without open date labels, an IV antibiotic bag stored improperly, and an unlocked medication cart with accessible blister packs. Additionally, a medication refrigerator and a black box with syringes were left unlocked, and loose pills were found in medication carts, all contrary to facility policy.
The facility failed to maintain the nutritive value and flavor of pureed foods for 17 residents by not following established recipes. The cook did not use recipes or measuring tools while preparing pureed pasta and meatballs, adding unmeasured amounts of ingredients. Interviews confirmed the lack of adherence to recipes, which is necessary to maintain the nutritive value of the food.
The facility failed to meet food safety standards, affecting 179 residents. Milk and eggs were improperly stored, opened food items were unsealed, and food products were unlabeled. The kitchen had unsanitary conditions, with grime on floors and damaged kitchenware. The emergency food storage lacked temperature monitoring, and the resident refrigerator log showed unsafe temperatures without corrective actions.
The facility failed to maintain effective infection control practices. A CNA did not use proper PPE or perform hand hygiene while caring for a resident on Enhanced Barrier Precautions due to MRSA. Additionally, an LN did not disinfect a glucometer according to the manufacturer's instructions, risking the spread of infections.
A resident was observed self-administering eye drops without a physician's order or proper assessment, contrary to the facility's policy. The resident, who had intraocular lenses and an order for cyclosporine emulsion for dry eyes, was not assessed for her capability to self-administer safely. The DON acknowledged the oversight, noting that a physician's order should have been obtained.
A resident with bladder cancer was discharged from Hospice Care, but the facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days as required. Interviews confirmed that an SCSA should have been conducted to reflect the resident's current status, as per facility policy.
A long-term care facility failed to accurately assess three residents, leading to deficiencies in their care plans. One resident's MDS inaccurately indicated that a restorative nursing program was not performed, another resident's MDS failed to reflect continuous oxygen use, and a third resident's wound assessments were inaccurately coded. These inaccuracies were confirmed by the MDS Coordinator and the DON, impacting the facility's ability to address the residents' care needs.
The facility failed to follow physician orders for four residents, including improper monitoring after a fall, incorrect diet administration, late IV antibiotic administration, and incorrect timing of pain medication. These actions did not adhere to professional standards of quality care.
A resident with a feeding tube did not receive proper care due to an incomplete enteral feeding order, lacking details such as formula type and administration method. This was confirmed by a nurse and the DON, who acknowledged the oversight.
A facility experienced a 10.71% medication error rate due to three errors: a resident's medication was unavailable, an extended-release medication was crushed, and chewable aspirin was given instead of delayed-release. Interviews confirmed these errors and a failure to follow medication administration policies.
A facility failed to protect residents' PHI when a Kiosk/computer was left unattended, displaying sensitive information. A nurse confirmed the screen showed the census of 179 residents, and a CNA admitted to leaving it unattended. The facility's policy requires safeguarding resident privacy and confidentiality.
A resident fell and was injured because the bed locks were not secured, despite the facility's policy requiring all bed wheels to be locked. Staff were either unaware of how to lock the bed or unable to do so, and the facility had not provided adequate training on securing bed locks.
A resident admitted for hip replacement aftercare experienced severe pain during physical therapy. Inconsistent communication among staff led to a failure in timely pain management, resulting in the resident's uncontrolled pain and subsequent hospital transfer.
A resident experienced neck pain after a bed malfunctioned, causing the head of the bed to drop suddenly. The incident was not documented in the maintenance log, and the Administrator was unaware of it until months later. The bed was replaced, but there was no formal documentation of the malfunction or replacement process.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from abuse when one resident physically struck another resident in the face. Resident 1, who had dementia with agitation and anxiety and a BIMS score of 10/15 indicating moderately impaired cognition, had a care plan revised on 6/21/25 that identified psychosocial/behavioral symptoms including striking out, grabbing others, and being verbally or physically abusive to staff and patients, with a goal that emotions would be controlled so as not to result in injury to self or others. On 2/22/26, facility staff witnessed Resident 1 hit Resident 4 in the face during an altercation between the two residents. Resident 4 had diagnoses including bipolar disorder, anxiety, major depressive disorder, and parkinsonism. Following the incident on 2/22/26, Resident 4’s progress note documented that the resident verbalized sadness and anger about the situation and appeared tearful. The DON stated in an interview that the expectation is to keep residents safe, that abuse can perpetuate and a resident can be hurt more, and that the goal is to have no abuse in the facility. The facility’s Resident Rights policy, revised February 2021, states that federal and state laws guarantee residents the right to be free from abuse, but this right was not upheld when Resident 1 hit Resident 4.
Failure to Report Resident’s Allegation of Injury During Care as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse reporting policy when a resident alleged injury during care. Resident 1, admitted in October 2025 with muscle weakness and gait and mobility abnormalities and documented moderate memory impairment on an MDS dated 11/5/25, reported to Licensed Nurse (LN) 1 that she had been injured while receiving care from facility staff and that she felt unsafe. LN 1 confirmed in an interview on 2/5/26 that he did not report this allegation to facility management. A progress note dated 11/5/25 documented that the resident reported recent trauma to both legs and feet from dangling off the bed, with a large area of bruising to the left lower leg and a 0.2 cm linear skin break on the lateral aspect of the left lower leg, and noted the resident’s preferences for using multiple staff members and gently moving her legs. Further record review showed that a hospital wound care record dated 11/6/25 documented the resident’s report that she was rolled by a CNA at the SNF and nearly fell out of bed, sustaining injuries to her left leg and right foot, and described discoloration on the plantar surface of the left foot possibly related to trauma. The resident’s care plan initiated on 11/6/25 identified impaired skin integrity related to trauma and risk for infection. The Director of Staff Development stated that staff are expected to immediately report new injuries to the nurse and that if a resident reports being injured during care with another staff member, the CNA is to report it as potential abuse. The DON stated that staff are expected to report any injury of unknown source or allegation of abuse to management and acknowledged that failure to report could result in residents potentially experiencing further abuse and injury. The facility’s abuse reporting and investigating policy, revised 9/22, requires that all reports of resident abuse, including injuries of unknown origin, be immediately reported to the administrator and appropriate officials within specified time frames, which did not occur in this case.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent abuse between two residents who were involved in a physical altercation in a hallway near the nurses' station. One resident, who had severe cognitive impairment and a history of physical aggression, was observed in her wheelchair when she bumped into another resident's wheelchair and initiated physical contact by hitting the other resident on the forearm. The second resident, who had moderate cognitive impairment and a history of hemiplegia and hemiparesis, responded by hitting back. Both residents exchanged blows to each other's arms before being separated by staff. Documentation and interviews revealed that the first resident was unable to recall the incident due to her cognitive status, while the second resident stated he retaliated because he was struck first and felt justified in doing so. Staff interviews confirmed that the first resident had a pattern of aggressive behavior, including attempts to hit other residents and staff, and that the second resident had not previously exhibited physical aggression toward others. The incident was witnessed by staff, including the DON and a licensed nurse, who intervened to separate the residents after the altercation had already occurred. The facility's policies require staff to monitor residents for aggressive or inappropriate behavior and to protect residents from abuse, including resident-to-resident altercations. However, the lack of effective supervision and monitoring allowed the altercation to occur, resulting in both residents being exposed to potential physical injury and emotional distress. The incident was documented in progress notes and discussed in interviews with staff and the residents involved.
Failure to Maintain Sanitary Dishwashing and Food Service Procedures
Penalty
Summary
The facility failed to maintain proper dishwashing processes and sanitary conditions in the dietary services area. During an initial kitchen tour, two metal pans with visible food debris were found stacked in a clean storage area, and both the Dietary Supervisor and Registered Dietitian confirmed that dishes should be clean and checked before storage. Facility policies required utensils and equipment to be thoroughly cleaned and air-dried before being stored, but these procedures were not followed. Further observations revealed that a Dietary Aide was unable to verbalize or demonstrate the correct water temperatures for the automated dishwashing machine or the proper procedures for manual dishwashing using a 3-compartment sink. The aide could not state the required sanitizer concentration or immersion time, and the posted instructions at the dishwashing station did not match the manufacturer's guidelines. Review of logs and interviews confirmed that the staff lacked knowledge of the correct procedures, despite having attended in-service training on cleaning and sanitizing. Record reviews and interviews also showed that the dishwashing machine was frequently operated below the manufacturer's recommended temperatures, with wash temperatures often below 140°F and rinse temperatures below 120°F. The Dietary Supervisor and Registered Dietitian were unaware of the manufacturer's posted guidelines and confirmed that the temperature logs did not meet these requirements. Facility policies and job descriptions required maintaining sanitary conditions and monitoring food service operations, but these standards were not met, potentially affecting all 172 residents who received food from the kitchen.
Failure to Follow Physician Orders and Professional Standards for Pressure Ulcer and Medication Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents. For one resident with a history of rhabdomyolysis and multiple pressure injuries, there was a physician order for a low air loss (LAL) mattress to aid in pressure ulcer prevention and treatment. Despite this order, the resident was observed on multiple occasions to be using a regular mattress after being moved to a different room, and the LAL mattress was not transferred with the resident. Documentation in the Medication Administration Record (MAR) incorrectly indicated that the LAL mattress was present, and staff interviews confirmed the mattress was not in use as ordered. For another resident with hypertension and atrial fibrillation, there was a physician order for Metoprolol Tartrate to be administered twice daily, with specific parameters to hold the medication if the systolic blood pressure was less than 100 mmHg or heart rate was less than 60 bpm. Review of the Medication Administration Record revealed that vital signs were not consistently taken before administering or holding the medication on several dates. Additionally, the medication was administered when the resident's blood pressure was below the hold parameter, and on multiple occasions, doses were held even though the vital signs were within the prescribed limits. Staff interviews confirmed these discrepancies and acknowledged that the medication was not administered according to the physician's hold parameters. Facility policies required that physician orders be followed as prescribed and that medications be administered in accordance with prescriber orders, including checking vital signs when necessary. The observed failures to follow these policies and physician orders for both residents resulted in services not meeting professional standards of quality.
Medication Administration and Management Deficiencies
Penalty
Summary
The facility failed to implement pharmaceutical policies and procedures consistent with standards of practice, resulting in multiple medication administration errors and lapses in medication management. In one instance, a nurse administered only one capsule of Flomax to a resident when the physician's order specified two capsules to be given 30 minutes after the same meal each day. The medication was also administered before breakfast, contrary to the prescribed timing. The nurse acknowledged the error and confirmed that the medication was not given as ordered. Another resident did not receive a prescribed dose of Valsartan for hypertension because the medication was not available at the time of administration. The nurse reported that a refill request had been faxed to the pharmacy, but there was a delay in delivery. The medication administration record confirmed that the scheduled dose was missed, and the DON acknowledged that pharmacy delivery issues sometimes led to such delays. A third resident did not receive prescribed topical antifungal treatment for several days due to unavailability of the medication. Nursing progress notes repeatedly documented that the medication was either awaiting delivery from the pharmacy or not available in house supply, and there was no evidence that the physician was notified about the missed doses. Additionally, expired medication was administered to another resident, and a loose, unidentified pill was found stored with controlled substances, as well as a loose pill observed on the hallway floor. These incidents were confirmed by staff interviews and direct observation, and were not in accordance with facility policies for safe medication administration and management.
Failure to Follow Prescribed Menus and Recipes for Therapeutic Diets
Penalty
Summary
The facility failed to ensure that planned menus and recipes were followed for residents on therapeutic diets during a lunch meal service. Specifically, a resident on a low fat and low cholesterol diet received tartar sauce instead of the prescribed lemon slice, as indicated on the facility's menu spreadsheet. Four residents requiring fortified diets did not receive the additional one ounce of margarine on their vegetables as specified for their nutritional needs. Additionally, three residents on mechanical soft texture diets were served fish prepared for dysphagia mechanical soft texture diets, which did not match the required flaked and moist fish with soft tomatoes. Five residents on dysphagia mechanical soft diets received fish that was not prepared according to the recipe, as the tomatoes were not pureed but served in pieces. These deficiencies were observed during a lunch meal distribution and confirmed through interviews with the Registered Dietitian, who acknowledged that staff did not follow the menu spreadsheet or recipes as required. Facility documents, including job descriptions and policies, indicated that staff are responsible for following prepared menus, accurately preparing special diets, and checking trays for accuracy before delivery. The failure to adhere to these protocols resulted in 13 residents not receiving meals that met their prescribed nutritional needs and food textures.
Failure to Implement Infection Prevention and Control Measures
Penalty
Summary
The facility failed to implement infection prevention and control measures as required, resulting in multiple deficiencies related to Enhanced Barrier Precautions (EBP) and proper use of personal protective equipment (PPE). Nursing staff did not follow EBP protocols for a resident with an indwelling Foley catheter and wound drain, as there was no EBP signage posted, no PPE caddy available, and staff did not use gowns or face protection during high-contact care activities. The nurse providing wound vacuum care to this resident was unaware of the EBP status and only wore gloves, contrary to the care plan and facility expectations. Housekeeping staff also failed to adhere to EBP requirements by not wearing a gown while cleaning a room under EBP, despite signage indicating the need for precautions. The staff member acknowledged forgetting to wear the gown and noted that gowns were not readily available in the room, requiring retrieval from the supply room. The Director of Nursing confirmed that all staff, including housekeeping, are expected to follow EBP protocols to prevent the spread of infection. Additional deficiencies included improper storage of a resident's nebulizer mask, which was left uncovered on a nightstand instead of being stored in a bag as per facility policy, and a treatment nurse providing wound care to a resident on EBP without wearing a gown. Both nursing and respiratory therapy policies required proper PPE use and equipment storage to prevent infection, but these protocols were not followed during the observed incidents.
Laundry Area Not Maintained in Sanitary Condition and Good Repair
Penalty
Summary
The facility failed to maintain the laundry area in a sanitary condition and in good repair, as evidenced by observations of dust particles on laundry supplies, racks, and window screens in the contaminated linen area. One window screen was found to be damaged with a hole. These conditions were confirmed by both the Housekeeping and Laundry Supervisor (HLS) and a Maintenance Worker during interviews. The HLS acknowledged that the laundry room should always be clean due to infection concerns. Additionally, the HLS stated that the contaminated linen area is only cleaned once a week, while the clean linen area is cleaned every shift, and was unable to provide cleaning logs for either area. Further interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed expectations that all areas, including the soiled linen area, should be kept clean and in good repair to prevent the entry of animals or rodents and to maintain infection control. A review of the facility's policy indicated that the facility should be clean, safe, sanitary, and in good repair at all times, with all window screens maintained in good condition. The failure to meet these standards had the potential to affect the safe and sanitary handling of laundry items for a census of 175 residents.
Failure to Document Indications for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs, including chemical restraints, by administering psychotropic medications without adequate documentation of specific target behaviors or appropriate indications for use. One resident with bipolar disorder and anxiety was prescribed aripiprazole and olanzapine for bipolar disorder, but the orders lacked detailed descriptions of the behaviors these medications were intended to address. The facility's Medication Regimen Review (MRR) questioned the appropriateness of these medications, noting that antipsychotics are not typically used for depression, especially when the manifestation is manic phases. During interviews, facility leadership acknowledged that the orders needed to specify behaviors to allow for accurate monitoring. Another resident with dementia was prescribed Depakote for behaviors manifested by dementia, but the order did not specify the particular behaviors being treated. The MRR repeatedly indicated that the documentation was insufficient to justify the use of Depakote. Facility staff confirmed that the recommendation to update the order with specific target behaviors was missed, partly due to the resident's hospitalization and subsequent hold on orders. The facility's policy requires that symptoms warranting psychotropic medication use be clearly identified, evaluated, and documented, which was not done in these cases.
Inaccurate MDS Assessments for Pressure Injuries and Discharge Status
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents. For one resident admitted with rhabdomyolysis and multiple unstageable pressure injuries, the admission MDS did not accurately reflect the correct number of pressure injuries present on admission. The Treatment Nurse confirmed the resident had five pressure injuries upon admission, but the MDS assessment did not match this information. The MDS Assistant Coordinator admitted to not verifying the number of pressure injuries with the Treatment Nurse during the assessment process, and the MDS Coordinator confirmed the inaccuracy in the recorded data. For another resident admitted for rehabilitation following hip surgery, the discharge MDS inaccurately documented the resident's discharge status. Although the resident was discharged home with family and home health physical therapy, the MDS indicated a discharge to an acute hospital. The MDS Assistant Coordinator confirmed the error after reviewing the records and acknowledged that the documentation did not reflect the resident's actual discharge destination. Facility policy requires that assessments be completed by knowledgeable staff and that all portions of the MDS be attested to for accuracy.
Failure to Implement Care Plan Interventions to Prevent Skin Tears
Penalty
Summary
A resident with a history of a syncopal episode resulting in left femur and humerus fractures was admitted to the facility and subsequently developed new skin tears on her left leg. The care plan, initiated after a skin tear incident, included interventions such as keeping nails trimmed, padding wheelchair arms and legs, wearing protective sleeves, using a pressure relief mattress, bunny boots, and exercising caution during transfers. Despite these documented interventions, the resident sustained additional skin tears during transfers, as noted in change of condition records. Observations revealed that the resident did not have protective sleeves on, her nails were long and unkept, and the wheelchair arms and legs were not padded, contrary to the care plan directives. Staff interviews confirmed that these interventions were not implemented as required. The facility's policy stated that the comprehensive care plan should describe the services necessary to maintain the resident's highest practicable well-being, but the specified interventions to prevent further skin tears were not carried out.
Failure to Follow Physician Order for Catheterization
Penalty
Summary
Nursing staff failed to follow a physician's order for straight catheterization for a resident who was admitted after joint replacement surgery and had a diagnosis of urinary retention. The physician's order specified that if the resident was unable to urinate after six hours, a bladder scan should be performed, and if the residual volume was greater than 450 ml, a straight catheterization should be done as needed. Instead, when the resident complained of inability to urinate and bladder pain, staff inserted a Foley catheter for continuous urinary drainage without a physician's order for this intervention. There was no documentation in the clinical record of a physician order for the Foley catheter, no order for catheter care, and no record of the date and time of insertion. Additionally, no care plan was initiated to address the presence of the Foley catheter. The resident and family expressed concerns about the use of the Foley catheter, and the DON confirmed that staff did not follow the physician's order and inserted the Foley catheter without proper authorization.
Failure to Address Progressive Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to recognize, evaluate, and address the nutritional needs of two residents who experienced significant and progressive weight loss. One resident, recently admitted after hospitalization for a lung infection and with diagnoses including muscle weakness and unsteadiness, had a care plan that did not include food preferences, weight monitoring, or updated interventions for weight loss. The resident reported dissatisfaction with the food, lack of menu choices, and stated that no one from dietary had discussed her weight loss or food preferences with her. Clinical records showed a 7-pound weight loss in 17 days, with no documentation that the weight loss was addressed or communicated to the registered dietitian (RD) or physician. The RD confirmed being unaware of the weight loss and acknowledged that the resident's food preferences were not documented, and the issue was not discussed in interdisciplinary team (IDT) meetings. Another resident, admitted with diagnoses of spinal fusion, protein-calorie malnutrition, and anemia, experienced a 17-pound weight loss since admission, including a 14-pound loss in one month. The resident appeared emaciated and expressed concern about the weight loss. Medical records lacked documentation of weights after a certain date, and there was no evidence of a nurse's assessment or physician notification regarding the significant weight loss. The RD acknowledged that the resident should have been placed on weekly weights and that this was not done, with no dietary interventions implemented despite the significant weight loss. Facility policy required the multidisciplinary team to monitor and intervene for undesirable weight loss, considering resident preferences and rights. However, in both cases, the facility did not follow its own policy, as there was a lack of timely assessment, communication, and intervention for the residents' nutritional needs and weight loss. The failures were confirmed by staff interviews and record reviews, with both the DON and RD acknowledging the deficiencies in monitoring, documentation, and care planning.
Failure to Maintain Required Head of Bed Elevation During Tube Feeding
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders and facility policy regarding the elevation of the head of bed (HOB) for a resident with a gastrostomy tube (G-tube) during enteral feeding. The resident, who had diagnoses including dysphagia and paralytic syndrome, was readmitted with a G-tube and had a care plan and physician orders specifying that the HOB should be elevated between 30 to 45 degrees during and for 30 minutes after tube feedings. During observation, the resident was found receiving continuous tube feeding with the HOB elevated to only 15-20 degrees, contrary to the required elevation. The resident was unable to adjust the bed due to paralysis, and the licensed nurse confirmed the HOB was not at the required angle at the time of observation. Further review of the resident's medical history indicated previous treatment for aspiration pneumonia and a diagnosis of silent aspiration pneumonia upon readmission. Interviews with nursing staff and administration confirmed awareness of the physician's order and the facility's policy, which required HOB elevation to prevent aspiration. The facility's policy also specified the need for HOB elevation during and after tube feedings. Despite these directives, the required positioning was not maintained, resulting in noncompliance with physician orders and facility policy for safe enteral feeding practices.
Failure to Provide Functioning CPAP Machine for Resident with Sleep Apnea
Penalty
Summary
A resident with a history of sleep apnea and obstructive sleep apnea was admitted with a physician's order for a continuous positive airway pressure (CPAP) machine to be used at bedtime. The resident's clinical record and interviews confirmed that the CPAP machine had been broken for over two months and had not been replaced, despite a documented order for replacement. The resident reported difficulty breathing at night and trouble sleeping due to the lack of a functioning CPAP machine. Observations confirmed that there was no CPAP or oxygen concentrator present in the resident's room during this period. Staff interviews, including with a CNA and a licensed nurse, verified the absence of a working CPAP machine and acknowledged that the issue had persisted for more than two months. The licensed nurse confirmed that the electronic medication administration record documented the CPAP as broken and missing parts throughout this time frame. No specific interventions were ordered to monitor the resident during sleep hours while awaiting the replacement machine. The facility's policy required that defective equipment be repaired or replaced, but this was not followed in the resident's case.
Failure to Follow Pain Medication Orders and Pain Assessment Protocols
Penalty
Summary
A deficiency occurred when a resident with multiple pain-related diagnoses, including lumbar spondylosis, rheumatoid arthritis, lumbosacral radiculopathy, and fibromyalgia, did not receive pain management services consistent with professional standards of practice. The resident had physician orders for oxycodone to be administered as needed for moderate to severe pain (pain level 4-10) and Tylenol for mild pain (pain level 1-3). The resident's care plan directed staff to administer medications as ordered to address pain and discomfort. Record review revealed that on one occasion, both oxycodone and Tylenol were administered simultaneously for pain levels of 7/10 and 4/10, respectively, which did not align with the prescribed parameters. Additionally, oxycodone was given at another time when the resident's pain level was documented as 0/10, indicating no pain. The DON confirmed these discrepancies and acknowledged that the expectation was to follow the pain scale as ordered. The facility's policy required staff to implement the medication regimen as ordered, which was not followed in these instances.
Failure to Prevent Blood Pressure Measurements on AV Fistula Arms in Dialysis Residents
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for two residents with end stage renal disease who required hemodialysis and had arteriovenous fistulas (AVF) in their left arms. For one resident, despite a care plan and physician order specifying to avoid taking blood pressure (BP) on the left arm with the AVF, BP measurements were recorded on that arm on three separate occasions. The Director of Nursing confirmed these incidents and acknowledged that BP should not be taken on the arm with the fistula, as per the resident's orders and care plan. For the second resident, the care plan indicated no BP should be taken on the arm with the AVF, and a visible sign was posted in the resident's room to this effect. However, BP was taken on the left arm on multiple occasions, and there was no physician order in place to avoid using the left arm for BP assessments. Both the licensed nurse and the assistant director of nursing confirmed that BP should not be taken on the AVF arm and that a physician order should have been present. The facility's policy and national guidelines also support avoiding BP measurements on the AVF arm.
Failure to Prevent Pressure Ulcers
Penalty
Summary
The facility failed to adhere to professional standards of practice in preventing pressure ulcers for a resident, resulting in the development of Stage 2 pressure ulcers on the resident's buttocks. The resident, who was admitted with multiple diagnoses including Diabetes Mellitus, was initially assessed to have no skin breakdown. However, the facility did not document daily skin checks as required by the care plan, which indicated the resident was at risk for skin breakdown and required daily skin checks and notification of a physician for any abnormal findings. Additionally, the facility did not provide bowel and bladder care at regular intervals, as evidenced by logs showing significant gaps in care provision. The Director of Staff Development acknowledged that bowel and bladder care was only provided once per shift, contrary to the expectation of every two hours, which increased the risk of skin breakdown. The facility's policy on pressure ulcer prevention required daily skin inspections and prompt cleaning after incontinence episodes, which were not followed, leading to the development of pressure ulcers.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that a resident was seen by their physician as required, which had the potential to delay services and treatment. The deficiency was identified during a review of the records for a resident who was admitted in the winter of 2013 with multiple diagnoses, including dementia, epilepsy, depression, cerebellar ataxia, anxiety, hydrocephalus, and a history of falls. The resident's Brief Interview for Mental Status (BIMS) indicated moderate memory loss. During the review, it was found that physician progress notes (PPN) for January and March 2024 were missing from the facility's electronic health record system. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Physician Assistant (PA), and the Director of Nurses (DON), confirmed the absence of the required physician visits. The facility's policy and procedure stated that the attending physician must visit patients at least once every thirty days for the first ninety days following admission, and then at least every sixty days thereafter. However, the physician did not have PPN in the provider's electronic health record system for the specified months, indicating a lapse in compliance with the facility's policy.
Resident Received Incorrect Dosage of Antifungal Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the resident receiving an incorrect dosage of Isavuconazonium Sulfate, an antifungal medication. The resident, who was admitted with conditions including allergic bronchopulmonary aspergillosis, chronic obstructive pulmonary disease, and chronic kidney disease, was supposed to receive the medication once daily as per the physician's order from the hospital. However, due to an error in entering the medication order into the electronic health record (EHR), the resident received the medication every eight hours, leading to 32 extra doses being administered. The error was identified through a review of the resident's Medication Administration Record (MAR) and confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The ADON acknowledged that the hospital orders were not correctly entered into the EHR, and the DON confirmed that the incorrect dosage was administered. The facility's policy and procedure for medication reconciliation and monitoring for adverse consequences were not followed, as there was no action taken on an automated system-generated warning indicating that the order was outside the recommended dose frequency. Interviews with the facility staff, including the Pharmacist and Physician's Assistant, further confirmed the discrepancy in the medication order and administration. The Pharmacist noted that the dose given was higher than the recommended dose, and the Physician's Assistant indicated that providers do not see the automated notes. The facility's policies on medication errors and reconciliation were not adhered to, leading to the resident receiving an incorrect dosage of medication over a period of time.
Failure to Manage Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide care according to professional standards for a resident with an indwelling urinary catheter. There was no active physician order for the catheter, and it was not included in the resident's care plan or weekly summary notes. The lack of documentation and oversight in managing the catheter and drainage bag according to professional standards was evident. The resident's medical records indicated a history of dementia, senile degeneration of the brain, and type 2 diabetes. Despite these conditions, the resident's Minimum Data Set (MDS) and Nursing Weekly Summary Notes did not reflect the presence of an indwelling urinary catheter, and the care plan lacked interventions to manage it. Observations revealed the urine collection bag was on the floor without a privacy cover, increasing the risk of contamination. Interviews with facility staff, including a CNA, Infection Preventionist, Licensed Nurse, and the Director of Nursing, confirmed the absence of a physician order and documentation for the catheter. Staff acknowledged the improper handling of the urinary drainage bag and the potential for infection due to these practices. The facility's policies required a physician's order for catheter insertion and maintenance, which was not followed in this case.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident in a timely manner, as required by their policy. The incident involved a resident who was admitted with diagnoses including post-traumatic stress disorder (PTSD) and unspecified psychosis. The resident, who had a Brief Interview of Mental Status (BIMS) score indicating memory problems, reported the alleged abuse to a licensed nurse on June 18, 2024. However, the report to the Department, Ombudsman, and Law Enforcement was not made until the following day, June 19, 2024. The delay in reporting was confirmed during interviews with the Social Services Director, Licensed Nurse, and Director of Nursing. The facility's policy, revised in September 2022, requires immediate reporting of abuse allegations within two hours. Despite this, the Director of Nursing acknowledged the report was made the next day, believing the required reporting time was within 24 hours. This failure resulted in a delay in the abuse investigation and decreased the facility's potential to protect the resident from harm.
Improper Disposal of Meal Tickets Compromises Resident Privacy
Penalty
Summary
The facility failed to protect residents' personal information for a census of 179 residents when meal tray tickets containing sensitive information were improperly disposed of. During an observation and interview, a dietary aide was seen discarding meal tickets into the regular trash along with food scraps. These tickets included residents' names, medical record numbers, room numbers, diet orders, food allergies, food preferences, and special instructions. The assistant dietary services supervisor confirmed that this was the standard procedure for disposing of meal tickets. The dietary services supervisor also stated there was no alternative method for disposing of these tickets. The director of nursing later indicated that for privacy and confidentiality, meal tickets should be shredded after recording intake information. The facility's policy on confidentiality, dated September 2023, mandates safeguarding the personal privacy and confidentiality of all residents' personal and medical records.
Deficiencies in Pharmacy Services and Medication Management
Penalty
Summary
The facility failed to maintain proper pharmacy services, as evidenced by several deficiencies. An injectable emergency medication box with a fill date of 2/29/24 was found opened and unsealed without proper documentation and was not replaced within the required 72 hours. The Director of Nursing (DON) acknowledged that the pharmacy was not contacted to replace the E-kit, and the Licensed Nurse (LN) did not follow the process of signing out medication on the E-kit log at the time of use. Additionally, an emergency medication E-kit in the refrigerator was accessed and used without proper documentation. A vial of lorazepam was missing, and there was no record of who took the medication. The DON suspected that the medication was taken for a resident experiencing a seizure, but there was no accurate record of the E-kit medications. The facility's policy requires that medication use be recorded as soon as possible, which was not adhered to in this instance. Furthermore, prescription medications for three residents were not available at the time of administration. Medications for pain relief, blood clot prevention, and mood disorder treatment were not given as prescribed. The DON stated that if a medication is not available, the LN should contact the pharmacy or the doctor for an alternative order. Lastly, a dose of lacosamide was administered without being signed out in the controlled medication binder, which could lead to an incorrect count of controlled substances.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. A partially used multi-dose inhaler was found in a medication cart without an open date label, which was confirmed by a licensed nurse and acknowledged by the Director of Nursing (DON) as a potential issue for medication effectiveness. Additionally, two containers of glucose test strips were found without open date labels in two separate medication carts. The licensed nurses involved admitted to not labeling the containers, and the DON confirmed that the expectation was for the strips to be dated upon opening to ensure they are used within their effective period. Further deficiencies were noted with the storage of an intravenous antibiotic bag, which was found in a narcotic binder on a medication cart, accessible to unauthorized individuals. The licensed nurse responsible admitted to improperly storing the medication, and the DON acknowledged the risk of unauthorized access. Additionally, a medication cart was left unlocked and unattended, with medication blister packs accessible, which was against the facility's policy. The DON confirmed that the cart should have been locked to prevent unauthorized access. The survey also found that a medication refrigerator and a black box containing syringes were left unlocked, contrary to the facility's policy requiring locked storage for medications. The DON acknowledged the risk of unauthorized access to narcotics. Lastly, loose pills were found in several medication carts, which the licensed nurses confirmed should have been disposed of properly. The DON stated that loose pills should not be present on the carts and should be disposed of in a drug buster, as per the facility's policy.
Failure to Follow Pureed Food Recipes
Penalty
Summary
The facility failed to maintain the nutritive value and flavor of pureed foods for 17 residents by not following established recipes. During an observation in the kitchen, it was noted that the cook did not use recipes or measuring tools while preparing pureed pasta and meatballs. The cook added unmeasured amounts of pasta, pasta water, meat, cooking juices, salt, and spices to the blender, which deviated from the facility's recipes. Interviews with the Dietary Services Supervisor and the Registered Dietitian confirmed that the cook did not measure food portions or use measuring tools, which is necessary to maintain the nutritive value of the food. The facility's recipes for pureed starches and meats require specific measurements and procedures to ensure the food is prepared to the correct consistency and nutritional standards. The failure to follow these recipes had the potential to impact the residents' nutrition and health.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 179 residents who received facility-prepared foods. Observations revealed that milk and eggs were stored only 1.5 inches above the floor, contrary to the facility's policy requiring food to be stored 6 inches off the floor. The Dietary Services Supervisor (DSS) was unaware of the required storage height, and the Registered Dietitian (RD) indicated that the height requirement depended on the food type. Additionally, opened food items in the dry storage area were not sealed, and food products were not labeled, which could lead to contamination. The kitchen environment was found to be unsanitary, with black grime on the floors, broken tiles, and chipped paint on the walls. The DSS and Assistant Dietary Services Supervisor (ADSS) acknowledged that unclean floors could lead to food contamination. However, there was confusion about which department was responsible for cleaning the dry goods storage room. The Maintenance Supervisor and the Supervisor for Housekeeping, Laundry, and Janitorial (SHLJ) had differing views on cleaning responsibilities, and the floors had not undergone a deep cleaning for an unspecified period. Unsafe kitchenware was also identified, with non-stick cooking pans having worn-out surfaces and a cutting board with deep cuts, both stored wet and available for use. The DSS was unaware of the damaged items and removed them upon discovery. Furthermore, the emergency food storage room lacked temperature monitoring, and the resident refrigerator log showed temperatures above the safe range without corrective actions. The Director of Nursing (DON) stated that food should be stored for three days, and refrigerator temperatures should be maintained within the required range for food safety.
Infection Control Deficiencies in PPE Use and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents. In the first incident, a Certified Nurse Assistant (CNA) did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident with a history of Methicillin Resistant Staphylococcus Aureus (MRSA) in her wound. The CNA was observed not wearing a gown and failed to perform hand hygiene between tasks, despite the resident being on EBP due to her chronic foot ulcer and MRSA history. The CNA admitted to not being aware of the requirement to wear a gown, and the resident confirmed that only a few staff members wore gowns during care. The facility's policy required the use of gowns and gloves during high-contact care activities for residents on EBP. In the second incident, a Licensed Nurse (LN) did not properly disinfect a glucometer after use, as per the manufacturer's instructions. During a medication pass, the LN cleaned the glucometer with an alcohol preparation pad instead of using a bleach wipe with a required dwell time of three minutes. The Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that the LN should have followed the manufacturer's instructions to prevent the spread of blood-borne pathogens. The facility's policy and the glucometer's user guide both specified the need for proper disinfection between uses.
Failure to Obtain Physician's Order for Self-Administration of Medication
Penalty
Summary
The facility failed to adhere to its policy regarding medication self-administration for one resident, identified as Resident 422. The deficiency was observed when Resident 422 was seen self-administering eye drops without a physician's order or proper assessment to determine her capability to do so safely. The resident was admitted with diagnoses including the presence of intraocular lenses in both eyes and had an order for cyclosporine emulsion eye drops for dry eyes. However, there was no documented order permitting self-administration of these medications. During an observation, a licensed nurse handed the eye drop vial to Resident 422, who then administered the drops herself without performing hand hygiene and expressed an intention to reuse the vial. The Director of Nursing confirmed that an assessment should have been conducted to ensure the resident's ability to self-administer medication safely, and a physician's order should have been obtained. The facility's policy requires that residents may only self-administer medications if deemed safe by the attending physician and the interdisciplinary planning team.
Failure to Complete SCSA After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days after a resident was discharged from Hospice Care. Resident 97, who was admitted with a diagnosis of bladder cancer, was initially placed in Hospice Care due to his condition. An SCSA was completed upon his admission to Hospice Care, reflecting a change in cognition. However, after the family decided to revoke the election of Hospice Care, no subsequent SCSA was initiated or completed within the required timeframe. Interviews with the MDS Coordinator and MDS Consultant confirmed that an SCSA should have been conducted following the resident's discharge from Hospice Care. The facility's policy mandates that the resident assessment coordinator ensures timely and appropriate assessments, which was not adhered to in this case. This oversight potentially impacted the facility's ability to provide appropriate care and services based on the resident's current status.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to accurately assess three residents, leading to deficiencies in their care plans. Resident 101's Minimum Data Set (MDS) inaccurately indicated that a restorative nursing program (RNA) was not performed, despite records showing that the resident received RNA exercises twice a week. This discrepancy was confirmed by both the MDS Coordinator and the Director of Nursing, who acknowledged the potential impact on the resident's care plan. Resident 88's MDS assessment failed to reflect her continuous use of oxygen, which was necessary due to her chronic respiratory failure. The MDS Coordinator confirmed the inaccuracy, noting that the resident's oxygen use should have been properly coded. Resident 143's MDS wound assessments were also inaccurately coded, with discrepancies between the admission and discharge assessments regarding the presence of stage 3 pressure ulcers. The MDS Coordinator admitted the coding errors, which were also acknowledged by the Director of Nursing. These inaccuracies in the MDS assessments for the three residents hindered the facility's ability to accurately identify and address the residents' care needs, as outlined in the facility's policy on resident assessments.
Failure to Follow Physician Orders for Multiple Residents
Penalty
Summary
The facility failed to adhere to professional standards of quality care for four residents, leading to deficiencies in the implementation of physician's orders. Resident 223, who had a history of falls and moderate mental impairment, experienced an unwitnessed fall. The physician ordered a specific monitoring schedule for 72 hours post-fall, which was not followed by the nursing staff. The Director of Nursing confirmed that the monitoring was not conducted as per the physician's order, indicating a lapse in following the prescribed care plan. Resident 43, diagnosed with dysphagia, had a physician's order to avoid using straws due to the risk of aspiration. However, observations revealed that the resident was using a straw during meals, contrary to the dietary restrictions outlined in her care plan. The Speech Therapist and Director of Nursing acknowledged that the physician's order was not followed, potentially increasing the resident's risk for aspiration. Resident 88 was prescribed an intravenous antibiotic to be administered every eight hours for a wound infection. The medication was not administered on time, as confirmed by the Licensed Nurse and the Director of Nursing. Additionally, Resident 525, who was recovering from hip replacement surgery, received Oxycodone at intervals shorter than the prescribed four hours. The Director of Nursing confirmed that the administration did not comply with the physician's order, and there was no documentation of physician approval for the deviation.
Incomplete Enteral Feeding Order for Resident
Penalty
Summary
The facility failed to provide proper care and services to a resident with a feeding tube, identified as Resident 420, due to an incomplete order for enteral feeding. The order lacked essential details such as the type of feeding formula, the duration of feeding, and the mechanism of administration. This oversight was discovered during an observation where a half-filled bottle of enteral feeding formula was found hanging by the resident's bed, indicating it had been there since the previous day. The resident was admitted with a diagnosis of cancer of the tonsils and had a feeding tube in place. Licensed Nurse 16 confirmed the order's incompleteness and acknowledged that it should have been modified to include the necessary information for proper administration. The Director of Nursing also recognized the deficiency, stating that the nursing staff should have accurately transcribed and followed the doctor's order. The facility's policy on enteral feedings requires checking the nutrition label against the order before administration, which was not adhered to in this case.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10.71% error rate during a medication administration observation. Three specific errors were identified: a medication was not available for a resident, an extended-release medication was crushed, and a chewable aspirin was administered instead of the prescribed delayed-release form. These errors were observed during a medication pass on May 6, 2024, involving three different residents and licensed nurses. The first error involved a resident who did not receive their prescribed dose of phenazopyridine due to its unavailability. The second error occurred when a licensed nurse crushed a bupropion XL tablet, which is contraindicated due to its extended-release formulation. The third error involved administering chewable aspirin instead of the delayed-release form as ordered by the physician. Interviews with the Director of Nursing and the involved licensed nurses confirmed these errors and highlighted a failure to adhere to the facility's medication administration policies.
Failure to Protect Resident PHI
Penalty
Summary
The facility failed to protect residents' protected health information (PHI) when a Kiosk/computer located between a resident's room and a storage room was left unattended, displaying sensitive information. This incident was observed during a survey, where a Licensed Nurse confirmed that the computer screen was on and showing the census of 179 residents. The nurse acknowledged that residents' information should be protected at all times to prevent unauthorized access. A Certified Nursing Assistant admitted to using the Kiosk/computer and leaving it unattended to attend to another resident, confirming that the resident's PHI was visible on the screen. The facility's policy on confidentiality, dated October 2021, mandates safeguarding personal privacy and confidentiality of all resident medical records.
Failure to Secure Bed Locks Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safety of a resident when the bed locks were not completely secured, leading to a fall. The resident, who was in the facility for rehabilitation after spine and thoracic region surgery, reported falling on his back because the bed was not locked. The fall resulted in the resident being sent to the hospital emergency room, where the doctor had to re-staple the incision site as some surgical staples were lost during the fall. Observations confirmed that the bed's head locks were not secured, and staff were unable to lock them properly, indicating a lack of training on how to secure the bed locks. Interviews with the Licensed Nurse, Maintenance Staff, and Certified Nurse Assistant revealed that the staff were either unaware of how to lock the bed or unable to do so. The Director of Staff Development and the Assistant Director of Nursing acknowledged that the facility had not provided in-service training on how to lock the resident's bed. The facility's policy stipulated that all bed wheels should be locked at all times unless the bed needed to be moved, and the ADON confirmed that the resident's fall could have been prevented if the bed had been securely locked.
Failure to Manage Resident's Pain Timely
Penalty
Summary
The facility failed to manage a resident's pain timely due to inconsistent communication among staff. The resident, who was admitted for aftercare following hip replacement surgery, experienced severe pain during a physical therapy session. Despite the resident's complaints of pain and hearing a 'pop' sound, the physical therapy assistant (PTA) and certified occupational therapy assistant (COTA) did not effectively communicate the severity of the situation to the morning licensed nurse (LN 1). As a result, no immediate action was taken to address the resident's pain during the morning shift. The resident's pain persisted throughout the day, and it was not until the evening shift that the second licensed nurse (LN 2) became aware of the situation. Upon entering the resident's room for a routine blood glucose check, LN 2 found the resident in severe pain and moaning. The resident and his spouse requested a hospital transfer due to the uncontrolled pain. LN 2 attempted to contact the doctor but was unsuccessful, leading to the resident being transferred to the hospital later that evening. The facility's policy on pain assessment and management, which requires acute pain to be assessed every 30 to 60 minutes until relief is obtained, was not followed. There was no documented evidence that the licensed nurses addressed the resident's acute pain or contacted the physician for new orders to manage the pain. This failure in communication and adherence to pain management protocols resulted in the resident experiencing uncontrolled pain and requiring a hospital transfer.
Failure to Maintain Safe Environment Due to Bed Malfunction
Penalty
Summary
The facility failed to provide an environment free of hazards when a resident's bed malfunctioned, causing the head of the bed to drop suddenly. This incident resulted in the resident experiencing neck pain. The resident, who was admitted with multiple diagnoses including a wedge compression fracture of the T11-T12 vertebra and abnormalities of gait and mobility, required limited assistance for transfers and bed mobility. The resident reported the bed malfunction to staff, and subsequent medical evaluations confirmed neck pain and degenerative changes in the cervical spine, although no acute fractures were found. Interviews with facility staff, including the Administrator, Maintenance Director, and nursing staff, revealed that the bed malfunction was not documented in the maintenance log. The Administrator was unaware of the incident until months after the resident's discharge. The Maintenance Director stated that if the malfunction was reported verbally, it would not have been recorded in the log. Nursing staff confirmed that the bed was replaced after the incident, but there was no formal documentation of the malfunction or the replacement process. The facility's policies on equipment maintenance and accident prevention were not provided upon request. The existing policies indicated that all accidents or incidents should be investigated and reported promptly, with documentation maintained. However, the lack of documentation and retention of maintenance logs in this case highlights a failure to adhere to these policies, resulting in inadequate supervision and an unsafe environment for the resident.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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