Roseville Point Health & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Roseville, California.
- Location
- 600 Sunrise Avenue, Roseville, California 95661
- CMS Provider Number
- 056139
- Inspections on file
- 94
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Roseville Point Health & Wellness Center during CMS and state inspections, most recent first.
A resident with a gastrostomy and laryngeal stenosis was on enhanced barrier precautions (EBP), as indicated by signage outside the room. During a bed-to-wheelchair transfer, two CNAs moved the resident without wearing gowns, despite the posted EBP requirements. Both CNAs later acknowledged they should have worn gowns, and an LN and the IP confirmed that proper PPE use, including gowns, was expected under EBP to minimize infection transmission. Facility policy stated that infection control procedures are intended to prevent and manage disease transmission and that staff are trained on these procedures.
A staff member exploited a resident with moderate cognitive impairment and major depressive disorder by taking her wallet and ATM card, then withdrawing over $12,000 from her bank accounts without consent. The resident, who trusted the staff member and provided her debit card and PIN, was unaware of the extent of the withdrawals until bank statements were reviewed. The incident caused significant emotional distress to the resident, who was observed crying and breaking down multiple times.
A resident with severe cognitive impairment and dementia was inappropriately touched in the groin area by another resident during a group activity. The incident was observed by an activity staff member, who intervened immediately. The facility's abuse prevention policy was not followed, resulting in a failure to protect the resident from abuse.
A resident with dementia was allegedly touched inappropriately by another resident with aphasia and hemiplegia during an activity. The staff member who witnessed the incident intervened but did not immediately report it to supervisors or authorities, resulting in the required abuse report being sent to the Department more than two hours after the event.
A housekeeper did not wear the required PPE, including a gown, while cleaning the room of a resident on Enhanced Barrier Precautions due to a stage 4 pressure ulcer. Despite clear signage and facility policy requiring gloves and gowns for environmental services staff in such cases, the housekeeper cleaned high-touch surfaces without proper protection, as confirmed by nursing and staff development personnel.
Boxes containing documents with residents' personal and medical information were found unattended and unsecured outside the facility on two carts. The DON confirmed the documents should have been secured and properly disposed of, in accordance with facility policies on confidentiality and PHI.
A resident with anxiety and no memory impairment was physically assaulted by another resident with dementia and memory impairment, who rammed his wheelchair into the first resident and punched him multiple times in the activity room. The incident was witnessed by staff, and the assaulted resident later reported feeling unsafe and fearful of returning to the activity room. Facility policy requires a safe environment free from physical abuse.
A resident with severe cognitive and physical impairments was found on the floor after a fall and was subjected to verbal abuse and neglect by a CNA, who used profane language, refused to assist the resident off the floor, and left after only providing a pillow and blanket. The incident was corroborated by another resident and confirmed through facility investigation and staff interviews.
Two residents identified as fall risks did not receive care consistent with their care plans and the facility's fall management policy. One resident with dementia experienced an unwitnessed fall that was not assessed or reported, leading to delayed care and a hip fracture diagnosis. Another resident with a history of pulmonary embolism had two falls, and required fall precautions such as a low bed and fall mat were not in place. Staff confirmed that fall protocols were not followed, and necessary documentation was missing.
A resident with severe dementia was reportedly slapped on the back by a CNA after knocking over a food tray, as witnessed by another CNA. The accused CNA claimed he only tapped the resident, but the witness described the action as a slap. No physical injuries were found, and the facility's leadership unsubstantiated the abuse allegation due to conflicting accounts and lack of additional witnesses.
A resident with bipolar disorder and intact cognition reported suspected staff abuse, but the facility did not submit the required SOC 341 report to authorities within the mandated two-hour timeframe. The delay in reporting was contrary to both regulatory and facility policy requirements.
A resident's privacy was compromised when the Business Office Manager opened a letter containing an EBT card without the resident's consent. Facility policy requires that personal mail be delivered unopened to residents, and staff interviews confirmed that mail should not be opened by personnel unless specifically requested by the resident.
The facility failed to conduct scheduled care conferences for three residents, all of whom had intact cognition and were capable of participating in their care planning. Despite being scheduled, the care conferences did not occur, and the residents were not involved in their care planning as required by the facility's policy.
A medication error rate of 9.09% was identified when a nurse crushed and administered medications to a resident without a physician's order. The resident, with depression and hypertension, received crushed carvedilol, lisinopril, and duloxetine, despite duloxetine's specifications against crushing. Facility policy requires a physician's order for crushing medications.
The facility failed to properly store medications, with expired sorbitol solution found in the storage room and various issues in medication carts, including an unbagged insulin pen, expired benzonatate, and loose pills. Additionally, medications lacked open dates, and a nasal spray had a torn label, making resident identification impossible. The DON confirmed that expired medications should not be stored and open dates are necessary.
The facility failed to ensure dietary staff demonstrated sufficient skills in using chemical sanitization test strips for a low temperature dishwasher and red bucket. A dietary aide did not follow the manufacturer's specifications, failing to blot the test strip before comparison and was unable to identify actions for incorrect sanitizing solution concentration. The Dietary Supervisor confirmed the expectation to follow instructions, and the facility's policy indicated re-education for staff unable to perform skills satisfactorily.
The facility failed to maintain food safety and sanitation standards, with uncovered and unlabeled food left on counters, personal items placed near food, expired tortillas in storage, and unclean air vents. Dietary staff confirmed these issues, acknowledging the need for proper labeling, dating, and cleanliness.
A resident with chronic respiratory failure and anxiety disorder was observed wearing soft mittens to prevent tracheostomy tube removal. The facility failed to obtain informed consent from the resident's representative for the use of these mittens, as required by their policy. Interviews confirmed the consent was incomplete and unsigned, potentially depriving the representative of decision-making regarding the resident's care.
A resident was transferred to a hospital without receiving a written bed hold agreement, as confirmed by a Licensed Nurse and the DON. The facility's policy requires notifying residents or their representatives in writing of the bed hold option during hospital transfers, which was not done in this case.
A facility failed to ensure an accurate MDS assessment for a resident with lung cancer requiring ventilator support. The resident's prior level of function was inaccurately coded as independent, despite using a mechanical lift. The MDS Coordinator confirmed the error, and the DON acknowledged the lack of a specific MDS policy.
The facility failed to update care plans for two residents, one with recurrent falls and another with a removed tracheostomy. Despite hospitalization and reminders, care plans were not revised, leading to outdated interventions. Staff acknowledged the oversight, which contradicted facility policy requiring updates for changes in condition.
The facility failed to meet professional standards for two residents by not properly managing tube feeding protocols. A resident's tube feeding was left connected after completion, and residual volumes were not documented as ordered. Another resident had an empty tube feeding container left hanging for over 24 hours, contrary to guidelines. Staff confirmed these practices, which did not align with physician orders or facility policies.
Two residents in the facility were not provided with the necessary restorative nursing assistance to maintain their range of motion. One resident, with cerebral infarction and hand contractures, was not wearing the prescribed splints, while another resident with a traumatic brain injury was not consistently using the ordered hand splints. Staff confirmed the lack of adherence to the care plans, which were designed to prevent further contracture progression.
A resident with acute and chronic respiratory failure was allowed to perform his own tracheostomy care without a risk and benefit assessment, care plan, or physician's order. The facility's policies on care planning and physician's orders were not followed, as confirmed by the MDS Coordinator and RT Director.
A LTC facility failed to implement proper infection control practices, including a nurse not performing hand hygiene during medication pass, a resident's unclean call cord mouthpiece, expired food in a resident's room, and dirty privacy curtains. These deficiencies were contrary to the facility's infection prevention policies.
The facility did not post nurse staffing information daily at the beginning of each shift for a census of 80 residents. Observations showed that staffing data was not posted for five consecutive days, and when posted, it was after the morning shift had started. The DON confirmed that postings should occur before the shift begins, as per the facility's policy.
A resident with quadriplegia and full mental capacity did not receive quarterly care conferences, violating their rights to participate in care planning. The facility missed conferences in January and March, as confirmed by the ADM and DON. The resident reported not being updated on their care since the last conference in October.
A resident's medical records request was delayed due to the absence of a designated medical records person, resulting in the facility failing to provide the records within the required two working days. The request, initially received on 7/31/24, was not addressed until 8/15/24, contrary to the facility's policy.
A resident with major depressive disorder and lymphedema, capable of making healthcare decisions, had a documented preference for female CNAs for personal care. Despite this, a male CNA attended to her, causing discomfort. The CNA was unaware of her preference, and the ADON confirmed that care plan preferences should be honored. The facility's policy requires person-centered care, but this was not implemented, leading to a deficiency.
The facility failed to treat residents with dignity and respect as staff were overheard speaking in a foreign language throughout the facility. Multiple staff members and residents confirmed that this behavior occurred frequently in hallways and at the nurses' station, making residents feel uncomfortable and insecure. Despite being raised in Resident Council meetings, the issue remained unaddressed by the administration.
A facility failed to inform a resident's responsible party about a new medication order for ivermectin, as required by its policy. The resident, diagnosed with a neurocognitive disorder, lacked the capacity to make healthcare decisions. Licensed Nurse 1 forgot to notify the RP, and the Director of Nursing confirmed the absence of documentation. This oversight had the potential to disregard the resident and her RP's right to be informed of her treatment.
A resident with hypertension and end-stage renal disease did not have their blood pressure checked before receiving BP medication, contrary to physician orders. The resident reported this issue had occurred multiple times. The facility's records confirmed that BP medication was administered despite systolic BP readings being below the threshold set by the physician.
A medication cart was left unlocked and unattended by a nurse while at the nursing station, with multiple residents and staff present in the hallway. The DON confirmed that the expectation is for medication carts to be locked. Facility policy states that medications should be stored securely and only accessible to authorized personnel.
A facility failed to separate two residents after an altercation, resulting in one resident sustaining bruises. Despite witnessing the incident, an LPN did not follow the facility's policy to separate the residents and did not report the incident to the Nurse Supervisor or DON. The residents, both with dementia, remained in the same room, leading to further harm.
A deficiency occurred when an LPN failed to immediately notify the NP and RPs after witnessing an altercation between two residents, one with severe memory problems and the other with moderate memory issues. This led to delayed assessments and diagnostic testing for injuries. The NP was not informed of the incident until the following day, and the DON confirmed that the LPN did not follow professional standards or facility policy, which requires immediate notification of changes in a resident's condition.
A resident with neurocognitive disorder slapped another resident with dementia, and the incident was not reported to authorities within the required timeframe. Despite being witnessed by an LPN, the report to the CDPH, Ombudsman, and police was delayed. The facility's policy mandates reporting within two hours for incidents resulting in serious injury, which was not followed.
A licensed nurse failed to document and assess two residents after witnessing an altercation where one resident slapped another. The nurse did not conduct or document assessments or initiate care plans for the residents involved, despite facility policy requiring such actions. The incident involved residents with dementia, resulting in one resident sustaining bruises, which were later documented by other staff.
An LPN in an LTC facility failed to document an altercation between two residents and did not notify their responsible parties in a timely manner. This incident involved a resident with severe memory problems and another with moderate memory issues. The LPN witnessed the altercation but did not record the details in the medical records or inform the Nurse Supervisor, Director of Nursing, or Nurse Practitioner promptly, leading to delayed assessments and distress for one resident's responsible party.
A licensed nurse in the facility failed to follow abuse prevention policies by closing a resident in her room to monitor her whereabouts, resulting in the resident being isolated. The resident, with a history of wandering and moderate cognitive impairment, confirmed she would not leave the room if the door was closed. The nurse was terminated for this violation.
The facility failed to document the administration of permethrin cream for a resident with scabies and two roommates treated prophylactically. The Infection Preventionist Nurse confirmed the medication was given, but it was not recorded in the MAR, and the Director of Nursing verified no electronic orders were present.
The facility failed to follow its abuse prevention policy when a CNA continued to provide care after allegedly tying a resident's hand to the bed. The incident was reported three hours later, and the CNA was not suspended until four hours after the shift ended, potentially risking further harm to other residents.
The facility failed to develop and implement a comprehensive care plan for a resident with a deep tissue injury pressure ulcer (DTI-PU). Despite the resident's high risk for pressure ulcers and severe cognitive impairment, the facility did not create a care plan or document regular turning and incontinent care, leading to the development of a pressure ulcer.
A resident with severe cognitive impairment and high risk for pressure ulcers developed a deep tissue injury pressure sore due to the facility's failure to follow preventive measures and create a care plan. The resident was not turned every two hours or provided with appropriate incontinent care, leading to significant skin breakdown.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices when staff did not follow enhanced barrier precautions (EBP) for a resident on transmission-based precautions. The resident was admitted in March 2024 with diagnoses including a gastrostomy and stenosis of the larynx. On 3/4/26 at 10:34 a.m., an observation showed a sign outside the resident’s room indicating the resident was on EBP. During this time, CNA 1 and CNA 2 transferred the resident from bed to wheelchair without wearing gowns, despite the posted EBP sign. In subsequent interviews, CNA 1 and CNA 2 confirmed they were not wearing gowns during the transfer. CNA 1 stated she was aware the resident was on EBP and that she should have worn a gown, and CNA 2 stated he should have been wearing a gown because it could spread an infection to other residents. LN 1 confirmed the resident was on EBP and stated CNAs should have been wearing proper PPE to minimize the risk of passing infection to other residents. The Infection Preventionist also confirmed the expectation that staff follow the precaution signs and wear appropriate PPE, including gowns, under EBP. Review of the facility’s infection control policy, dated 1/12/12, indicated the facility’s infection control policies and procedures are intended to help prevent and manage transmission of diseases and infections and that staff are trained on these policies upon hire and periodically thereafter.
Failure to Protect Resident from Financial Exploitation by Staff
Penalty
Summary
A staff member at the facility failed to protect a resident with moderate cognitive impairment and a history of major depressive disorder from misappropriation of property and exploitation. The resident, who was admitted with diagnoses including major depressive disorder, adult failure to thrive, and economic difficulties, reported that a staff member took her wallet and ATM card, and subsequently withdrew money from her personal bank accounts without her consent. The resident and her cousin both reported the missing wallet and alleged that the staff member had borrowed money and failed to return it. Bank statements reviewed by facility staff and the resident's cousin showed multiple unauthorized withdrawals over several months, totaling $12,773, with the staff member's name appearing on the transactions. Interviews with the resident, her cousin, and facility staff confirmed that the staff member had access to the resident's bank accounts and had transferred money to her own account. The resident consistently stated that she trusted the staff member, provided her with the debit card and PIN, and was unaware of the extent of the withdrawals. The resident experienced significant emotional distress upon learning of the financial exploitation, as evidenced by multiple episodes of crying and emotional breakdowns documented in psychosocial notes and observed by staff. Facility policy explicitly prohibits exploitation, misappropriation of resident property, and financial abuse, defining these as the deliberate or wrongful use of a resident's belongings or money without consent. Despite these policies, the staff member was able to access and withdraw funds from the resident's accounts over an extended period, resulting in substantial financial loss and emotional harm to the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and dementia was touched in the groin area by another resident during a facility activity. The incident was witnessed by an Activity Assistant, who observed one resident using his left hand to touch the lap near the groin area of the other resident. The staff member immediately intervened and separated the two residents. The resident who was touched had a history of cognitive communication deficit and dementia, with a Brief Interview of Mental Status (BIMS) score indicating severe cognitive impairment. The resident who initiated the contact had diagnoses of aphasia and hemiplegia, but was assessed as having intact cognition. The facility's policy prohibits any form of resident abuse, neglect, or mistreatment, but this policy was not upheld in this instance.
Delayed Reporting of Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to immediately report an alleged incident of sexual abuse involving a resident with cognitive communication deficit and dementia. The incident occurred when an activity assistant observed another resident, who has aphasia and hemiplegia, touching the first resident's lap near the groin area during a group activity. The activity assistant intervened by stopping the behavior and separating the residents but did not notify her supervisor or report the incident to the appropriate agencies at that time. Documentation shows that the required Report of Suspected Dependent Adult/Elder Abuse (SOC 341) was not faxed to the Department until the following day, more than two hours after the incident occurred. The facility's policy requires immediate reporting of all allegations of abuse as mandated by law and regulation. The delay in reporting was confirmed through interviews and review of the facility's fax log and policy documents.
Failure to Follow Enhanced Barrier Precautions During Environmental Cleaning
Penalty
Summary
A housekeeper failed to follow required infection control practices while cleaning the room of a resident who was admitted with a stage 4 pressure ulcer to the sacrum. The resident had been placed on Enhanced Barrier Precautions (EBP) due to the presence of a chronic wound, as indicated by a physician order and signage outside the room. During an observation, the housekeeper was seen cleaning the resident's room without wearing the appropriate personal protective equipment (PPE), specifically a gown, despite being aware of the EBP status. Interviews with a licensed nurse and the Director of Staff Development confirmed that the housekeeper did not adhere to the facility's policy, which requires environmental services personnel to use gloves and gowns when cleaning and disinfecting the environment around residents on EBP. The facility's policy, revised in October 2024, specifically states that gown and gloves must be used when cleaning high-touch surfaces in the rooms of residents on EBP, such as those with chronic wounds.
Unsecured Resident Records Found Outside Facility
Penalty
Summary
During an observation by the facility's back patio, boxes containing documents with residents' personal information were found unattended and unsecured on top of two carts. This was confirmed during a concurrent observation and interview with the DON, who acknowledged that the documents belonged to residents and should have been secured, shredded, and properly disposed of. A review of the facility's policies indicated requirements to protect confidential clinical information and residents' rights regarding protected health information (PHI). The documents were left outside the facility, creating the potential for unauthorized access to residents' personal and medical information.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him in the leg in the activity room. According to progress notes and staff interviews, one resident, who had no memory impairment and was admitted with anxiety, was sitting in the activity room when another resident, diagnosed with dementia and depression and exhibiting significant memory impairment, rammed his wheelchair into the first resident's wheelchair and proceeded to punch him in the leg multiple times. The incident was witnessed by the activities assistant, who also reported that the aggressive resident attempted to hit her as well. Following the altercation, the assaulted resident expressed feeling unsafe and scared to return to the activity room when the other resident was present. Documentation from the social services director confirmed the resident's fear and reluctance to participate in activities due to the incident. The facility's abuse prevention policy defines physical abuse as including hitting and punching and requires the administrator or designee to provide a safe environment for residents. The failure to prevent this incident decreased the potential for the resident to maintain his highest practicable physical, mental, and psychosocial well-being.
Resident Subjected to Verbal Abuse and Neglect After Fall
Penalty
Summary
A resident with significant cognitive and physical impairments, including aphasia, memory problems, and dependence on staff for daily activities, was found on the floor after a fall. The resident was unable to explain why he was on the floor and called out for help. A Certified Nursing Assistant (CNA) who was not assigned to the resident entered the room, used profane and demeaning language, and told the resident he would remain on the floor until the end of the shift. The CNA placed a pillow and blanket under the resident and then left, rather than assisting him off the floor or ensuring his immediate safety and comfort. The incident was witnessed and corroborated by the resident's roommate, who reported hearing the CNA use inappropriate language and dismiss the resident's needs. The CNA herself admitted to using profanity in the presence of residents and staff, citing frustration as the reason for her behavior. Facility records and interviews confirmed that the CNA's actions were verbally abusive and neglectful, as she failed to provide appropriate care and respect for the resident's dignity following his fall. The facility's investigation substantiated the allegations of verbal abuse and neglect, with both the resident and his roommate providing consistent accounts of the CNA's conduct. The facility's policy requires staff to treat residents with dignity and respect at all times, and prohibits demeaning practices. The CNA's actions directly violated these standards, resulting in a failure to protect the resident from abuse and neglect.
Failure to Implement Fall Prevention Protocols and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two of four sampled residents. For one resident with dementia, the care plan identified a risk for falls and required adherence to the facility's fall protocol. However, the fall risk evaluation was incomplete and lacked a score, and after an unwitnessed fall in the hallway, the resident was assisted back to a wheelchair without assessment or physician notification. There was no documentation of the fall, no post-fall assessment, and no follow-up, despite the resident later experiencing acute hip pain and being diagnosed with a femoral neck fracture. Staff interviews confirmed the fall was not reported or documented, and the Director of Nursing acknowledged that facility protocol was not followed, resulting in delayed care and increased risk for repeat falls. For another resident admitted with a history of pulmonary embolism, the care plan also identified a fall risk and called for fall precautions. Despite this, the resident experienced two falls—one in the bathroom and another from bed. When observed, the resident's bed was not in the lowest position and a fall mat was not in place, contrary to required precautions. The facility was unable to provide documentation of fall risk precautions for this resident, and staff confirmed that fall precautions were not implemented as required, increasing the risk of injury. The facility's fall management policy required specific interventions and documentation, which were not followed in these cases.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) was reported to have hit a resident with dementia on the back after the resident knocked over a food tray. The resident, who had a history of unspecified dementia and a BIMS score of 0 indicating severe cognitive impairment and inability to express ideas or wants, was involved in an incident during dinner time. According to another CNA, the staff member became upset and slapped the resident on the back multiple times. The accused CNA stated he only tapped the resident on the shoulder to redirect him, but the witness differentiated between a tap and a slap, describing the action as a side-to-side motion consistent with slapping. The incident was documented in the resident's progress notes, and an assessment found no physical injuries such as redness or bruising. The facility's administrator and director of nursing ultimately unsubstantiated the abuse allegation, citing a lack of witnesses and conflicting accounts. The facility's abuse prevention policy prohibits any form of resident abuse, neglect, or mistreatment, and the expectation is for staff to ensure resident safety and follow established protocols.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required timeframe. A resident with a diagnosis of bipolar disorder and a perfect score on the Brief Interview for Mental Status (BIMS) reported suspected staff-to-resident abuse to the Social Services Director. The notification from the resident was documented at 6 p.m., but the written SOC 341 report was not faxed to the Department until the following day at 4:28 p.m., exceeding the mandated two-hour reporting window. Additionally, the initial document presented by the Administrator lacked the resident's name or any identifying information. During interviews and policy review, the Administrator acknowledged the regulatory requirement to report allegations of abuse within two hours if there is serious bodily injury, and within 24 hours if there is no injury, as outlined in the state operations manual. The facility's own policy also required notification of outside agencies within two hours for all allegations of abuse. The delay in reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.
Resident Mail Privacy Breach
Penalty
Summary
The facility failed to maintain the privacy of communication for a resident when the Business Office Manager (BOM) opened a letter addressed to the resident without the resident's consent. The letter contained an electronic benefit transfer (EBT) card. According to interviews, the BOM acknowledged opening the mail and stated that, typically, mail addressed to residents, including EBT cards, should be delivered directly to them by staff such as the Activities Director and not opened by the BOM. The Administrator confirmed that business office personnel should not have opened the resident's mail without consent, as this action infringed on the resident's privacy rights. A review of the facility's policy indicated that residents are allowed to send and receive personal mail unopened, and staff are not to open mail unless requested by the resident.
Failure to Conduct Scheduled Care Conferences
Penalty
Summary
The facility failed to ensure that three residents participated in their care planning as required. Resident 1, who was admitted with quadriplegia and had full cognitive capacity, did not have his care conference on the scheduled date. The Director of Nursing confirmed that the care conference was not conducted as planned. Similarly, Resident 4, also with quadriplegia and intact cognition, did not have a care conference in December as scheduled, and the Social Services Director did not communicate with him about it. Resident 5, diagnosed with multiple sclerosis and with intact cognition, also missed her scheduled care conference in December. The facility's policy requires that residents and their representatives be notified and involved in care planning meetings, which should be documented. However, the Director of Nursing confirmed that no Interdisciplinary Team notes were found for the scheduled care conferences of Residents 4 and 5, indicating that these meetings did not occur. This lack of adherence to the facility's policy resulted in the residents not being able to participate in their care planning as intended.
Medication Error Due to Improper Administration
Penalty
Summary
The facility was found to have a medication error rate of 9.09% during a medication pass, exceeding the acceptable threshold of 5%. This error rate was observed when three medication errors occurred out of 33 opportunities. Specifically, a licensed nurse crushed and administered medications to a resident without a physician's order to do so. The resident, who was admitted with diagnoses of depression and hypertension, was given crushed medications mixed with applesauce, despite the absence of an order permitting this method of administration. The medications involved included carvedilol, lisinopril, and duloxetine. Notably, duloxetine's manufacturer's specifications explicitly state that the medication should not be crushed or mixed with food or liquids. The facility's policy also requires a physician's order for medications to be crushed. Interviews with the nurse practitioner and the director of nursing confirmed that an order was necessary for crushing medications, and the facility's pharmacist had previously noted the need to add a 'do not crush' instruction for duloxetine in the medication regimen review.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications, which was observed during a survey. In the medication storage room, 10 bottles of sorbitol solution were found with an expiration date of the previous month. A licensed nurse acknowledged that expired medications should not be stored in the medication room. Additionally, in a skilled nursing medication cart, a used insulin pen was stored without a plastic bag, a medication card of benzonatate pills was found expired, and six loose pills were discovered in the drawer. The nurse confirmed these issues, stating that the insulin pen should have been bagged to prevent cross-contamination, the expired benzonatate should have been discarded, and loose pills should not be present in the cart. Further observations in another medication cart revealed an opened bottle of simethicone tablets, an unwrapped inhaler, and a bottle of atropine sulfate eye drops, all without open dates. A bottle of lansoprazole powder was expired, and a vial of nasal spray had a torn prescription label, making it impossible to identify the resident it belonged to. The nurse confirmed the lack of open dates and the presence of expired medications and loose pills. The Director of Nursing stated that expired medications should not be stored and that medications needed open dates. The facility's policy indicated that outdated or deteriorated medications should be immediately removed from stock.
Deficiency in Dietary Staff's Use of Sanitization Test Strips
Penalty
Summary
The facility failed to ensure that dietary staff demonstrated sufficient skills in using chemical sanitization test strips for a low temperature dishwasher and red bucket, affecting the food and nutrition services for a census of 80. During an observation, a dietary aide (DA) did not follow the manufacturer's specifications for using chlorine test strips, as she did not blot the test strip on a tissue paper before comparing it against the test strip kit. This was confirmed during an interview with the DA, who acknowledged not following the manufacturer's instructions. Additionally, the DA was unable to identify the appropriate actions to take when the sanitizing solution did not meet the target concentration. The Dietary Supervisor (DS) confirmed that the DA was expected to follow the manufacturer's specifications. The manufacturer's instructions specified that the test strip should be dipped, removed quickly, blotted immediately with a paper towel, and compared to the color chart at once. The facility's policy indicated that re-education would be provided to employees unable to satisfactorily perform their skills.
Food Safety and Sanitation Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to ensure that food was prepared and stored in a safe and sanitary manner, as observed during a survey. A large container of cooked Brussels sprouts was left uncovered on a stove burner, and containers of corn with sliced bell pepper and cooked carrots were found undated and unlabeled on a counter. Additionally, personal items such as a cell phone and water jug were placed next to the uncovered food. These actions were confirmed by the Dietary staff, who acknowledged that food should have been covered, dated, and labeled, and personal belongings should not be placed near food. Further observations revealed expired food items and unsanitary conditions in the dry storage area. Three packs of corn tortillas were found to be expired, and the air vents in the storage area had a whitish substance on the slats. The Dietary Supervisor confirmed these findings and stated that the expired tortillas should have been discarded and the air vents cleaned. The facility's policies on food storage and maintenance were reviewed, indicating that food should be labeled and dated, and maintenance should ensure cleanliness and safety.
Failure to Obtain Informed Consent for Restraint Use
Penalty
Summary
The facility failed to obtain informed consent for the use of bilateral mittens for a resident, identified as Resident 34, who was admitted with chronic respiratory failure and anxiety disorder. During an observation and interview, it was noted that the resident was wearing soft mittens to prevent him from pulling out his tracheostomy tube. The order for the mittens was documented in the resident's Order Summary Report, but the informed consent was incomplete and unsigned by the resident's representative. Interviews with Licensed Nurse 2 and the Director of Nursing confirmed that the informed consent for the use of mittens was not completed, lacking the prescriber's name, the representative's name, and a signature. The facility's policy on restraints requires that informed consent be obtained before any restraint is used, and if the resident lacks decision-making capacity, consent should be obtained from the surrogate. This oversight had the potential to deprive the resident's representative of making informed decisions regarding the resident's care.
Failure to Provide Bed Hold Agreement Notification
Penalty
Summary
The facility failed to provide a written bed hold agreement to a resident or their representative before and upon transfer to a hospital. This deficiency was identified during a review of the resident's admission record and Minimum Data Set (MDS), which indicated the resident was admitted to the hospital for further evaluation due to low oxygen saturation. The Licensed Nurse confirmed that there was no copy of the completed bed hold policy agreement signed by the resident or their representative. During an interview with the Director of Nursing, it was confirmed that if the bed hold policy agreement was not available, then the resident or their representative did not receive a notice and were not informed of the transfer. The facility's policy and procedure require that the resident and/or representative be notified in writing of the bed hold option whenever the resident is transferred to an acute care hospital. This oversight had the potential to leave the resident or their representative unaware of their right to return to the facility after hospitalization.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one of the sampled residents, identified as Resident 27. This resident was admitted with diagnoses including lung cancer, which required dependence on a ventilator. The comprehensive MDS assessment inaccurately coded Resident 27's prior level of function (PLOF) as independent with indoor/outdoor mobility and transfers, despite the use of a mechanical lift. During a review, the MDS Coordinator confirmed the inaccuracy and acknowledged the need for modification. The Director of Nursing (DON) stated that the facility lacked a specific MDS policy and expected staff to accurately complete MDS assessments to provide appropriate care. This inaccuracy in coding increased the risk of inadequate care planning for Resident 27.
Failure to Update Care Plans for Residents with Changed Conditions
Penalty
Summary
The facility failed to revise and review comprehensive care plans for two residents, leading to deficiencies in their care. Resident 2, who had a history of Parkinson's disease and recurrent falls, was hospitalized due to falls but did not have their fall care plan updated with new interventions to prevent further incidents. The Minimum Data Set Coordinator confirmed that the care plan was not reviewed or revised as required, which was a lapse in maintaining the resident's safety and well-being. Similarly, Resident 44, diagnosed with quadriplegia, had their tracheostomy removed, but the care plan was not updated to reflect this significant change. Despite the resident's mental capacity and repeated reminders to staff, the care plan still included outdated tracheostomy care interventions. The Licensed Nurse and Director of Nursing acknowledged that the care plan should have been revised to ensure appropriate care. The facility's policy mandates that care plans be updated with any change of condition, which was not adhered to in these cases.
Failure to Adhere to Tube Feeding Protocols
Penalty
Summary
The facility failed to provide services meeting professional standards of quality for two residents. For Resident 9, who was admitted with dysphagia, the tube feeding was left connected after completion, and the residual volume was not documented in the Medication Administration Record (MAR) as ordered. Licensed Nurse 8 confirmed the practice of leaving the tube connected until the next feeding, and the Director of Nursing acknowledged the incomplete documentation and incorrect practice, which should have included checking and documenting the residual volume to follow the physician's order. For Resident 45, who was admitted with traumatic brain injury, persistent vegetative state, and quadriplegia, an empty container of tube feeding was left hanging for more than 24 hours. Licensed Nurse 3 confirmed the container's date and stated it should be changed every 24 hours to prevent infection risk. The Director of Staff Development and the Director of Nursing both stated that the tube feeding containers and tubing should be changed every 24 hours, in accordance with the manufacturer's guidelines and facility policy.
Failure to Apply Hand Splints as Ordered
Penalty
Summary
The facility failed to provide restorative nursing assistance to two residents, leading to deficiencies in maintaining and improving their range of motion (ROM). Resident 9, who was admitted with cerebral infarction and bilateral hand contractures, was observed without the prescribed carrot and foam roll splints on multiple occasions. Despite the order for daily application of these splints to minimize contracture risk, both the Restorative Nurse Assistant and a Licensed Nurse confirmed that Resident 9 was not wearing the splints as required. Similarly, Resident 40, admitted with a traumatic brain injury and limited ROM in the upper limbs, was not consistently wearing the ordered bilateral resting hand splints with finger separators. Observations and interviews revealed that the splints were not applied as per the care plan, which was intended to prevent further contracture progression. The Director of Nursing acknowledged that both residents should have been assisted and monitored to ensure adherence to their care plans, as outlined in the facility's contracture-prevention policy.
Failure to Ensure Proper Tracheostomy Care
Penalty
Summary
The facility failed to ensure proper tracheostomy care for a resident, identified as Resident 15, who was allowed to perform his own tracheostomy gauze change, suction, and inner cannula insertion without a risk and benefit assessment, care plan, or physician's order in place. Resident 15 had diagnoses of acute and chronic respiratory failure with hypoxia and was tracheostomy dependent. During observations and interviews, it was confirmed that Resident 15 had all the necessary supplies at his bedside and was independently managing his tracheostomy care. The Minimum Data Set Coordinator and the Respiratory Therapy Director both confirmed that there was no documentation of a risk and benefit assessment, care plan, or physician's order to ensure Resident 15's capability to safely perform his own tracheostomy care. The facility's policies on comprehensive person-centered care planning and physician's orders were not followed, as they require a clear and complete description of the physician's plan of care and documentation in the resident's medical record.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices during a medication pass when a licensed nurse did not perform hand hygiene. The nurse entered a resident's room, checked the resident's blood pressure, and then prepared medication without sanitizing hands after removing gloves. This was contrary to the facility's infection prevention and control program, which mandates hand hygiene upon entering and leaving a room and before and after medication preparation. Another deficiency was observed with Resident 44, who had a breath-activated call cord disposable mouthpiece that was not changed and had a large brown substance in it. The resident, diagnosed with quadriplegia, indicated that the mouthpiece was not replaced regularly. Staff confirmed the presence of the substance and acknowledged the risk of infection, including pneumonia, due to the unclean mouthpiece. The facility's policy requires regular replacement of such equipment to prevent infection. Additionally, a container of yogurt dated beyond its safe consumption date was found in Resident 17's room, posing a risk of foodborne illness. The facility's policy requires perishable food items to be discarded if not consumed within two hours. Furthermore, the privacy curtains in the rooms of Residents 17 and 44 were found to be dirty and stained, which could contribute to infection control issues. The facility's policy emphasizes maintaining a clean and sanitary environment for residents.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily at the beginning of each shift for a census of 80 residents. Observations and interviews revealed that staffing information was not posted for five consecutive days, including weekends and weekday morning shifts. On 10/7/24, the staffing information displayed was outdated, showing data from 10/2/24. On 10/8/24, the staffing information was observed to be posted after the morning shift had already started, as confirmed by Licensed Nurse 2 and the Staffing Coordinator. The Director of Nursing acknowledged that the staffing information should be posted before the start of the morning shift, as per the facility's policy from 2018, which mandates daily postings at the beginning of each shift.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences for a resident, resulting in a violation of the resident's rights to participate in their care planning. The resident, who was admitted in 2022 with quadriplegia, had a full mental capacity to make decisions as indicated by a perfect score on the Brief Interview for Mental Status. Despite this, the resident did not have care conferences in January and March of 2024, as confirmed by both the Administrator and the Director of Nursing. The resident expressed that they and their spouse were not kept informed about their care situation, with the last care conference before June 2024 occurring in October 2023.
Delay in Providing Resident's Medical Records
Penalty
Summary
The facility failed to provide the requested medical records for a resident within the required two working days, as per the facility's policy. The resident, who was admitted in 2023 with a diagnosis of respiratory failure, had their medical records requested on 7/30/24. However, due to the absence of a designated medical records person at the time, the request was overlooked. The Director of Nursing (DON) confirmed that the policy was not followed, and the initial request was missed. The Medical Records (MR) staff acknowledged that the request was not found until 8/13/24 and was not sent until 8/15/24, despite being received on 7/31/24. The facility's policy, titled 'Resident Access to PHI,' mandates that medical records be provided within two working days of a written request. The DON verified that the records should have been sent by 8/2/24, but as of 8/15/24, the records had not been sent to the requesting party.
Failure to Implement Resident's Care Plan Preference
Penalty
Summary
The facility failed to implement a care plan for a resident who had expressed a preference for personal care to be provided by female staff members. The resident, who had been diagnosed with major depressive disorder and lymphedema, was capable of making healthcare decisions and had a care plan initiated that specified her preference for female CNAs for personal care needs, including changing and showers. Despite this documented preference, the resident was attended to by a male CNA, which made her feel uncomfortable during perineal care. Interviews conducted during the investigation revealed that the male CNA was not informed of the resident's preference for female staff. The Assistant Director of Nursing confirmed that resident preferences indicated in the care plan should be honored. The facility's policy on comprehensive person-centered care planning, revised in 2018, mandates that the facility provide care that meets the health, safety, psychosocial, behavioral, and environmental needs of the resident to maintain their highest well-being. However, the failure to communicate and implement the resident's care plan preference resulted in a deficiency in providing person-centered care.
Staff Language Use Affects Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as staff were overheard speaking in a foreign language throughout the facility. This behavior was observed by multiple staff members, including a Respiratory Therapist, Housekeeper, Certified Nursing Assistants, a Licensed Nurse, and the Activities Director, who all confirmed that staff frequently spoke in a foreign language in the hallways, at the nurses' station, and around residents. The issue was raised in Resident Council meetings, indicating that it was a persistent concern among residents. Four residents, who had no memory impairments, expressed feeling uncomfortable, insecure, and like outsiders due to the staff's behavior. They reported that the issue had been discussed extensively in Resident Council meetings, but no action had been taken by the administration. The Infection Preventionist acknowledged the problem, stating that the expectation was for staff to speak English in work areas to prevent residents from feeling that they were being talked about. The Administrator also agreed that staff should not speak loudly in a foreign language around residents, as it was their home.
Failure to Inform Responsible Party of New Medication Order
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding informing the responsible party (RP) of a resident about a new medication order. This deficiency was identified for one of the four sampled residents, who was diagnosed with a neurocognitive disorder with Lewy bodies and lacked the capacity to make her own healthcare decisions. The facility's policy required that the family or RP be informed of any changes in the resident's condition. However, when a new order for ivermectin was prescribed for scabies prophylaxis, the RP was not notified. The deficiency was confirmed through interviews and record reviews. Licensed Nurse 1 admitted to forgetting to inform the RP about the new medication order. The Director of Nursing also acknowledged the absence of documentation indicating that the RP was informed before the medication was administered. The facility's policy, revised in 2015, clearly stated that licensed nurses must notify the family or surrogate decision-makers of any changes in the resident's condition as soon as possible and document the time of contact. This oversight had the potential to disregard the resident and her RP's right to be informed of her treatment.
Failure to Check Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for a resident when the resident's blood pressure (BP) was not checked against physician orders before administering BP medication. The resident, who was admitted with diagnoses including hypertension and end-stage renal disease on dialysis, reported that nurses did not check his BP before giving his BP medications, which had occurred five times. This oversight had the potential to affect the resident's health by administering BP medication not in accordance with the physician's order. A review of the resident's Order Summary Report indicated that the resident had three different BP medications ordered, all with parameters to hold the medication if the systolic BP was less than 130. However, the Medication Administration Record showed that on two occasions, the resident received nifedipine 30 mg despite having systolic BP readings below 130. The Director of Nursing confirmed that the medication was administered without checking the BP and acknowledged that the medication should have been held according to the doctor's order.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications were kept locked or under the direct observation of authorized staff, which had the potential for unauthorized access by staff or residents. During an observation and interview, a Licensed Nurse left a medication cart unlocked and unattended while at the nursing station on the telephone. At that time, multiple residents and other staff were present in the hallway. The Licensed Nurse acknowledged that the medication cart should have been locked. The Director of Nursing confirmed that the expectation is for the medication cart to be locked. A review of the facility's policy on medication storage indicated that medications and biologicals should be stored safely, securely, and properly, accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. The policy also stated that medication rooms, carts, and supplies should be locked or attended by authorized personnel.
Failure to Separate Residents After Altercation
Penalty
Summary
The facility failed to ensure the safety of two residents after an altercation occurred between them. Licensed Nurse 1 witnessed Resident 1 slap Resident 2 on the face but did not separate the two residents into different rooms, as required by the facility's policy. This inaction led to Resident 1 sustaining a bruise on the right cheek and jaw due to continued exposure to the perpetrator. Resident 1 was admitted with diagnoses including neurocognitive disorder with Lewy Bodies and dementia with psychotic disturbance, and had a severe memory problem. Resident 2 was admitted with dementia with other behavioral disturbances and had a moderate memory problem. On the evening of the incident, Resident 1 became aggressive and combative, leading to the altercation with Resident 2. Despite the altercation being witnessed by LN 1, the residents were not separated, and the incident was not reported to the Nurse Supervisor or the Director of Nursing. The facility's policy requires immediate separation of residents involved in altercations to ensure safety, but this was not followed. Interviews with staff revealed that LN 1 did not inform the Nurse Supervisor or the Director of Nursing about the incident, and the residents remained in the same room. The failure to separate the residents and report the incident promptly resulted in Resident 1 sustaining multiple bruises, which were later documented by other nursing staff.
Failure to Notify NP and RPs After Resident Altercation
Penalty
Summary
The report details a deficiency involving the failure of a Licensed Nurse (LN 1) to immediately notify the Nurse Practitioner (NP) and Responsible Parties (RP) for two residents after witnessing an altercation. Resident 1, who has a neurocognitive disorder with Lewy Bodies and dementia with psychotic disturbance, slapped Resident 2, who has dementia with other behavioral disturbances. This incident was not promptly communicated to the NP or the RPs, leading to delayed assessments and diagnostic testing for potential injuries. Resident 1 was admitted to the facility with severe memory problems, while Resident 2 had moderate memory issues. On the morning following the altercation, another nurse (LN 2) noticed bruises on Resident 1 and notified the NP, who ordered an x-ray and cold compress. However, the NP's progress note indicated that there was no documentation on how Resident 1 acquired the bruises, and the NP was not informed of the altercation until the following day. The NP stated that had she been informed earlier, she would have evaluated both residents immediately. The Director of Nursing (DON) confirmed that LN 1 did not adhere to professional standards by failing to notify the NP or on-call physician and the RPs of both residents promptly. The facility's policy requires immediate notification of changes in a resident's condition, including incidents involving altercations. The failure to follow this policy resulted in distress for Resident 1's RP, who discovered the injuries without prior notification from the facility staff.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of abuse within the regulatory timeframe involving two residents. Resident 1, who has a neurocognitive disorder with Lewy Bodies and dementia with psychotic disturbance, slapped Resident 2, who has dementia with other behavioral disturbances, on the face. This incident was documented by Licensed Nurse 1 (LN 1) in Resident 1's progress note, indicating that the altercation had occurred twice. Despite being aware of the incident, LN 1 did not report it to the California Department of Public Health (CDPH) and other authorities within the required timeframe. The incident was witnessed by LN 1, who intervened by separating the residents and redirecting them to their beds. However, the report to the CDPH, the Ombudsman, and the police department was not made until several days later, as confirmed by the Director of Nursing (DON). The facility's policy requires that any known instances of physical abuse be reported to the proper authorities within two hours if it results in serious bodily injury, which was not adhered to in this case. The facility's training records show that LN 1 attended sessions on abuse prevention and reporting, indicating that they were aware of the procedures. Despite this, the incident was not reported promptly, leading to a deficiency in the facility's compliance with state and federal regulations. The delay in reporting was acknowledged by the DON, who confirmed that LN 1 was the only witness to the incident and should have reported it earlier.
Failure to Document and Assess After Resident Altercation
Penalty
Summary
The report identifies a deficiency in the care provided by a licensed nurse (LN 1) at a nursing facility, where LN 1 failed to adhere to professional standards following an altercation between two residents. LN 1 witnessed Resident 1 slap Resident 2 but did not conduct or document an assessment of either resident after the incident. Additionally, LN 1 did not initiate a care plan for either resident following the altercation, which is a requirement according to the facility's policy and procedure for changes in condition. Resident 1, who has a diagnosis of neurocognitive disorder with Lewy Bodies and dementia with psychotic disturbance, was involved in the altercation with Resident 2, who has dementia with other behavioral disturbances. The incident resulted in Resident 1 sustaining bruises on the face and body, which were later documented by other nursing staff. However, there was no initial documentation by LN 1 regarding the altercation or the resulting injuries, which was confirmed by the Nurse Supervisor and other staff members during interviews. The facility's policy requires that any change in a resident's condition, such as an altercation, be documented promptly, and a care plan be updated to reflect the resident's current status. The Director of Nursing (DON) confirmed that LN 1 did not meet these professional standards, as there was no documentation of the altercation or assessments in the residents' charts, nor was there an immediate update to their care plans following the incident.
Failure to Document and Notify After Resident Altercation
Penalty
Summary
The report identifies a deficiency in the documentation and notification process following an altercation between two residents in a long-term care facility. Licensed Nurse 1 (LN 1) witnessed Resident 1 slap Resident 2 but failed to document the details of the incident in the medical records of both residents. Additionally, LN 1 did not record the time at which the responsible parties (RPs) of both residents were notified, leading to a delay in assessments and diagnostic testing for injuries. Resident 1, who has a diagnosis of neurocognitive disorder with Lewy Bodies and dementia with psychotic disturbance, was admitted to the facility with severe memory problems. Resident 2, diagnosed with dementia with other behavioral disturbances, was admitted with moderate memory issues. The altercation occurred on the evening of 5/2/24, but LN 1 did not document the incident in the residents' charts, nor did she notify the Nurse Supervisor (NS), Director of Nursing (DON), or Nurse Practitioner (NP) in a timely manner. The NP was only informed of Resident 1's bruises the following morning, which delayed the necessary medical evaluations. The facility's policy requires that any change in a resident's condition, including incidents, be reported and documented promptly. LN 1's failure to adhere to these standards resulted in distress for Resident 1's RP, who discovered the injuries during a video call without prior notification from the facility. The DON confirmed that LN 1 did not meet professional standards by failing to notify the NP or on-call physician and the RPs of both residents as soon as the residents' safety was ensured.
Failure to Prevent Abuse and Isolation of Resident
Penalty
Summary
The facility failed to follow their policy and procedure to prevent abuse for one of three sampled residents when a licensed nurse closed a resident in her room. This action resulted in the resident being isolated, which had the potential for further abuse or injury. The resident, who was admitted with Alzheimer's disease, hypertension, and unspecified dementia, was described as usually able to make herself understood and understand others, with a moderate cognitive impairment. The resident had a history of wandering, and the licensed nurse closed the door to her room to monitor her whereabouts, which was against the facility's policy on abuse prevention. Interviews with staff members and a review of facility documents revealed that the licensed nurse had a practice of closing doors and isolating residents. Two CNAs confirmed that the nurse would close the door and curtains to monitor residents' whereabouts. The facility's policy clearly stated that residents have the right to be free from involuntary seclusion and isolation. The licensed nurse was terminated for violating this policy. The resident confirmed during an interview that she would not leave the room if the door was closed, indicating that the action effectively isolated her against her will.
Failure to Document Administration of Permethrin Cream
Penalty
Summary
The facility failed to provide services according to professional standards of practice for three residents when permethrin cream, used to treat scabies, was not accurately documented in their Medication Administration Record (MAR). Resident 1, who tested positive for scabies, and his two roommates, who were treated prophylactically, did not have proper documentation of the administration of permethrin cream. The Infection Preventionist Nurse confirmed that the medication was administered but not recorded in the MAR, and the Director of Nursing verified that there were no electronic orders for the medication in the residents' records. Resident 1 was readmitted to the facility with multiple diagnoses, including scabies, and tested positive for the condition. Resident 2 and Resident 3, who were roommates of Resident 1, were treated prophylactically with permethrin cream. However, there was no documented evidence in their clinical records or MARs that the medication was given. The facility's policy requires that medication orders be received by a licensed nurse prior to administration and that the administration be documented in the MAR, which was not followed in this case.
Failure to Follow Abuse Prevention Policy
Penalty
Summary
The facility failed to follow its own policy and procedure for the prevention of further abuse when it allowed a Certified Nursing Assistant (CNA) to continue providing resident care after an alleged abuse incident. The incident involved a Respiratory Therapist (RT) witnessing the CNA tying a resident's hand to the side of the bed using a sheet. The resident had a laceration on her nose and a swollen lip. Despite the facility's policy requiring immediate suspension and removal of the staff member from the premises upon an allegation of abuse, the CNA was allowed to work an additional three hours before being suspended. The Director of Nursing (DON) confirmed that the alleged abuse was not reported to the nurse until the end of the night shift, approximately three hours after the incident occurred. The DON acknowledged that the CNA should have been suspended and sent home immediately when the situation was first reported. The CNA confirmed that he completed his full shift and was not suspended until approximately four hours after the shift had ended. This failure to promptly remove the CNA from resident care could have potentially resulted in further harm to other residents in the facility, which had a census of 87 residents at the time.
Failure to Develop and Implement Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a deep tissue injury pressure ulcer (DTI-PU). Resident 4, who was admitted with severe cognitive impairment and high risk for pressure ulcers, developed a pressure ulcer during her stay. The clinical records indicated that Resident 4 was dependent on staff for mobility and had a high Braden Scale score, indicating a high risk for pressure ulcers. Despite these indicators, the facility did not create a care plan or document regular turning and incontinent care for Resident 4, leading to the development of a pressure ulcer on her coccyx and buttocks. Interviews with the Assistant Director of Nursing (ADON) and Licensed Nurse 4 (LN 4) confirmed that there was no care plan created for Resident 4's DTI-PU and no documentation of the required two-hourly turning and incontinent care. The ADON and LN 4 acknowledged that the care plan should have been initiated as soon as the wound was identified, and the staff should have been monitoring and documenting the resident's care to prevent skin breakdown. The facility's policy on Comprehensive Person-Centered Care Planning, which mandates addressing resident-specific health and safety concerns to prevent decline or injury, was not followed in this case.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to follow their policy and procedures to prevent a pressure sore from developing for Resident 4, who was admitted with severe cognitive impairment and high risk for pressure ulcers. Despite being dependent on staff for mobility and being incontinent, there was no documentation that Resident 4 was turned every two hours or received appropriate incontinent care. The resident developed a deep tissue injury pressure sore on the left and right buttocks and coccyx area, which was identified by a licensed nurse on 12/15/23. The wound was later confirmed to be a deep tissue pressure injury with significant necrotic tissue. The Assistant Director of Nursing (ADON) and Licensed Nurse 4 (LN 4) both acknowledged that Resident 4 was at high risk for pressure sores and should have been turned every two hours. However, there was no documentation to confirm that these preventive measures were taken. Additionally, no care plan was created for Resident 4's pressure sore, which was against the facility's policy. The facility's policy on skin integrity management required the identification, evaluation, and intervention to prevent and heal pressure ulcers, but these steps were not followed in Resident 4's case.
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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