Royal Vista Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Gabriel, California.
- Location
- 909 W. Santa Anita Ave, San Gabriel, California 91776
- CMS Provider Number
- 055105
- Inspections on file
- 47
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Royal Vista Care Center during CMS and state inspections, most recent first.
The facility failed to maintain clear exit doors and hallways, with multiple obstructions such as wheelchairs, linen bins, and carts noted during observations. Staff interviews confirmed awareness of the need for clear egress paths, but the policy was not effectively implemented, posing risks to emergency evacuation and safety.
A resident with dementia and high fall risk sustained a fracture from an unwitnessed fall. The facility failed to report this unusual occurrence to the State Agency within 24 hours as required by their policy. The incident was only discovered upon the resident's readmission from a hospital.
A resident with dementia and muscle weakness, assessed as high risk for falls, experienced a deficiency in care when the facility failed to implement a care plan intervention of placing a floor mat at the bedside after an unwitnessed fall. The mat was found under the bed, contrary to the care plan, as confirmed by an RN.
A staff member failed to follow hand hygiene protocols while assisting a resident with chronic kidney disease, UTI, and diabetes. The staff member fed the resident with bare hands, touched another resident, and returned to assist the first resident without performing hand hygiene, contrary to the facility's policy.
A resident with dementia and a high risk for falls was left unattended in a wheelchair by the Director of Activities, resulting in a fall and rib fractures. The care plan lacked specific interventions for wheelchair safety, and staff interviews confirmed the need for constant supervision. The facility's fall risk policy was not adequately followed, leading to this deficiency.
A resident reported alleged rough handling by staff, but the facility failed to implement the care plan, including 72-hour monitoring for psychosocial wellbeing. Despite having a care plan addressing emotional distress and safety, there was no documentation or monitoring by licensed nurses, as confirmed by staff interviews. This oversight contravened facility policies requiring ongoing assessments and care plan revisions.
A resident on enhanced barrier precautions (EBP) did not receive care with proper PPE use, as staff failed to wear gowns during high-contact activities like diaper changes and medication administration via gastrostomy tube. Despite EBP signage, there was no PPE cart available, and staff were unaware of the requirements. The Director of Nursing confirmed the resident's care plan lacked EBP, and the facility's policy was not followed.
A resident with a history of chronic conditions developed a worsening pressure ulcer due to the facility's failure to assess, document, and communicate changes in the resident's skin and wound condition. The facility did not use the SBAR tool to document changes on multiple occasions, leading to the ulcer progressing to stage 4. The resident was later hospitalized with an infected ulcer and required surgical intervention.
A facility failed to ensure accurate documentation of a resident's skin condition and wound care. The resident, with chronic kidney disease and coordination issues, was at risk for pressure ulcers. Despite ongoing treatments for MASD and a stage 2 pressure ulcer, nurses' notes and weekly summaries did not consistently reflect these conditions. Interviews confirmed the documentation inconsistencies, and facility policies on pressure ulcer assessment and documentation were not followed.
A facility failed to maintain the dignity and privacy of several residents. A resident was fed by a CNA standing over them, contrary to policy. Two residents were changed with curtains and doors open, exposing them to passersby. Another resident was repeatedly called "Mama" against her preference, and a resident was fed without a chair for the CNA to sit, compromising a dignified dining experience.
The facility failed to provide communal dining, impacting residents' social interactions and emotional well-being. Since 2020, residents have been eating in their rooms, leading to feelings of loneliness and dissatisfaction. Despite residents expressing their desire for communal dining, the facility has not resumed this practice, which is essential for a homelike environment and resident dignity.
The facility failed to provide communication boards in the appropriate language for three residents, hindering their ability to communicate with staff. One resident with severe cognitive impairment had a board in a non-English language, while another resident's board was only recently placed in their room. A third resident, who does not speak English, reported that staff did not use a communication board, relying instead on his sister for communication. The facility's policies on communication needs were not effectively implemented.
Two residents in an LTC facility were not provided with activities based on their preferences and needs, leading to a deficiency. One resident, with intact cognitive skills, was not offered his preferred activity of listening to the radio, while another resident expressed dissatisfaction with the limited activities available, such as Bingo and exercise videos. The facility's policy on activity programs, which requires a variety of activities to meet individual needs, was not followed.
The facility failed to ensure appropriate use and monitoring of psychotropic medications for four residents. One resident was prescribed two anxiety medications without specific behavior monitoring, while another received an antipsychotic without justified need. A third resident's antidepressant use lacked behavior monitoring, and a fourth resident did not receive a recommended dose reduction for an antipsychotic. Staff interviews and record reviews highlighted inadequate documentation and communication regarding medication effectiveness and necessity.
A LTC facility experienced a 16% medication error rate during a med pass, involving two residents. Errors included improper insulin administration by an LVN and missed and delayed doses by an IPN. The residents had significant medical histories, requiring precise medication management, which was not adhered to, potentially impacting their health.
The facility failed to properly label and store medications, leaving them unattended and improperly stored, risking resident safety. Unopened insulin pens were not refrigerated, an opened Ipratropium-Albuterol solution was not labeled with an open date, and expired Mometasone spray was not removed. Additionally, opened medications in the storage room lacked proper labeling, leading to potential medication errors.
The facility failed to follow proper food handling practices, including not discarding expired food, improper labeling, and unclean kitchen equipment. Additionally, dietary staff did not consistently perform hand hygiene or change gloves during food preparation, increasing the risk of food contamination.
The facility staff failed to follow infection control protocols, including improper handling of soiled linens, inadequate disinfection of a glucometer, lack of proper signage for isolation precautions, and failure to perform hand hygiene during medication administration. These deficiencies involved residents with various medical conditions, posing a risk of infection spread.
The facility failed to ensure a safe environment by allowing a wheelchair to block an emergency exit and cluttering hallways with equipment, posing risks to a resident with mobility issues. Staff interviews confirmed the hazards, and facility policies emphasized the need for clear exits and safe environments.
The facility failed to obtain informed consent for two residents. One resident was admitted without completing the necessary Admission Consent Forms, which include consent for treatment and disclosure of medical records. Another resident was prescribed Seroquel, an antipsychotic medication, without obtaining informed consent, despite the resident's severe cognitive impairment. The facility's policies require informed consent for treatment and medication, which was not adhered to in these cases.
A facility failed to follow its policy on self-administration of medications for a resident by not obtaining a physician's order and not conducting an assessment to determine the resident's capability. The resident had moderately impaired cognitive skills and was found with unprescribed medications at her bedside, which were not reported to the physician as required by the facility's policy.
A resident with multiple diagnoses, including dementia and total dependency on staff, was unable to reach their call light, which was found under the draw sheet. This was against the facility's policy and care plan, which required the call light to be within reach to ensure the resident could call for assistance when needed.
A facility failed to inform a resident with severe cognitive impairment and multiple health conditions about the option to formulate an advance directive, as required by policy. The absence of documentation in the resident's medical record was confirmed by the Social Services Director, who highlighted the importance of having such directives to guide medical decisions.
A resident's medical records were left exposed and unattended on a medication cart, violating HIPAA regulations. The resident, who had been admitted with serious health conditions, had their Physician's Order Details left out by an LVN to remind them of the resident's orders post-discharge. This was confirmed as a breach of confidentiality by a Registered Nurse Supervisor.
A facility failed to accurately complete the PASARR for a resident with psychosis and dementia, leading to a deficiency in care. The resident's PASARR Level I Screening incorrectly indicated no serious mental disorder and no psychotropic medication, despite a diagnosis of psychosis and a prescription for Quetiapine Fumarate. Interviews with staff confirmed the screening should have reflected the resident's mental health status and medication.
A resident with severe cognitive impairment and hearing loss had a care plan that failed to specify which ear was functional and did not address their refusal to wear hearing aids. Staff interviews revealed a lack of awareness about the resident's hearing needs, and the care plan lacked individualized interventions, potentially delaying care delivery.
A resident with type 2 diabetes mellitus did not receive appropriate blood sugar monitoring after insulin was discontinued. Despite the facility's protocol requiring regular checks, no orders or tests were conducted, as confirmed by staff interviews. The facility's policy mandates physician-ordered lab tests and monitoring, which were not followed.
A facility failed to place a floor mat in a resident's room as ordered by a physician, despite the resident's moderate to high fall risk due to a history of lumbar fracture, osteoarthritis, and dementia. An observation confirmed the absence of the mat, and a nurse supervisor acknowledged the oversight, which contradicted the facility's fall prevention policy.
A resident with end-stage renal disease and a 1000 cc fluid restriction received excess fluids due to improper monitoring and communication among staff. The CNA delivered a dinner tray with items exceeding the fluid limit, and the LVN administered additional fluids during medication. The facility's policy for fluid restrictions was not followed, risking the resident's health.
A resident with a gastrostomy tube did not receive the prescribed continuous feeding order, leading to inadequate nutrition and weight loss. Despite a nurse practitioner's directive to reinstate the continuous feeding regimen, the facility's staff continued with an insufficient bolus feeding method for 12 days, resulting in the resident's weight dropping from 95 to 90 pounds. The facility's policy for enteral nutrition was not adhered to, contributing to the deficiency.
A resident with a history of chronic opioid use disorder and chronic back pain did not receive timely administration of methadone, leading to severe pain. The facility failed to administer the medication as ordered and did not reassess the resident's pain level after administering pain medication. The delay in medication administration was due to a shortage of LVNs, and the facility did not follow its policy for pain reassessment, resulting in significant physical distress for the resident.
A long-term care facility failed to provide adequate pharmaceutical services for two residents. One resident did not receive the full dose of insulin due to improper administration technique, while another resident missed a dose of Letrozole and received other medications outside the prescribed time frame. These deficiencies were due to non-adherence to the facility's policies and procedures for medication administration.
The facility failed to communicate the pharmacist's recommendations for a gradual dose reduction of Seroquel for two residents. The Director of Nurses was on leave, and the MRR was not reviewed, leading to the recommendations not being relayed to the physician. Both residents were on Seroquel for behavioral issues, but the physician did not acknowledge or act on the recommendations due to a breakdown in communication processes.
Two residents in an LTC facility experienced significant medication errors. One resident received improperly administered insulin, as the LVN did not follow the required procedure to ensure absorption. Another resident was given expired Mometasone spray, missed a dose of Letrozole due to an empty bubble pack, and had medications administered outside the prescribed timeframe. These errors were confirmed by facility staff, highlighting a failure to adhere to medication administration policies.
A resident with specific dietary preferences was not provided with meals that aligned with her preferences, leading to dissatisfaction and limited meal intake. Despite having intact cognitive skills, the resident reported receiving unappetizing meals that did not match her preferred diet. The facility's policy required documentation of food preferences, but the resident's care plan lacked this information, contributing to the deficiency.
A resident with dysphagia and severely impaired cognitive skills was not provided with the prescribed mechanically altered diet, posing a choking hazard. A CNA mistakenly delivered a regular texture meal instead of the required pureed diet, which was confirmed by the RN Supervisor as a potential risk for the resident.
The facility failed to complete the Resident's Clothing and Possessions Forms for two residents, missing necessary signatures from both the residents or their representatives and staff. This oversight involved residents with severe cognitive impairments and total dependency on staff, highlighting the importance of these forms in tracking personal belongings.
A resident's call light system was found to be non-functional, preventing them from signaling for assistance. The issue was not reported to the Maintenance Supervisor, and the malfunction was not logged in the Maintenance Communication book. The facility's policy requires functional call lights at all times, but this was not adhered to, potentially delaying the resident's access to necessary help.
The facility did not post daily staffing information in a visible location as required. Observations revealed that the information was missing or outdated, and the DSD admitted to not posting it due to misplacing the form. The facility's policy requires staffing details to be posted for every shift based on resident needs.
The facility failed to meet the square footage requirement of 80 sq. ft. per resident in 10 rooms, as identified through observations and interviews. Despite this, residents and staff reported no issues with space for care and mobility. A room waiver was submitted, indicating that the rooms had adequate space for nursing care and did not jeopardize residents' health and safety.
A resident's representative requested medical records, but the LTC facility failed to provide them within the required 48-hour timeframe. The resident had severe cognitive impairments and required full assistance for daily activities. The delay was due to a lack of medical records personnel during a specific period.
A resident with Alzheimer's and severe cognitive impairment experienced multiple falls due to the facility's failure to update their care plan with specific interventions. Despite the resident's history of falls and need for assistance, the care plan lacked necessary measures such as frequent visual checks and a toileting schedule. Facility staff acknowledged the need for personalized interventions, but the care plan remained outdated, not reflecting the resident's current needs.
A resident with intestinal obstruction and dementia experienced a severe fecal impaction due to the facility's failure to monitor and document bowel movements as per the care plan. Despite the care plan's requirement for daily recording and reporting of bowel movements, there was no documentation for 19 days. Staff interviews revealed a lack of proper documentation and communication, leading to the resident's hospitalization for manual evacuation of the impaction.
A breach of medical record confidentiality occurred when a resident's records were mistakenly sent with another resident during a hospital transfer. The error involved sending the wrong medical records, leading to a HIPAA violation. The facility's staff, including the DON, acknowledged the mistake, which was contrary to the facility's policies on protecting health information.
The facility failed to store insulin injections properly and dispose of expired medications in two medication carts. Unused insulin was not refrigerated, and expired medications were found, which could compromise safety and efficacy. LVNs acknowledged the oversight, and the DON confirmed the violation of facility policy.
A resident with dementia and Alzheimer's was injured during a Hoyer lift transfer when CNAs failed to properly support the lift, resulting in a head injury. The resident was left unattended, leading to a laceration and cephalohematoma. Staff interviews revealed non-compliance with the facility's safe lifting policy.
A resident reported being hit by their roommate, but the LTC facility failed to report the incident to authorities within the required two-hour timeframe. Despite the facility's policy, the DON delayed reporting, citing a misunderstanding of the timeframe. Interviews with staff confirmed the policy requires prompt reporting to prevent further abuse.
Obstructed Exit Doors and Hallways in Facility
Penalty
Summary
The facility failed to ensure that exit doors and hallways were free from obstruction and clutter, which could potentially impede emergency evacuation and increase the risk of accidents. During observations on March 13, 2025, multiple instances were noted where wheelchairs, soiled linen bins, a bed, drawer carts, and a linen cart were blocking exit doors in various hallways. These obstructions were observed at different times in the morning, indicating a consistent issue with maintaining clear egress paths. Interviews with facility staff, including the Interim Director of Nursing (IDON), a Certified Nurse Assistant (CNA), and the Director of Staff Development (DSD), confirmed that staff were aware of the requirement to keep hallways and exit doors clear. The IDON acknowledged that objects should be placed three feet away from exit doors, and only one side of the hallway should be used for storage. The CNA and DSD reiterated the importance of keeping pathways clear for safety and emergency evacuation. The facility's policy, reviewed with the Administrator, also emphasized the need for unobstructed hallways and exits, yet the policy was not being effectively implemented, as evidenced by the observed obstructions.
Failure to Timely Report Resident's Fracture from Fall
Penalty
Summary
The facility failed to report an unusual occurrence to the State Agency within 24 hours as required by their policy. This deficiency involved a resident who sustained a fracture from an unwitnessed fall. The resident, who had a history of dementia, muscle weakness, and was at high risk for falls, was admitted to the facility and later readmitted with a fracture of the left ilium. The facility became aware of the fracture upon the resident's readmission from a general acute care hospital. Despite the facility's policy requiring unusual occurrences to be reported within 24 hours, the incident was not reported in a timely manner. Interviews with the Registered Nurse and Director of Nursing confirmed that the fall and resulting fracture were considered unusual occurrences that should have been reported. The facility's policy, revised in February 2025, mandates that such incidents be reported to appropriate agencies as required by law, but this was not adhered to in this case.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident who was at high risk for falls. After an unwitnessed fall on January 26, 2025, which resulted in a fracture, the care plan for the resident included placing a floor mat at the bedside to prevent further injury. However, during an observation on March 3, 2025, the floor mat was found placed under the bed, contrary to the care plan's instructions. This oversight was confirmed by a registered nurse who acknowledged that the facility was not adhering to the resident's plan of care for fall risk. The resident involved had a history of dementia, muscle weakness, and a fracture of the left ilium. The resident was assessed as being at high risk for falls and required substantial assistance with daily activities, including hygiene and transfers. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan, which was not followed in this instance, leading to the potential for further falls and injury.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff, as observed during an interaction involving Resident 3. Resident 3, who has chronic kidney disease, a urinary tract infection, and diabetes mellitus, was dependent on staff for various activities, including eating. During an observation, Activities 1 was seen feeding Resident 3 with bare hands and subsequently touching another resident's hair and ears without performing hand hygiene. Activities 1 then touched a third resident's shoulder and wheelchair before returning to assist Resident 3 with meals, again without performing hand hygiene. Interviews with the Activities Director and the Infection Preventionist Nurse confirmed that Activities 1 should have worn gloves and performed hand hygiene before and after assisting each resident to prevent the spread of infection. The facility's policy on hand hygiene, revised in October 2023, clearly states that hand hygiene is required immediately before and after touching a resident and after touching a resident's environment. The failure to adhere to these policies had the potential to spread infection among staff and residents.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident assessed as high risk for falls, leading to an incident where the resident fell and sustained injuries. The resident, who had a history of dementia, cerebral infarction, lack of coordination, and repeated falls, was left unattended in a wheelchair in the hallway outside the activity room by the Director of Activities (DOA). This lack of supervision resulted in the resident attempting to turn the wheelchair, slipping, and falling, which caused redness on the forehead and later revealed rib fractures. The resident's care plan, dated a day before the incident, identified the resident as at risk for falls but did not include specific interventions to prevent falls while in a wheelchair. The incident occurred when the DOA left the resident unattended to attend to other residents, without informing another staff member to supervise the resident. Interviews with staff, including the DOA, a Certified Nursing Assistant (CNA), and a Registered Nurse (RN), confirmed that the resident required constant monitoring due to the high risk of falls, and the fall could have been prevented with proper supervision. The facility's policy and procedure for fall risk assessment, reviewed with the Director of Nursing (DON), emphasized the need for identifying and documenting resident risk factors for falls and establishing a resident-centered falls prevention plan. However, the lack of specific interventions in the care plan and the failure to supervise the resident adequately led to the fall and subsequent injuries, highlighting a deficiency in the facility's adherence to its fall prevention policies.
Failure to Implement Care Plan for Alleged Rough Handling
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who reported alleged rough handling by a staff member. The resident, who was moderately impaired in cognitive skills and dependent on assistance for daily activities, reported the incident on January 7, 2025. Despite having a care plan that included interventions for addressing physical pain, emotional distress, and ensuring a safe environment, the facility did not place the resident on the required 72-hour monitoring for psychosocial wellbeing. Licensed nurses were expected to monitor and document the resident's status every eight hours, but this was not done. Interviews with facility staff, including a Licensed Vocational Nurse, MDS nurse, and the Director of Nursing, confirmed the lack of documentation and monitoring following the resident's report of alleged abuse. The facility's policies required ongoing assessments and revisions of care plans based on changes in the resident's condition, but these were not adhered to. The absence of documentation and monitoring meant that the resident's emotional distress and potential changes in psychosocial state were not assessed, which was crucial for determining the need for further treatment.
Infection Control Deficiency Due to Improper PPE Use
Penalty
Summary
The facility failed to adhere to its infection control policy for a resident who was on enhanced barrier precautions (EBP). The resident, who had a gastrostomy tube and was dependent on staff for various activities, was not provided care with the appropriate use of personal protective equipment (PPE). During observations, staff members were seen providing incontinent care and administering medication via the gastrostomy tube without wearing gowns, which is a requirement under EBP. The deficiency was observed when Certified Nurse Assistants (CNAs) and a Licensed Vocational Nurse (LVN) did not wear gowns while performing high-contact activities with the resident. Despite the presence of EBP signage outside the resident's room, there was no PPE cart available to remind or provide staff with the necessary equipment. Interviews with the staff revealed a lack of awareness and adherence to the EBP requirements, as they acknowledged the need for gowns but failed to use them during care. The Director of Nursing confirmed that the resident's care plan did not include EBP, and the facility's policy on EBP was not followed. The policy clearly stated that gowns and gloves should be worn during high-contact activities, such as diaper changes and medication administration through a gastrostomy tube, to prevent the transmission of infections. The absence of a PPE cart and the failure to include EBP in the resident's care plan contributed to the deficiency in infection control practices.
Failure to Monitor and Document Pressure Ulcer Progression
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the worsening of a pressure ulcer for a resident. The resident, who was at risk of developing pressure ulcers, had a history of chronic obstructive pulmonary disease and type 2 diabetes mellitus. The facility did not assess and document detailed observations of the resident's skin and wound condition changes using the SBAR communication tool on multiple occasions, including 10/17/2024, 10/24/2024, 11/14/2024, and 11/30/2024. This lack of documentation and communication led to the resident's pressure ulcer worsening from moisture-associated skin damage to a stage 4 pressure ulcer. The facility also failed to monitor the resident's wound condition every shift after noting a foul odor on 11/25/2024 and an increase in wound size on 11/27/2024. The resident developed a fever and was admitted to a general acute care hospital with an infected sacral decubitus ulcer, fever, and leukocytosis. The resident required broad-spectrum antibiotic treatment and underwent excisional debridement of the sacral pressure ulcer. Interviews with facility staff, including the Wound Treatment Nurse, MDS Nurse, Registered Nurse Supervisor, and Director of Nursing, revealed that there was no documented evidence of SBAR completion or interdisciplinary team notification regarding the resident's wound condition changes. The facility's policies and procedures required prompt notification of changes in a resident's condition, detailed observations, and documentation in the resident's medical record, which were not followed in this case.
Inaccurate Documentation of Wound Care and Skin Condition
Penalty
Summary
The facility failed to ensure that licensed nurses documented accurate information regarding a resident's skin condition and wound care treatment. Specifically, the documentation in the Skilled Nursing Assessment form and the Weekly Summary form did not accurately reflect the resident's condition on several occasions. The resident, who had chronic kidney disease and lack of coordination, was at risk for developing pressure ulcers and had a stage 2 pressure ulcer that was not present upon admission. The review of the resident's medical records revealed inconsistencies in the documentation of wound treatments. The Treatment Administration Record (TAR) indicated ongoing treatments for Moisture Associated Skin Damage (MASD) and later a stage 2 pressure ulcer, but these were not consistently documented in the nurses' notes or weekly summaries. The Wound Care Doctor's communication log confirmed the presence of MASD and later a stage 2 pressure ulcer, but the nurses' documentation failed to reflect these findings accurately. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the documentation was not consistent with the resident's actual condition. The DON acknowledged that the nurses should have conducted and documented complete and accurate weekly skin assessments. The facility's policies on pressure ulcer assessment and documentation were not followed, leading to inaccurate representation of the resident's skin condition and wound treatment in the medical records.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of several residents, as evidenced by multiple observations and interviews. Resident 47, who was severely cognitively impaired and dependent on assistance for eating, was fed by a CNA who stood over the resident, contrary to the facility's policy that staff should sit at eye level to provide a dignified dining experience. This practice was confirmed by the Registered Nurse Supervisor, who acknowledged that sitting while feeding residents is respectful and indicates that staff are not rushed. Residents 59 and 73 experienced breaches of privacy during personal care. Resident 59, who had severe cognitive impairment and required assistance with personal hygiene, was changed by a CNA with the curtain and door open, exposing the resident to passersby. Similarly, Resident 73, who also had severe cognitive impairment and required substantial assistance, was changed with the curtain and door open. Both CNAs admitted to not closing the curtain or door, acknowledging that this was against the facility's policy to maintain resident privacy. Resident 25, who had a preference to be called by her name, was repeatedly addressed as "Mama" by staff, despite expressing irritation and requesting to be called by her name. This disregard for the resident's preference was confirmed by both the resident and staff interviews. Additionally, Resident 75, who was dependent on assistance for eating, was fed by a CNA standing up, as there was no chair available, which did not align with the facility's policy for a dignified dining experience. These actions and inactions by the facility staff failed to respect the residents' rights to dignity and privacy, as outlined in the facility's policies.
Lack of Communal Dining Affects Resident Well-being
Penalty
Summary
The facility failed to provide a comfortable and homelike environment by not offering communal dining to its residents, which was a concern raised by five of the seven sampled residents during a Resident Council meeting. The absence of communal dining has been ongoing since 2020, following the closure of the dining room during the COVID-19 pandemic. Residents expressed their desire for communal dining, highlighting its importance for social interaction and emotional well-being. Resident 8, who requires assistance with eating, expressed a desire for communal dining, noting its absence since 2020. Resident 22, who also requires supervision with eating, emphasized the social benefits of communal dining and reported having raised the issue with the Activity Director multiple times without resolution. Resident 43, who has hemiplegia and requires supervision with eating, mentioned the logistical benefits of dining in the activity room to avoid congestion and potential accidents. Resident 44, diagnosed with major depressive disorder, and Resident 72, who does not require supervision with eating, both expressed feelings of loneliness when eating alone in their rooms and a preference for communal dining. The Activity Director acknowledged the lack of communal dining since 2020 and recognized its importance for creating a homelike environment and supporting residents' psychosocial well-being. The facility's policies emphasize providing a homelike environment and dignified dining experiences, which were not upheld in this instance.
Failure to Provide Appropriate Communication Boards
Penalty
Summary
The facility failed to provide communication boards in the appropriate language for three residents, which hindered their ability to communicate effectively with staff. Resident 41, who has severe cognitive impairment and physical disabilities, was observed with a communication board in a non-English language, which she could not understand. Her responsible party expressed concerns about the communication barrier, stating that the resident often resorted to pointing at objects to express her needs. The Activity Director admitted that communication binders were not consistently available in residents' rooms until the day before the surveyor's visit. Resident 42, who has severely impaired cognitive skills and prefers a non-English language, was found with a communication folder in her room for the first time during the survey. Her care plan indicated the need for alternative communication tools due to language barriers and visual impairment. However, the communication board was only recently placed in her room, and staff were not consistently using it to facilitate communication. Resident 63, who is moderately impaired cognitively and does not speak English, reported that staff did not use a communication board to communicate with him. He relied on his sister for assistance in communicating with staff. The communication board was only delivered to his bedside shortly before the surveyor's visit. The facility's policies on translation and communication needs were not effectively implemented, as adaptive devices like communication boards were not consistently provided to residents with limited English proficiency.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide activities based on comprehensive assessments and resident preferences for two residents, leading to a deficiency in meeting their physical, mental, and psychosocial needs. Resident 78, who was admitted with multiple health conditions including cancer and sepsis, expressed that he had not been offered any activities since his admission. Despite having intact cognitive skills and a desire to engage in his favorite activities, such as listening to the radio, he remained in bed without any engagement. The Activities Director acknowledged the oversight and confirmed that Resident 78 had not been offered his preferred activity. Resident 22, who was admitted with chronic obstructive pulmonary disease and hepatic failure, also experienced a lack of personalized activities. Although capable of making decisions, Resident 22 expressed dissatisfaction with the limited activities offered, such as Bingo and exercise videos, and desired more diverse options like mahjong and outings. The Activities Director noted that the facility's van, previously used for outings, was broken and had not been repaired, limiting the ability to provide off-site activities. The facility's policy on activity programs, which was not adhered to, requires activities to be designed to meet individual resident needs and interests, with a variety of options available daily. The policy also mandates that activities should include cardiovascular stimulation, intellectual engagement, and outings, which were not provided to the residents in question. This failure to follow the policy contributed to the deficiency in meeting the residents' needs.
Failure to Monitor and Adjust Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for four residents were free from unnecessary medication use, as required by their policy. Resident 47 was prescribed two anxiety medications, Clonazepam and Lorazepam, without specific indications for their use being monitored. Additionally, the resident's behaviors related to the use of Cymbalta and Zyprexa were not adequately monitored, as hashmarks were not used to tally episodes of crying and paranoid delusions. Interviews with staff revealed that Resident 47 exhibited daily behaviors of crying and yelling, which were not properly documented, indicating a need for medication adjustment. Resident 62 was prescribed Quetiapine Fumarate for psychosis, but the specific behavior for its use was not monitored. The facility's policy required that antipsychotic medications be used only when behavioral symptoms present a danger to the resident or others, and the symptoms are due to mania or psychosis. The consultant pharmacist noted that the current behavior of restlessness/agitation did not justify the need for an antipsychotic medication, and the behavior needed to be more specifically described. Resident 33 was prescribed Escitalopram for depression without a specific indication or behavior being monitored. The resident reported feeling sad and anxious, which affected her ability to eat and participate in physical therapy. Resident 45 was prescribed Seroquel for psychosis, but a gradual dose reduction was not attempted, nor was a clinical rationale documented for why it would be contraindicated. The facility failed to notify the physician of the pharmacist's recommendation for a dose reduction, resulting in the resident continuing to receive the medication without displaying any behaviors of psychosis.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 16% error rate during a medication pass observation. This deficiency involved two residents, with four medication errors identified out of 25 opportunities. One of the errors involved a Licensed Vocational Nurse (LVN) who did not wait the required five seconds before removing the needle after administering Humulin R insulin to a resident with diabetes mellitus. This action was contrary to both the facility's policy and the manufacturer's instructions, potentially affecting the resident's blood sugar management. Another error involved the Infection Preventionist Nurse (IPN) failing to administer Letrozole as ordered for a resident with a history of breast cancer. The medication was not available during the scheduled administration time, and the dose was missed. Additionally, the IPN administered Clopidogrel Bisulfate and Metoprolol Succinate outside the prescribed one-hour window, which was not in accordance with the facility's policy for timely medication administration. The residents involved had significant medical histories, including diabetes mellitus and breast cancer, which required precise medication management. The failure to adhere to prescribed medication administration protocols and timing could have impacted the residents' health conditions. The facility's policies on insulin administration and medication timing were not followed, leading to these medication errors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to several deficiencies. Medications were left unattended on top of a medication cart, which could have been accessed by residents, posing a risk of adverse consequences. Additionally, unopened insulin pens for two residents were stored in the medication cart instead of the refrigerator, contrary to manufacturer's guidelines, potentially affecting the efficacy of the insulin. Another deficiency involved the failure to label an opened box of Ipratropium-Albuterol solution with the date it was opened, which is crucial as the medication expires seven days after opening. This oversight could lead to the administration of expired medication, reducing its effectiveness for the resident with COPD. Furthermore, an expired Mometasone nasal spray was found in the medication cart, which should have been removed according to the facility's policy, risking the use of ineffective medication. The facility also failed to maintain proper storage and labeling of medications in the medication storage room. Several opened medications were found without labels indicating the date they were opened, and some were improperly stored in the medication storage room instead of the medication cart. This practice could lead to medication errors and contamination, as medications were being transferred between containers by the nursing staff, which is against the facility's policy.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices, as observed during a survey. Expired food was not discarded, and food items in the dry storage room, refrigerators, and freezers were not labeled with the item name, date opened, and expiration date. This oversight was noted with various food items, including bread, cheesecake powder, cookie dough, and ground meat. Additionally, the facility did not ensure that kitchen equipment and food carts were clean and free of food debris, with observations of dirty microwave knobs, food processors, and can openers. The facility also failed to maintain cleanliness in the kitchen environment. Dusty electric fans were stored in the dry storage room, and food storage areas were cluttered with items like open Styrofoam cups and plastic cup lids. The garbage container was improperly placed next to a freezer, and leaking soy sauce was found inside a refrigerator. These conditions were acknowledged by the dietary staff, who admitted to lapses in maintaining cleanliness and proper storage practices. Furthermore, dietary staff did not consistently perform hand hygiene or change gloves during food preparation and tray line assembly. Instances were observed where staff members used the same gloves for multiple tasks, such as handling food trays, opening refrigerators, and using kitchen tools, without changing gloves in between. This practice was contrary to the facility's policy and procedure, which emphasized the importance of hand hygiene and changing gloves to prevent food contamination.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to adhere to infection control measures in several instances, leading to potential risks of infection spread among residents. In one case, a Certified Nursing Assistant (CNA) was observed handling soiled linens from a resident with chronic obstructive pulmonary disease, diabetes, and hypertension without wearing gloves and holding the linens close to her body, contrary to the facility's policy. This practice was confirmed by the Director of Staff Development and a Registered Nurse Supervisor, who emphasized that such actions could lead to contamination of staff clothing and subsequent transmission of infections to residents. Another deficiency involved the improper cleaning and disinfection of a glucometer used for a resident with radiculopathy and diabetes. A Licensed Vocational Nurse (LVN) failed to disinfect the glucometer after use, placing it back in the medication cart drawer without cleaning it. This oversight was acknowledged by the LVN and a Registered Nurse Supervisor, who noted the importance of disinfecting equipment to prevent the spread of bloodborne pathogens and contamination of other items in the drawer. Additional lapses in infection control were observed with the lack of proper signage for enhanced barrier precautions for a resident on isolation due to tuberculosis and other conditions. The absence of appropriate signage was noted by an MDS Nurse and a Registered Nurse Supervisor, who stated that such signage is crucial for reminding staff and visitors of necessary precautions. Furthermore, both a Licensed Vocational Nurse and an Infection Preventionist Nurse failed to perform hand hygiene before and after administering medications to residents, which they acknowledged as a breach of infection control protocols.
Facility Fails to Maintain Safe and Unobstructed Hallways
Penalty
Summary
The facility failed to provide a safe environment for Resident 43 by not ensuring that the designated exit door was clear of obstructions. During an observation, a wheelchair was found blocking the emergency exit doors, which could impede a rapid evacuation in case of an emergency. Interviews with the Activity Director and the Interim Director of Nursing confirmed that wheelchairs should not be left in the middle of the hallway leading to emergency exits, as this could prevent residents from evacuating quickly and safely. The facility's policy and procedure on exits clearly stated that all personnel should keep exits clear at all times. Additionally, the facility did not maintain a clutter-free hallway for Resident 43, who has hemiplegia and hemiparesis following a cerebral infarction. Observations revealed multiple wheelchairs, a Hoyer lift, a walker, and a clean linen cart cluttering the hallway, posing a risk of accidents, tripping, or falls for Resident 43. Interviews with Resident 43 and staff members, including a Certified Nursing Assistant and a Licensed Vocational Nurse, highlighted the potential hazards caused by the cluttered hallways, especially during busy times when residents move between activities and meals. The facility's policy on Safety and Supervision of Residents emphasized the importance of identifying and mitigating environmental hazards and individual resident risks. However, the presence of wheelchairs, equipment, and bins in the hallway for extended periods was acknowledged by staff, including a Registered Nurse Supervisor, as a potential issue for patient injury and tripping hazards. The facility's Quality Assurance and Performance Improvement committee was responsible for evaluating and addressing such hazards, but the report does not mention any corrective actions taken to resolve these deficiencies.
Failure to Obtain Informed Consent for Treatment and Medication
Penalty
Summary
The facility failed to fully inform two residents of the risks and benefits of their proposed care, which is a violation of the facility's policy. Resident 185 was admitted with several diagnoses, including dementia and adult failure to thrive, and was totally dependent on staff for daily activities. However, the Admission Consent Forms, which include consent for treatment, disclosure of medical records, and photography, were not completed or signed upon admission. The Registered Nurse Supervisor acknowledged that the forms should have been completed during admission or the following day, and the family should have been contacted. The absence of a signed Admission Consent Form meant that the resident did not give consent for treatment or the disclosure of medical records. Resident 62, who was admitted with diagnoses of psychosis and dementia, was prescribed Seroquel, an antipsychotic medication, without obtaining informed consent. The resident's cognitive skills for daily decision-making were severely impaired, and the facility's policy requires that informed consent be obtained from the resident or their representative before administering such medication. The Registered Nurse Supervisor confirmed that informed consent was not obtained, which is necessary due to the potential side effects of the medication. The facility's policy on antipsychotic medication use mandates that residents and their representatives be informed of the risks, benefits, and potential adverse consequences of the medication.
Failure to Follow Self-Administration of Medications Policy
Penalty
Summary
The facility failed to adhere to its policy on self-administration of medications for one resident, identified as Resident 20, by not obtaining a physician's order and not conducting an assessment to determine the resident's capability to self-administer medications. Resident 20 was admitted with diagnoses including calculus of gallbladder with acute cholecystitis, lack of coordination, and unspecified glaucoma. The Minimum Data Set (MDS) assessment indicated that Resident 20 had moderately impaired cognitive skills for daily decision-making and required assistance with various activities of daily living. During observations and interviews, it was found that Resident 20 had bottles of Cod Liver Oil and Halibut Liver Oil on her bedside table, which she stated were brought by her family and not prescribed by her physician. The Registered Nurse Supervisor confirmed that these medications were not prescribed and should have been reported to the physician. The facility's policy requires that the interdisciplinary team assess a resident's ability to self-administer medications and that any unauthorized medications found at the bedside be turned over to the nurse in charge. However, this process was not followed, as there was no interdisciplinary team assessment form for Resident 20 to self-administer medication.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, which was not in accordance with the facility's policy and procedure for the Residents' Call System. The deficiency was identified during an observation and interview with the resident, who was unable to locate the call light and expressed a need for assistance to request hot tea or water. The call light was found placed under the draw sheet, out of the resident's reach, which prevented the resident from calling for help when needed. The resident involved in this deficiency was admitted with multiple diagnoses, including adult failure to thrive, benign prostatic hyperplasia, syncope, and a history of falls. The resident was noted to be totally dependent on staff for bed mobility, transfer, locomotion, and toileting, and had cognitive and communication deficits due to dementia. The care plan for the resident specifically indicated the need to keep the call light within reach, highlighting the importance of this intervention given the resident's condition. Despite this, the call light was not accessible, as confirmed by a Licensed Vocational Nurse during an observation.
Failure to Inform Resident of Advance Directive Option
Penalty
Summary
The facility failed to inform and provide written information to a resident about the option to formulate an advance directive, as required by the facility's policy. This deficiency was identified during a review of the resident's admission record and medical record, which showed no documentation of an advance directive or an acknowledgment form indicating that the resident or their representative was informed of their right to create one. The resident, who was admitted with diagnoses including heart failure, chronic kidney disease, and hypertensive heart disease, had severely impaired cognitive skills for daily decision-making and was dependent on assistance for various activities of daily living. During an interview, the Social Services Director (SSD) confirmed the absence of the advance directive and acknowledgment form in the resident's medical record. The SSD emphasized the importance of having advance directives in the resident's chart to guide staff on medical decisions and identify the decision-maker. The facility's policy, dated 2001, mandates that residents or their representatives be provided with written information about their rights to accept or refuse medical treatment and to formulate an advance directive.
Failure to Maintain Resident's Medical Record Confidentiality
Penalty
Summary
The facility staff failed to maintain the privacy and confidentiality of a resident's medical records, specifically for Resident 71. During a record review, it was noted that Resident 71 was admitted with diagnoses including nontraumatic intracerebral hemorrhage, encephalopathy, and acute kidney failure. The resident's Minimum Data Set (MDS) indicated intact cognitive skills for daily decision-making, but dependency on assistance for toileting hygiene and dressing. Despite these needs, the resident's Physician's Order Details, containing sensitive information such as the resident's name, diagnoses, and diagnostic tests, were left exposed and unattended on top of a medication cart in the hallway. Observations confirmed that the Physician's Order Details remained exposed for an extended period, from 10:49 AM to 12:28 PM. Interviews with facility staff, including a Licensed Vocational Nurse (LVN 3) and a Registered Nurse Supervisor (RNS 1), revealed that the documents were left out to remind the LVN to carry out the resident's orders following their discharge. However, this action was acknowledged as a violation of the Health Insurance Portability and Accountability Act (HIPAA) by RNS 1, who confirmed that resident files should not be left on the medication cart. The facility's policy and procedure on HIPAA, revised in 2007, mandates the confidentiality of residents' protected health information, which was not adhered to in this instance.
Inaccurate PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to accurately complete the preadmission screening and annual resident review assessment (PASARR) for a resident with a mental illness, leading to a deficiency in care. Resident 62, who was admitted with diagnoses of psychosis and dementia, was not properly assessed in the PASARR Level I Screening. The screening incorrectly indicated that the resident did not have a serious mental disorder and was not prescribed psychotropic medications, despite the resident's diagnosis of psychosis and prescription for Quetiapine Fumarate, an antipsychotic medication. Interviews with the Admissions Coordinator and MDS Nurse revealed that the PASARR Level I Screening should have reflected the resident's mental health diagnosis and medication. The facility's policy requires all new admissions to be screened for mental disorders, intellectual disabilities, or related disorders, but this was not accurately done for Resident 62. This oversight resulted in the resident not receiving the necessary psychiatric evaluation and treatment within the facility.
Deficient Care Plan for Hearing-Impaired Resident
Penalty
Summary
The facility failed to develop a resident-centered comprehensive care plan for a resident who was hard of hearing and refused to wear his hearing aid. The resident, who had been readmitted with acute respiratory failure, pneumonia, and type 2 diabetes, was assessed as having severely impaired cognitive skills and moderate difficulty with hearing. Despite these assessments, the care plan did not specify which ear the resident could hear from, nor did it address the resident's refusal to wear hearing aids. This lack of detailed and individualized interventions in the care plan had the potential to negatively affect and delay the delivery of care and services for the resident. Interviews with facility staff revealed a lack of awareness regarding the resident's specific hearing needs. A Certified Nursing Assistant was unaware of which ear was the good ear, while the MDS Nurse and a Responsible Party confirmed that the resident could only hear from the right ear. The care plan, dated several months prior, failed to include this critical information and did not provide alternative communication strategies for staff to use given the resident's refusal to wear hearing aids. The facility's policy on comprehensive, person-centered care plans emphasized the need for measurable objectives and timetables to meet residents' needs, which was not adhered to in this case.
Failure to Monitor Blood Sugar in Diabetic Resident
Penalty
Summary
The facility staff failed to ensure that a resident received treatment and care in accordance with professional standards by not performing appropriate laboratory tests and monitoring the resident's blood sugar levels. The resident, who was diagnosed with type 2 diabetes mellitus without complications, was readmitted to the facility with several diagnoses, including acute respiratory failure with hypoxia and pneumonia. Despite the resident's diabetes diagnosis, there was no order to monitor blood sugar levels after insulin treatment was discontinued, and no blood tests were conducted to check blood sugar from the time insulin was stopped until the survey date. Interviews with facility staff revealed a lack of adherence to the facility's diabetes management protocol. The Minimum Data Set Nurse acknowledged the absence of blood sugar monitoring orders and tests, while the Interim Director of Nursing admitted the importance of continued monitoring and the need to inform the physician about the lack of orders. The Registered Nurse Supervisor emphasized the necessity of regular blood sugar checks to prevent complications. A review of the facility's policy indicated that the physician should order appropriate lab tests and monitoring parameters, which were not incorporated into the resident's care plan or medication administration record.
Failure to Implement Fall Prevention Measures for At-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident, who was assessed at moderate to high risk for falls, had a floor mat placed in their room as ordered by the facility physician. This deficiency was identified during a review of the resident's records and a concurrent observation and interview with a Registered Nurse Supervisor. The resident, an elderly male with a history of lumbar fracture, osteoarthritis, and dementia, was admitted to the facility with a documented history of falls and was dependent on staff for activities of daily living. Despite the physician's order for floor mats to be present every shift due to the resident's fall risk, an observation revealed that no floor mats were in place in the resident's room. The Registered Nurse Supervisor confirmed the absence of the floor mats and acknowledged that not following the physician's orders could lead to potential injury for the resident, especially given their medical history of osteoarthritis and previous falls. The facility's policy on managing falls and fall risk emphasized the importance of identifying interventions to prevent falls and minimize complications, which was not adhered to in this instance.
Failure to Monitor Fluid Intake for Resident with Fluid Restrictions
Penalty
Summary
The facility failed to provide and accurately monitor fluid intake for a resident with fluid restrictions, leading to a potential risk of fluid overload or dehydration. The resident, who was admitted with end-stage renal disease, chronic kidney disease, and other conditions, was on a 1000 cc fluid restriction per 24 hours as per physician orders. However, during an observation, a Certified Nurse Assistant (CNA) delivered a dinner tray to the resident that included items exceeding the fluid restriction, such as a cup of juice, soup, and dessert, without any indication of the fluid restriction on the meal cart or signage in the resident's room. The CNA was unaware of the fluid restriction, indicating a lack of communication and proper monitoring. Interviews with the Dietary Supervisor and Licensed Vocational Nurse (LVN) revealed further discrepancies in fluid management. The Dietary Supervisor confirmed that the resident received more fluids than prescribed during dinner, and the LVN acknowledged exceeding the fluid restriction during medication administration. The facility's policy and procedure for fluid restrictions were not followed, as the fluid intake was not properly divided between the Food and Nutrition Services and Nursing, leading to the resident receiving excess fluids. This oversight could potentially cause health complications for the resident, such as fluid overload, edema, and chest pain.
Failure to Implement Prescribed Enteral Feeding Order
Penalty
Summary
The facility failed to implement the prescribed gastrostomy tube feeding order for a resident, leading to a deficiency in care. The resident, who was admitted with conditions including malignant neoplasm of the nasopharynx, sepsis, and adult failure to thrive, was dependent on enteral feeding for nutrition. The resident's nutritional care plan required an increase in tube feeding to meet their caloric and fluid needs due to a low body mass index. However, the facility did not adhere to the prescribed continuous feeding order, resulting in the resident not receiving the necessary volume of tube feeding formula. The deficiency arose when the facility's staff did not follow the nurse practitioner's order to reinstate the continuous feeding regimen after a temporary switch to bolus feeding. Despite the nurse practitioner's directive to revert to the continuous feeding order, the licensed nurses continued with the bolus feeding, which was insufficient to meet the resident's nutritional requirements. This oversight persisted for 12 days, during which the resident experienced weight loss, dropping from 95 pounds to 90 pounds. The facility's policy and procedure for enteral nutrition, which requires complete orders including the administration method and volume, were not followed. The registered dietician confirmed that the resident did not receive the correct caloric intake due to the failure to implement the continuous feeding order. This lapse in following the prescribed nutritional plan contributed to the resident's inadequate nutrition and weight loss.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 64, by not administering methadone as ordered by the physician and failing to reassess the resident's pain level after administering pain medication. On 11/18/2024, the resident did not receive her scheduled methadone dose at 9 AM, resulting in severe pain with a score of 9 out of 10 from 10 AM to 12:01 PM. The delay was attributed to a shortage of licensed vocational nurses (LVNs) available to pass medications, as confirmed by LVN 8, who acknowledged the delay and its potential to cause uncontrollable pain and physical distress. On 11/21/2024, the resident received her pain medication, including methadone and Percocet, at 10 AM, but her pain level remained at 8 out of 10. The Infection Prevention Nurse (IPN) administered the medication but did not return to reassess the resident's pain level to determine the effectiveness of the medication. The facility's policy requires reassessment of acute or worsening chronic pain every 30 to 60 minutes after onset, which was not followed in this instance. Resident 64, a female with a history of chronic opioid use disorder and chronic back pain, was admitted with diagnoses including thoracic fracture, osteomyelitis of the spine, and opioid dependence with withdrawal. The Director of Nursing (DON) and Director of Staff Development (DSD) both emphasized the importance of timely medication administration to prevent exacerbation of symptoms related to opioid withdrawal and chronic pain. The facility's failure to adhere to its policies on medication administration and pain management resulted in the resident experiencing significant physical distress.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. For Resident 31, the facility did not adhere to its policy and procedure for insulin administration. The Licensed Vocational Nurse (LVN) did not wait the required five seconds before removing the needle after administering Humulin R insulin, as per the facility's policy. This oversight was confirmed by both the LVN and the Registered Nurse Supervisor, who acknowledged the importance of the five-second wait to ensure proper insulin absorption and prevent potential blood sugar management issues. For Resident 284, the facility failed to administer medications as prescribed. The resident was supposed to receive Letrozole, Clopidogrel Bisulfate, and Metoprolol Succinate at 9 AM. However, during a medication pass, it was observed that the Letrozole medication was not administered because the bubble pack was empty, and the pharmacy had not been contacted in time to replenish the supply. Additionally, the other medications were not administered within the prescribed time frame, which could affect the resident's health management. The facility's policies and procedures for medication administration were not followed, leading to missed doses and improper timing of medication administration. The Infection Preventionist Nurse acknowledged the missed dose of Letrozole and the importance of timely medication administration to maintain the continuity of treatment. These deficiencies highlight lapses in the facility's medication management processes, which could have significant implications for the residents' health and well-being.
Failure to Communicate Pharmacist's Recommendations for Medication Review
Penalty
Summary
The facility failed to communicate the pharmacist's recommendations from the Medication Regimen Review (MRR) to the attending physician for two residents, Resident 45 and Resident 55, during September 2024. The MRR suggested a gradual dose reduction (GDR) of Seroquel, an antipsychotic medication, for both residents. However, due to the Director of Nurses being on leave, the MRR was not reviewed, and the recommendations were not relayed to the physician. This oversight was confirmed by the Registered Nurse Supervisor and the Administrator, who acknowledged that the MRR results were not reviewed or implemented. Resident 55, who was admitted with diagnoses including major acute respiratory failure, anxiety disorder, unspecified dementia, and sepsis, was receiving Seroquel for agitation and dementia. The MRR recommended reevaluating the appropriateness of a GDR since Resident 55 had been on Seroquel for six months. Similarly, Resident 45, diagnosed with dementia and dependent on staff for daily activities, was on Seroquel for psychosis. The pharmacist recommended a dose reduction or a clinical rationale for maintaining the current dose, as no combative behaviors were observed in recent months. However, the physician did not acknowledge or act on these recommendations. Interviews with the MDS Nurse and Social Services Director revealed that the process for informing the physician of the pharmacist's recommendations was not followed. The Social Services Director admitted to not handing over the recommendations to the physician, which should have been done to prevent delays in treatment. The facility's policy requires the consultant pharmacist to contact the physician immediately if an irregularity poses a risk, but this protocol was not adhered to, resulting in the physician not reviewing or responding to the pharmacist's recommendations for both residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident 31, the deficiency involved the improper administration of Humulin R insulin. The Licensed Vocational Nurse (LVN) did not follow the facility's policy and procedure or the manufacturer's guidelines, which required leaving the needle in the skin for at least five seconds to ensure proper absorption of the insulin. This oversight was confirmed by both the LVN and the Registered Nurse Supervisor, who acknowledged the importance of proper insulin administration to prevent high blood sugar levels. For Resident 284, multiple medication errors were identified. The resident was administered an expired Mometasone spray, and there was a failure to administer Letrozole as ordered due to an empty medication bubble pack. Additionally, the administration of Clopidogrel Bisulfate and Metoprolol was not within the required 60-minute timeframe. The Infection Preventionist Nurse (IPN) and the Director of Staff Development confirmed these errors, noting the importance of timely and accurate medication administration to maintain the resident's health. The facility's policies on medication administration were not adhered to, leading to these deficiencies. The policies required medications to be administered safely, timely, and as prescribed, with specific instructions for insulin administration and checking medication expiration dates. The failure to follow these protocols resulted in significant medication errors for both residents, potentially impacting their health and well-being.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to provide appropriate food preferences for Resident 284, which had the potential to result in decreased meal intake and lead to weight loss and malnutrition. Resident 284, who was admitted with diagnoses including malignant neoplasm of the breast, COPD, and peripheral vascular disease, expressed dissatisfaction with the meals provided. Despite having intact cognitive skills for daily decision-making, the resident reported receiving meals that did not align with her preferences, such as hamburgers and sandwiches with cheese, instead of her preferred Chinese food. The resident consistently found the meals unappetizing and unpalatable, describing them as junk food and expressing dissatisfaction with the repetitive and dry nature of the meals. The facility's policy and procedure for resident food preferences, dated 2001, required that individual food preferences be assessed upon admission and documented in the care plan. However, a review of Resident 284's care plan revealed no indication of her diet preferences. The facility's failure to document and accommodate Resident 284's food preferences, as outlined in their policy, contributed to the deficiency. The resident's dissatisfaction with the meals was further evidenced by her limited intake, as she only consumed certain parts of the meals provided, such as vegetables and rice soup, while finding other components, like the chicken, dry and unappealing.
Failure to Provide Mechanically Altered Diet as Ordered
Penalty
Summary
The facility failed to provide a mechanically altered diet to a resident as indicated on the physician's order. The resident, who was admitted with diagnoses including type two diabetes mellitus, dysphagia, and depression, was documented to have severely impaired cognitive skills and was dependent on assistance for daily activities, including eating. The Minimum Data Set (MDS) indicated that the resident required a mechanically altered diet. However, during an observation, a Certified Nurse Assistant (CNA) mistakenly brought a dinner tray with a regular texture diet instead of the prescribed pureed diet to the resident's bedside. The CNA acknowledged the error, stating that the tray was intended for another resident and confirmed that the resident required a pureed diet and needed assistance with feeding. The Registered Nurse Supervisor (RNS) also confirmed that the resident should have been given a cardiac pureed meal tray, as regular texture food posed a choking hazard. This oversight in dietary management had the potential to cause significant harm to the resident due to the risk of choking.
Incomplete Resident Clothing and Possessions Forms
Penalty
Summary
The facility failed to ensure the completeness of medical records for two residents, specifically regarding the Resident's Clothing and Possessions Form. For Resident 21, who was admitted with diagnoses including heart failure, chronic kidney disease, and hypertensive heart disease, the form lacked signatures from both the resident or their representative and the staff. This oversight was identified during a review of the resident's admission record and Minimum Data Set, which indicated severe cognitive impairment and dependency on staff for daily activities. The Registered Nurse Supervisor acknowledged the form's incompleteness and emphasized its importance in monitoring and ensuring the resident's belongings are accounted for. Similarly, for Resident 185, admitted with conditions such as adult failure to thrive, benign prostatic hyperplasia, and syncope, the form was also incomplete, missing both the resident or responsible party's signature and the staff's signature. The resident was noted to be totally dependent on staff for mobility and toileting. The Registered Nurse Supervisor reiterated the significance of the form as a record of the resident's belongings upon admission and during their stay, which serves as proof if any items are missing. The facility's policy requires that residents' personal belongings and clothing be inventoried and documented upon admission and updated as necessary.
Non-Functional Call Light System for Resident
Penalty
Summary
The facility failed to ensure that the call light system was functioning for a resident, identified as Resident 25, which is crucial for signaling the need for assistance. During an observation and interview, it was found that the call light indicator did not activate when the resident pressed the button. The resident expressed uncertainty about how to call for help due to the malfunctioning system. A Certified Nursing Assistant (CNA) confirmed that the call light indicators, both inside and outside the room, did not light up, indicating a malfunction. Further investigation revealed that the Maintenance Supervisor was unaware of the issue as it had not been reported or logged in the Maintenance Communication book, which is checked daily. The facility's policy requires that call lights be functional at all times and that any malfunctions be reported immediately. The failure to report and repair the broken call light system could delay the resident's access to necessary assistance, especially during emergencies.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted in a visible and prominent place, as required. During an observation on November 18, 2024, at 8:45 AM, it was noted that the daily staffing information was not posted at the nursing station. Registered Nurse Supervisor 1 indicated that the Director of Staff Development (DSD) was responsible for this task. On November 21, 2024, at 8:42 AM, the staffing information posted was outdated, showing the date of November 19, 2024. In an interview, the DSD confirmed her responsibility for posting the staffing information daily, including projected and actual hours, and admitted to not posting it for the past few days due to being unable to find the form. The facility's policy, revised in August 2022, mandates that staffing numbers and skill requirements are determined by resident needs and must be posted for every shift.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 10 out of 36 rooms met the square footage requirement of 80 square feet per resident in multiple resident rooms. The rooms in question were Rooms 17, 42, 43, 44, 51, 52, 53, 54, 62, and 63. The deficiency was identified through observation, interviews, and record reviews. The facility had a room waiver dated 11/18/2024, which acknowledged that these rooms did not meet the federal requirements according to 42 CFR 483.70. However, the waiver indicated that the rooms had adequate space for nursing care and did not jeopardize the health and safety of the residents. The waiver also stated that the rooms were in accordance with the special needs of the residents and would not adversely affect their health and safety or impede their ability to attain their practical well-being. During interviews with the Administrator, it was confirmed that the rooms did not meet the minimum requirement of 80 square feet per resident. Observations showed that residents were able to maneuver their wheelchairs and ambulate inside the rooms without difficulty, and the nursing staff had enough space to provide care. Residents and nursing staff did not express concerns regarding the room sizes, stating there was enough space for care and privacy. The facility submitted a room waiver request letter, indicating that there was ample room for wheelchairs, medical equipment, and mobility, and that the health and safety of residents were not in jeopardy. Multiple observations confirmed that the room sizes did not adversely affect the residents' health or safety.
Delay in Providing Resident's Medical Records
Penalty
Summary
The facility failed to provide a copy of the medical records for a resident within 48 hours, excluding weekends and holidays, as required by their policy. The request for the records was made by the resident's representative on October 3, 2024, but the records were not made available until October 25, 2024. The delay was acknowledged by the facility's administration, who cited a lack of medical records personnel from September 27, 2024, to October 9, 2024, as a contributing factor. The resident involved had a history of Alzheimer's disease and dementia, with severe cognitive impairments affecting daily decision-making and requiring full assistance for daily activities. The facility's policy, revised in November 2009, mandates that residents or their representatives have access to records within 48 hours of a request. Despite this, the facility did not comply with the timeframe, resulting in a delay in providing the requested medical records.
Failure to Update Care Plan Leads to Repeated Falls
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident with a history of falls, resulting in multiple fall incidents. The resident, diagnosed with Alzheimer's disease and muscle wasting, was admitted to the facility and had severe cognitive impairments, requiring assistance with daily activities. Despite these needs, the care plan was not updated with specific interventions after the resident experienced falls on multiple occasions. The resident's care plan, last updated in 2022, did not reflect necessary interventions to prevent further falls, even after incidents on 5/22/2024, 7/26/2024, and 9/27/2024. Interviews with facility staff, including the LVN, MDSN, CNA, and DON, revealed that the care plan lacked specific interventions such as frequent visual checks and a toileting schedule, which were crucial given the resident's tendency to attempt activities independently and the risk of dizziness when getting up from bed. The facility's policies emphasized the need for individualized, resident-centered approaches to safety and fall risk management. However, the care plan did not incorporate these guidelines effectively, as it failed to address the resident's noncompliance with using the call light and did not specify the frequency of visual checks. The DON acknowledged the need for personalized interventions and the importance of reviewing and updating care plans to ensure they meet the resident's specific needs.
Failure to Monitor and Document Bowel Movements Leads to Severe Fecal Impaction
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident diagnosed with intestinal obstruction and dementia. The resident's care plan for constipation required daily recording of bowel movement patterns, which was not adhered to on multiple occasions. Specifically, there was no documentation of bowel movements from July 5, 2024, to July 23, 2024, despite the care plan's directive to monitor and report any complications related to constipation to the physician. Interviews with facility staff, including CNAs, LVNs, and the Director of Nursing, revealed a lack of proper documentation and communication regarding the resident's bowel movements. The staff acknowledged that the absence of documented bowel movements for 19 days was unacceptable and that interventions such as PRN medications should have been administered after three days without a bowel movement. The failure to monitor and document the resident's bowel movements led to the resident developing a severe fecal impaction, which required hospitalization and manual evacuation by a gastrointestinal specialist. The resident was eventually transferred to a General Acute Care Hospital due to a persistent abdominal bulge, which was found to be a severe fecal impaction. The facility's policy on monitoring bowel disorders was not followed, as there was no consistent documentation or communication among staff regarding the resident's condition. This oversight placed the resident's well-being at risk and resulted in significant discomfort and hospitalization.
Breach of Resident Medical Record Confidentiality
Penalty
Summary
The facility failed to safeguard the personal privacy and confidentiality of a resident's medical records, resulting in a breach of protected health information. The incident involved the incorrect transfer of medical records during a hospital transfer. Specifically, the medical records of Resident 1 were mistakenly sent with Resident 2 during their transfer to a General Acute Care Hospital (GACH) for further evaluation and treatment. This error was identified when the emergency room at GACH received the wrong set of medical records, prompting a call to the facility for verification. Resident 1, who was admitted with conditions including type 2 diabetes mellitus with chronic kidney disease and end-stage renal disease, had their medical records, including the face sheet, history and physical assessment, medications list, POLST, and physician's order of transfer, sent out instead of Resident 2's records. Resident 2, who was admitted with hypertensive heart disease with heart failure and other serious conditions, required immediate medical attention at GACH due to fever and low oxygen levels. The error was discovered when the emergency room charge nurse at GACH contacted the facility to confirm the identity of the resident and obtain the correct medical records. The breach occurred due to the actions of a Licensed Vocational Nurse (LVN1) who coordinated the transfer and sent the incorrect records. The Director of Nursing (DON) and other staff members acknowledged the mistake, recognizing it as a violation of HIPAA regulations. The facility's policy and procedure on the management and protection of protected health information emphasize the responsibility of personnel to prevent unauthorized release or disclosure, which was not adhered to in this instance.
Improper Storage and Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services by improperly storing and failing to dispose of expired medications in two medication carts. During an observation and interview, it was found that Medication Cart 1 contained three unopened Novolin R insulin Flex Pen injections and one unopened Basaglar insulin injection, which were not stored in the refrigerator as required. Additionally, a Novolin R insulin Flex Pen injection was found with an open date but no labeled expiry or discard date, and it should have been discarded after 28 days. Licensed Vocational Nurse 3 acknowledged the oversight and stated that LVNs were responsible for checking medication carts to ensure proper storage and disposal of expired medications. Similarly, Medication Cart 3 contained an Aspart insulin Flex Pen injection with an open date but no labeled expiry or discard date, and it should have been discarded after 28 days. The cart also contained expired Catapres and Zofran tablets. Licensed Vocational Nurse 1 confirmed that the expired medications could be ineffective and unsafe for residents. The Director of Nursing stated that improper storage and expired medications could compromise medication efficacy and safety, violating the facility's policy. The facility's policy requires that all drugs and biologicals be stored securely and that outdated drugs be returned or destroyed.
Resident Injury During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure a safe environment for Resident 1, who was diagnosed with dementia and Alzheimer's, during a transfer using a Hoyer lift. The incident occurred when Resident 1 was suspended in the lift, and CNA 1 left to retrieve a wheelchair, leaving the resident unsupported. As a result, Resident 1 tilted backward, causing his head to hit the lift, resulting in a 1.5 cm laceration and a small bump on the left frontal part of his head. A subsequent CT scan at a general acute care hospital revealed a scalp cephalohematoma. Interviews with staff revealed that proper procedures were not followed during the transfer. The Director of Nursing and LVN 2 indicated that both ends of the Hoyer lift sling should have been supported to prevent accidents. CNA 1 admitted to not holding the sling, assuming it would tilt normally, and left the resident unattended to get the wheelchair. The facility's policy on safe lifting and movement of residents, dated 2001, emphasizes using appropriate techniques and devices to ensure safety, which was not adhered to in this instance.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation involving physical abuse to the State Survey Agency, the state ombudsman, and local law enforcement within the required two-hour timeframe. This incident involved Resident 1, who reported being hit on the left arm by their roommate, Resident 2. Despite the facility's policy mandating immediate reporting of such incidents, the Director of Nursing (DON) delayed the report, citing a misunderstanding of the reporting timeframe. Resident 1, who has a history of osteoarthritis and heart disease, was able to communicate and make decisions independently. On the day of the incident, Resident 1 reported to the Charge Nurse that they had been hit by Resident 2, who has a history of psychosis and schizophrenia. The Charge Nurse documented the incident and reported it to the DON, but the DON did not report the incident to the appropriate authorities within the required timeframe, instead waiting for advice before taking action. Interviews with facility staff, including the Social Service Director and Certified Nurse Assistant, confirmed that the facility's policy requires reporting such incidents within two hours. The DON admitted to not being aware of the specific reporting timeframe and failed to complete the necessary abuse reporting form. The facility's policies clearly outline the need for prompt reporting to prevent further abuse and ensure resident safety, which was not adhered to in this 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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