Saint Vincent Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1810 N. Fair Oaks Ave, Pasadena, California 91103
- CMS Provider Number
- 555119
- Inspections on file
- 18
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Saint Vincent Healthcare during CMS and state inspections, most recent first.
The facility failed to follow proper food handling practices, including improper storage of frozen meats, unlabeled and improperly sealed dry pasta, and expired food items in the kitchen. These deficiencies were observed during a kitchen inspection, with the Dietary Service Supervisor acknowledging the importance of adhering to storage protocols to prevent contamination and potential illness among the 67 residents consuming food by mouth.
The facility failed to keep two dumpsters in the parking lot closed and free from overflowing trash, contrary to its policy. During an inspection, the Maintenance Supervisor and Assistant observed that the dumpsters were overflowing, preventing the lids from closing. The facility's policy requires lids to remain closed to deter pests. A review of the policy confirmed that trash should be packed down, boxes folded, and lids closed when not in use.
The facility failed to implement enhanced barrier precautions (EBP) for 11 residents, as required by their policy, to prevent the spread of multidrug-resistant organisms (MDROs). Staff did not consistently wear gowns during high-contact care activities, and there was a lack of signage and PPE availability outside residents' rooms. This deficiency placed residents at a higher risk for cross-contamination and increased the spread of infection.
A resident with Parkinson's disease and other conditions was observed with an uncovered urinary catheter bag, contrary to the facility's policy requiring dignity bags. Staff interviews confirmed the policy's importance for maintaining dignity and self-esteem, highlighting a deficiency in adhering to these standards.
A resident with hand contractures and limited mobility was not provided with an appropriate call light device, relying instead on verbal calls for assistance. Despite facility policies emphasizing the need for adaptive devices, the resident was given a standard call cord, which she could not use. Staff confirmed the resident's inability to use the call cord, highlighting a failure to accommodate her needs.
A resident with chronic kidney disease, urinary retention, dementia, and gross hematuria had a care plan that included inappropriate interventions, such as providing fluids via a PEG tube, despite the resident not having one. Additionally, the care plan included cranberry use for UTI prophylaxis without an order. These discrepancies were identified by an RN, highlighting a failure to ensure the care plan was resident-centered and based on accurate data.
A resident was diagnosed with schizophrenia without proper evaluation by a Medical Doctor, leading to a potential provision of unnecessary care. The resident, initially admitted with dementia and other conditions, was prescribed Seroquel for aggressive behavior. The CNP added the schizophrenia diagnosis based on staff reports, without documenting delusions or consulting the resident's family. Observations showed no symptoms of schizophrenia, and the DON noted the diagnosis was inconsistent with the resident's history.
A resident with reduced mobility and Parkinson's disease was not provided necessary assistance during meals, as required by their care plan. Observations showed the resident struggling to eat, resulting in food spillage, and interviews confirmed the resident's preference for assistance over using a plate guard. The facility's policies on daily living activities and accommodation of needs were not followed, leading to this deficiency.
A resident with a stage 3 pressure injury on the right heel did not receive the prescribed wound care treatment from October 1 to October 7. The resident, with severe cognitive impairment and multiple health conditions, required specific wound care that was not followed due to discrepancies between the physician's order and the wound care physician's progress note. Nursing staff acknowledged the failure to implement the correct treatment plan, which was essential for proper wound care and healing.
A resident receiving gastrostomy tube feeding was observed with the head of bed (HOB) less than 30 degrees, contrary to the facility's policy requiring 30 to 45 degrees elevation to prevent aspiration. The resident, with dysphagia and severe cognitive impairment, was dependent on assistance for daily activities. Both the LVN and DON confirmed the necessity of HOB elevation during feeding.
A facility failed to provide trauma-informed care for a resident with PTSD, as staff were unaware of the resident's diagnosis and triggers. The resident had informed staff about his PTSD triggers, but there was no care plan in place. The Social Services Director confirmed the lack of reassessment and care planning upon the resident's readmission, contrary to the facility's policy.
A facility failed to verify the competency of a Registry Certified Nursing Assistant (RCNA) before they provided care to residents. The Director of Staff Development did not check or request documentation of the RCNA's skills or certification, relying only on verbal confirmation from the registry. The Director of Nursing acknowledged the importance of knowing staff competencies for resident safety, but the facility lacked documentation. This oversight had the potential to compromise resident care and safety.
A resident was administered Risperdal without a clinical justification, as there was no diagnosis of schizophrenia, which the medication is intended to treat. The facility's DON and RN acknowledged the lack of evidence for the diagnosis, and the facility's policy requiring evaluation of antipsychotic medication use was not followed. This resulted in the unnecessary use of Risperdal, contrary to the facility's guidelines.
A resident with severe cognitive impairments and specific food preferences, including Mexican food, was not provided with their requested meals on multiple occasions, despite these preferences being documented in their care plan. The facility's failure to honor these preferences led to the resident refusing meals, as observed in the Daily Meal Eating Log. Interviews with staff revealed a lack of awareness and documentation regarding the resident's preferences, and the facility's policy on accommodating resident needs was not followed.
A facility failed to offer the pneumococcal vaccine to a resident upon readmission, as required by its policy. The resident, with a history of ventricular tachycardia, Parkinson's Disease, and major depressive disorder, had previously refused the vaccine but was not offered it again during the current admission. Interviews with the DON and IPN confirmed the lapse in protocol, and the resident expressed interest in receiving the vaccine, citing a history of pneumonia.
The facility failed to meet the minimum square footage requirements for resident rooms, affecting 25 out of 27 rooms. Despite this, residents and staff reported no issues with space for care and movement. A waiver was recommended for the affected rooms.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as outlined in their policies and procedures, which could potentially lead to foodborne illnesses among the 67 residents consuming food by mouth. During an observation in the kitchen, it was noted that frozen food items, such as sliced bacon and frozen meat, were not stored in airtight, moisture-resistant wrappers as required by the facility's policy. Instead, the kitchen staff only folded the flaps of the original boxes, which the Dietary Service Supervisor incorrectly stated was sufficient. Additionally, dry pasta was improperly stored; a bag of twisted pasta was ripped and not sealed, and a bag of egg noodles was neither labeled nor dated, contrary to the facility's procedures for dry storage. Further inspection revealed expired food items in the kitchen, including Worcestershire sauce, peanut butter, baking soda, and a package of seasoning with an unreadable expiration date. The Dietary Service Supervisor confirmed that opened food items should be labeled with the date they were opened and a use-by date, and expired items should be discarded. The facility's policy mandates that all food items in storage must be labeled and dated, and opened items should be used by the date following storage guidelines. The failure to follow these protocols was acknowledged by the Dietary Service Supervisor, who emphasized the importance of proper storage to prevent contamination and potential illness among residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two garbage containers (dumpsters) in the parking lot had their lids closed and were not overflowing with trash, as per the facility's policy. During an observation and interview with the Maintenance Supervisor and Maintenance Assistant, it was noted that the dumpsters were overflowing with trash, causing the lids to remain open. The Maintenance Assistant acknowledged the issue, stating that the trash was overflowing and the lids could not be closed. The Maintenance Supervisor confirmed that the facility's policy required dumpster lids to remain closed to prevent pests such as rodents, flies, and insects from being attracted to the dumpsters and potentially entering the facility. A review of the facility's Policy and Procedure on Exterior Maintenance indicated that garbage and trash containers should be maintained in a clean and pest-free condition, with trash packed down, boxes folded, and lids closed when not in use.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for 11 residents, as required by their policy, to prevent the spread of multidrug-resistant organisms (MDROs). This deficiency was observed through various instances where staff did not wear the appropriate personal protective equipment (PPE) such as gowns during high-contact care activities. For example, a Licensed Vocational Nurse (LVN) did not wear a gown while administering medications through a gastrostomy tube (GT) for a resident, and a Certified Nurse Assistant (CNA) did not wear a gown while changing a resident's diaper. Additionally, there was a lack of signage and PPE availability outside the rooms of residents on EBP. The facility's policy indicated that EBP should be implemented for residents with wounds, indwelling catheters, and feeding tubes, regardless of their MDRO status. However, observations revealed that the facility did not adhere to this policy. For instance, there were no EBP signs or PPE carts outside the rooms of residents who required them, and staff members were not consistently using gowns during high-contact activities. Interviews with staff, including the Infection Prevention Nurse (IPN), revealed a misunderstanding of when EBP should be applied, with some staff believing it was only necessary for residents with current infections. The failure to implement EBP as per the facility's policy placed residents at a higher risk for cross-contamination and increased the spread of infection. The facility's policy clearly outlined the need for gowns and gloves during specific high-contact activities, yet these measures were not consistently followed. This lack of adherence to infection control protocols was evident in multiple instances across the facility, highlighting a systemic issue in the implementation of EBP and the availability of necessary PPE.
Failure to Use Dignity Bag for Resident's Catheter
Penalty
Summary
The facility failed to ensure that a foley catheter was covered with a dignity bag for one resident, which is a violation of the resident's right to a dignified existence. The resident, who was admitted with diagnoses including Parkinson's disease, muscle wasting, atrophy, and polyneuropathy, was observed with an uncovered urinary catheter bag. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for substantial assistance with daily activities, including toileting. Despite the resident's capacity to understand and make decisions, as noted in their Initial History & Physical, the facility did not adhere to its policy requiring dignity bags for catheter bags. Interviews with facility staff, including a Treatment Nurse and the Director of Nursing, confirmed that the facility's policy mandates the use of dignity bags to maintain residents' dignity and self-esteem. The facility's Policy and Procedure on Dignity, revised in February 2021, emphasizes the importance of treating residents with dignity and respect, prohibiting practices that compromise dignity. The failure to cover the catheter bag as per policy was identified as a deficiency that could potentially impact the resident's self-worth and self-esteem.
Failure to Provide Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 63, by not providing an appropriate call light device. Resident 63 was admitted with several diagnoses, including left hand contracture, pain in the right shoulder, weakness, and major depressive disorder. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and functional limitations in both upper extremities, requiring substantial assistance with daily activities. Despite these limitations, the resident was provided with a standard call cord, which she was unable to use due to her hand contractures. Observations and interviews revealed that Resident 63 was unaware of the call cord's presence and unable to reach or use it effectively. Staff members, including Certified Nursing Assistants (CNAs) and a Registered Nurse (RN), confirmed that the resident had restricted movement in her arms and hands, making it difficult for her to use the call cord. Instead, the resident relied on verbally calling for assistance or waiting for staff to check on her during regular rounds. The RN acknowledged that Resident 63 had not been evaluated for a more suitable call light device, such as a pad call light, which could accommodate her physical limitations. The facility's policies and procedures emphasized the importance of accommodating residents' individual needs and preferences, including the use of adaptive devices. However, the failure to provide an accessible call light device for Resident 63 demonstrated a lack of adherence to these policies. This oversight had the potential to impact the resident's quality of care and life, as she was unable to independently call for help when needed.
Inappropriate Care Plan Interventions for a Resident
Penalty
Summary
The facility failed to ensure that the care plan for one of its residents, identified as Resident 3, was applicable and resident-centered. Resident 3 was readmitted to the facility with several diagnoses, including chronic kidney disease, urinary retention, dementia, and gross hematuria. The Minimum Data Set (MDS) assessment indicated that Resident 3 had severely impaired cognitive skills and required significant assistance with daily activities. However, the care plan included an intervention to provide fluids via a PEG tube, which was inappropriate as Resident 3 did not have a PEG tube and consumed food and liquids orally. This inappropriate intervention was acknowledged by Registered Nurse 1 (RN1) during a review. Additionally, the care plan for Resident 3 included an intervention for cranberry use as a prophylaxis for urinary tract infections, but there was no order for cranberry in the resident's records. RN1 confirmed that Resident 3 never had an order for cranberry, indicating that the care plan was not aligned with the resident's current needs. The facility's policy on comprehensive, person-centered care plans emphasizes the importance of developing care plans based on accurate data gathering and relevant clinical decision-making, which was not adhered to in this case.
Improper Schizophrenia Diagnosis Without MD Evaluation
Penalty
Summary
The licensed nursing staff at the facility failed to meet professional standards of quality by not ensuring that a resident was properly assessed and evaluated by a Medical Doctor before adding a new diagnosis of schizophrenia. The resident, who was admitted with diagnoses including dementia, major depressive disorder, and Alzheimer's Disease, was given a physician order for Seroquel to manage aggressive behavior associated with dementia. However, the diagnosis was later changed to schizophrenia without proper documentation or evaluation by a psychiatrist. The Certified Nurse Practitioner (CNP) added the schizophrenia diagnosis based on his evaluation and reports from facility staff, despite the resident's psychiatric follow-up note indicating no new symptoms or need for medication adjustment. The CNP admitted to not documenting the resident's delusions in the psychiatric follow-up note and planned to write a late entry note. The Director of Nursing confirmed that there was no documentation of communication with the resident's family to confirm the mental history or schizophrenia diagnosis, and noted that schizophrenia typically develops at a younger age. Observations of the resident showed no aggressive behavior or symptoms consistent with schizophrenia, and the resident's psychiatric condition was noted as generally unchanged. The American Psychiatric Association's guidelines indicate that schizophrenia symptoms usually appear in early adulthood and require a thorough medical examination to rule out other conditions. The facility's failure to adhere to these standards resulted in a potential provision of unnecessary care for the resident.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to provide necessary assistance to a resident with limitations in mobility, specifically during meal times, as outlined in the care plan and facility policy. The resident, who was diagnosed with reduced mobility and Parkinson's disease, had a care plan indicating the need for assistance with activities of daily living due to a right hand contracture. Despite this, observations revealed that the resident was not provided with the required assistance while eating, which was necessary to meet their nutritional needs and prevent further decline in their ability to perform daily activities. During dining observations, the resident was seen struggling to eat using only their right hand, resulting in food spillage onto their clothes and the floor. The occupational therapy notes had recommended the use of a plate guard to aid in self-feeding, but this was not utilized during the observations. Interviews with the resident and staff confirmed that the resident preferred assistance over using the plate guard and expressed dissatisfaction with the lack of help, which led to food spillage and frustration. The facility's policies on activities of daily living and accommodation of needs emphasize providing appropriate care and assistance to maintain or improve residents' abilities to perform daily tasks. However, the staff failed to adhere to these policies, as evidenced by the lack of assistance provided to the resident during meals, despite the resident's clear need for support due to their physical limitations and cognitive impairments.
Failure to Follow Wound Care Treatment Plan for Resident with Stage 3 Pressure Injury
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a stage 3 pressure injury on the right heel. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, unspecified protein-calorie malnutrition, and hyperlipidemia, was assessed as having severely impaired cognitive skills and required substantial assistance with daily activities. Despite having an order for specific wound care treatment starting on October 1, 2024, the treatment plan was not followed from October 1 to October 7, 2024. The treatment plan required cleansing with normal saline, applying collagen powder, and covering with a dry dressing, but this was not implemented as per the physician's order. Interviews with nursing staff revealed discrepancies between the treatment plan documented in the physician's order and the wound care physician's progress note. The registered nurse and treatment nurse acknowledged the inconsistency and failure to follow the wound care physician's treatment plan, which included using a wound cleanser, applying collagen, and covering with calcium alginate and bordered gauze dressing every three days. The Director of Nursing confirmed that the treatment plan should have been verified and followed to ensure proper wound care and healing, as per the facility's policy and procedure on pressure ulcers and skin breakdown.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
The facility failed to ensure the head of bed (HOB) was elevated at a 30-degree angle for a resident receiving gastrostomy tube (GT) feeding, as per the facility's policy. The resident, identified as Resident 28, was observed receiving GT feeding with the HOB less than 30 degrees elevation. This observation was made during a concurrent room visit and interview with LVN 1, who acknowledged that the HOB should be at least 30 to 45 degrees to prevent aspiration, which can lead to pneumonia if the resident vomits and the feeding enters the lungs. Resident 28 was initially admitted to the facility with diagnoses including dysphagia and was dependent on assistance for daily activities. The resident's care plan, initiated on 4/9/2024, indicated the need to elevate the HOB during GT feeding. The facility's policy, revised in November 2018, also required the HOB to be elevated at least 30 degrees during tube feeding to prevent aspiration. Despite these directives, the deficiency was noted during the survey, with both the LVN and the Director of Nursing confirming the requirement for HOB elevation during feeding.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as required by their policy. The resident, who had an intact cognitive ability for daily decision-making, had previously informed staff about his PTSD triggers, which included seeing guns and violence on television. However, during interviews, both a CNA and an LVN were unaware of the resident's PTSD diagnosis and triggers, indicating a lack of communication and awareness among the staff. The Social Services Director confirmed that the resident did not have a care plan for trauma-informed care and acknowledged that the resident should have been reassessed for trauma-informed care upon readmission. The facility's policy on trauma-informed care emphasized the importance of minimizing triggers and re-traumatization through proper assessment and care planning, which was not followed in this case.
Failure to Verify Competency of Temporary Nursing Staff
Penalty
Summary
The facility failed to ensure that a Registry Certified Nursing Assistant (RCNA 1) had the necessary competencies before providing care to residents. RCNA 1 worked in the facility on a specific date without the Director of Staff Development (DSD) verifying their competency skills and certification. The DSD admitted to not having checked or requested documentation of RCNA 1's competency skills or certificate verification, relying solely on verbal confirmation from the registry. This oversight meant that the facility did not have any documentation or information regarding RCNA 1's competency skill sets before they began working. The Director of Nursing (DON) also acknowledged the importance of knowing the competency skill sets of staff to ensure proper care and resident safety. However, the facility lacked documentation of RCNA 1's competencies. The facility's policy and procedure on competency and training emphasized the need for an effective training program for all staff, including those under contractual arrangements, to ensure they possess the necessary skills to meet resident needs and ensure safety. This deficiency had the potential to result in residents not receiving appropriate nursing services and placed them at risk for injury or harm.
Unjustified Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from the unnecessary use of a psychotropic drug, specifically Risperdal, as there was no clinical justification for its use. The resident, who was initially admitted and later readmitted to the facility, had diagnoses including major depressive disorder and dementia but did not have a diagnosis of schizophrenia, which is one of the conditions Risperdal is used to treat. Despite this, the resident was prescribed Risperdal 0.5 mg twice a day upon discharge from a general acute care hospital, and this prescription was continued at the facility without proper justification. The Director of Nursing (DON) and Registered Nurse 3 (RN 3) both acknowledged that there was no evidence to support a diagnosis of schizophrenia for the resident. The DON confirmed that the resident received Risperdal without a diagnosis of schizophrenia, and RN 3 admitted to transcribing the medication order from the hospital discharge without verifying the diagnosis. The facility's policy requires that residents transferred from a hospital and receiving antipsychotic medications be evaluated for the appropriateness and indications for use, which was not adhered to in this case. The facility's policy and procedure on antipsychotic medications, revised in July 2022, clearly state that residents should not receive medications that are not clinically indicated to treat a specific condition. Despite this policy, the resident's psychiatric evaluations did not list Risperdal as a current medication, and there was no documentation of a schizophrenia diagnosis in the resident's health records. This oversight led to the unnecessary administration of Risperdal, which was not clinically justified according to the facility's own guidelines.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident 68, which is a violation of the care plan and facility policy. The resident had expressed a preference for Mexican food, including tacos and beef soup, on multiple occasions. However, these preferences were not honored on specific dates, despite being documented in the resident's care plan and food preference records. This failure to provide the requested meals was observed through various records, including the resident's Speech/Language Pathology Daily Note and Dietary Progress Notes. Resident 68, who has severe cognitive impairments and requires assistance with daily activities, was admitted with diagnoses including major depressive disorder, metabolic encephalopathy, and dementia. The resident's nutritional care plan specified a mechanical soft, no added salt diet, and emphasized the importance of honoring reasonable food preferences. Despite this, the facility did not provide the requested Mexican food, leading to multiple meal refusals by the resident throughout September 2024, as documented in the Daily Meal Eating Log. Interviews with facility staff, including the Dietary Service Supervisor (DSS) and the Director of Nursing (DON), revealed a lack of awareness and documentation regarding the resident's food preferences. The DSS admitted that Mexican food was not regularly included in the menu, except on specific occasions like Cinco de Mayo. The DON acknowledged the absence of documentation showing that the resident's meal preferences were offered, which could lead to meal refusals and potential weight loss. The facility's policy on accommodating resident needs and food preferences was not adhered to, as evidenced by the lack of Mexican food options provided to Resident 68.
Failure to Offer Pneumococcal Vaccine Upon Readmission
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to Resident 2 upon readmission on 9/26/2024, as required by the facility's policy. Resident 2, who was admitted with conditions including ventricular tachycardia, Parkinson's Disease, and major depressive disorder, had previously refused the vaccine on 4/14/2022. However, there was no documentation of the vaccine being offered or declined during the current admission, nor was there any record of education provided to the resident about the vaccine. Interviews with the Director of Nursing and the Infection Preventionist Nurse confirmed that the facility's protocol requires staff to offer the pneumococcal vaccine during all admissions and readmissions, and to document the administration or declination in the resident's medical record. The Infection Preventionist Nurse acknowledged that the vaccine was not offered to Resident 2 during the current admission, which was a deviation from the facility's policy. Resident 2 expressed interest in receiving the vaccine, citing a history of pneumonia, but could not recall being offered the vaccine during the current admission.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required square footage per resident bed in 25 out of 27 resident rooms. The deficiency was identified during a re-certification survey conducted from October 15 to October 18, 2024. Observations revealed that rooms 1 to 9 and 11 to 26 did not meet the minimum requirement of 80 square feet per resident. Despite the deficiency, residents did not express complaints about the room size, and staff reported that there was sufficient space to provide care and store residents' belongings. Wheelchair-bound residents were able to move in and out of their rooms without difficulty. Interviews with residents and staff further supported that the room sizes did not hinder the provision of care. For instance, Resident 45, who uses a wheelchair, stated that she had no issues with the room size and that staff assistance was adequate. Similarly, a Certified Nursing Assistant (CNA) reported that the room was spacious enough to care for residents, as demonstrated by the successful transfer of Resident 52 from bed to wheelchair. Despite these observations, the facility's room waiver request indicated that the rooms did not meet the required square footage, prompting the Department to recommend a waiver for the affected rooms.
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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