San Diego Post-acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Cajon, California.
- Location
- 1201 South Orange Ave., El Cajon, California 92020
- CMS Provider Number
- 555659
- Inspections on file
- 64
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at San Diego Post-acute Center during CMS and state inspections, most recent first.
A resident with a history of hip prosthesis infection and iliac vein injury was admitted with an order for Eliquis 5 mg, two tablets twice daily for DVT, but scheduled doses were not administered when the eMAR showed the medication as pending delivery or not available. The resident later called 911 from her room, reporting she had not received Eliquis for days and had right lower limb pain, and a NP note documented her concern about missed doses and subsequent ER transfer where Eliquis was given. Interviews with LNs revealed inconsistent practices for obtaining unavailable medications, uncertainty about e-kit contents, and lack of documented MD notification about missed doses, while the DON confirmed the medication had been delivered before the first scheduled dose and that staff should have administered it as ordered and notified the MD when it was not given.
A resident with CHF and anxiety had ordered morning doses of Furosemide and Lorazepam left in a medication cup on the bedside table after an LPN documented administration but then left the room to assist the roommate without confirming ingestion. Later observation found the resident in bed with the two pills still at the bedside. Other nursing staff, the DSD, and the DON stated that complete medication administration requires verifying that medications are swallowed and that medications should not be left at the bedside, consistent with facility policies requiring safe, timely administration as prescribed.
The facility failed to identify, assess, and care plan for one resident’s behavioral triggers related to perceived theft, control of meal carts, and belief that he was an LVN, as well as another resident’s confused wandering into others’ rooms. As a result, the aggressive resident pushed a resident to the floor near a meal cart, punched a cognitively intact resident in the mouth while she sat in a wheelchair, and later yelled at and grabbed a confused, wandering resident who had entered his room and worn his clothes, leading that resident to strike him in the face and knock him to the floor. Staff interviews and record review showed that unit staff were often unaware of the aggressive resident’s PTSD‑related triggers or the wandering resident’s room‑entering behavior, and these issues were not incorporated into their care plans, contributing to repeated resident‑to‑resident physical abuse and distress for affected residents.
Two residents were involved in a room change where one cognitively impaired resident, whose responsible party was the decision maker, was moved into another resident’s room without written notice to the responsible party, and the existing resident did not receive written notification of receiving a new roommate. The ADON and Social Service Assistant acknowledged that facility policy required advance written notice and documentation of room and roommate changes for all involved parties, but this was not completed or documented in either resident’s record.
Two residents with cognitive and psychiatric conditions were involved in separate resident‑to‑resident altercations in which one resident struck another in the face and later confronted a confused, wandering resident who had entered his room and worn his clothing, leading to a physical exchange. The aggressive resident had known behavioral triggers related to other residents entering his room or closet and being near meal carts, and another resident was known to wander into others’ rooms and be hard to redirect. Despite this pattern, IDT notes and care plans did not identify or address these specific triggers or wandering behaviors as contributing factors, and investigative summaries did not clearly verify the incidents or specify actions taken. The abused resident was not documented as being informed of how she would be protected, and leadership acknowledged that the investigations were not thorough and did not include needed corrective actions, contrary to facility abuse‑investigation policy.
A resident with traumatic brain injury, PTSD, bipolar disorder, and dementia had documented aggression toward other residents in situations involving perceived theft, room entry, clothing use, and proximity to meal carts, yet the facility did not complete a PTSD‑specific assessment or develop care plans with resident‑specific behavioral triggers and interventions. Instead, care plans remained generic and did not list the known triggers identified in hospital discharge instructions and by staff. Several CNAs and a nurse reported they were unaware of the resident’s PTSD diagnosis or triggers, even though they recognized that all staff should know them to prevent aggression. The resident was also allowed to wear tape on his jacket labeling himself as an LVN, which staff stated was unsafe and could contribute to aggressive interactions, while facility policies required individualized trauma‑informed and behavioral care planning that was not implemented for this resident.
A resident with dementia and schizophrenia, documented as cognitively impaired and lacking decision-making capacity, frequently wandered into other residents’ rooms and was difficult to redirect, according to staff notes and interviews. On one occasion, the resident spent much of the day in a neighboring resident’s room, was repeatedly but unsuccessfully redirected by a CNA, and later was found wearing that resident’s clothing, leading to a physical altercation when the other resident confronted him. Despite these known behaviors, the resident’s care plans for elopement and cognitive impairment did not identify or address the wandering into other residents’ rooms with individualized interventions, even after the altercation, in conflict with the facility’s dementia and resident-to-resident altercation policies.
A resident with traumatic brain injury, PTSD, bipolar disorder, and Alzheimer’s dementia was involved in multiple physical altercations with other residents and was described in a psychiatric note as anxious, aggressive, and having mood swings. However, behavior monitoring on the MAR for agitation, irritability, and hypervigilance was left blank on one day and recorded as zero episodes on days when these altercations occurred, and nursing notes did not document the anxiety, aggression, or mood swings reported to the provider. This resulted in an incomplete and inaccurate medical record that did not reflect the resident’s actual behavioral condition.
A resident with a history of cerebrovascular disease and severe cognitive impairment was re-admitted without a current or revised discharge care plan. The Social Service Designee initially planned discharge to another state, but after contact with the resident's family, learned the preferred location was in California. Despite this, no updated discharge care plan was found, and staff interviews confirmed that discharge planning was not initiated or updated as required.
A resident with a history of diabetes and no cognitive deficits was re-admitted and had a discharge care plan initiated, but the plan was not updated or revised as their needs changed. There was no documentation of revised discharge goals or updated interventions, and no IDT review was completed. Both the SSD and DON acknowledged that the discharge care plan was not person-centered, not reviewed by the IDT, and not discussed with the resident or their representative.
Surveyors found two medication carts left unlocked and unattended, with one cart next to a resident and containing an open Control Drug Record and an open computer displaying a medication administration record. Prescription bottles and unlabeled medications were also found in an unlocked cart, and both nurses responsible admitted to forgetting to secure the carts. Facility policy requires all medication carts to be locked when not in use, a standard not followed in these instances.
A resident with significant ADL needs and cognitive impairment was not provided or offered showers on scheduled days during the first week of admission. Staff interviews and record reviews confirmed that showers were missed and not documented as required, despite facility policy mandating appropriate hygiene care.
The facility did not ensure that a resident received proper care for existing pressure ulcers and failed to implement adequate preventive measures to stop new ulcers from developing.
Staff did not consistently use required PPE, specifically eye protection, when entering rooms under Transmission Based Precautions. A housekeeper and a CNA both entered TBP rooms without eye protection, despite posted instructions and facility policy. The CNA stated she forgot, while the housekeeper believed there was no supply available. The DON confirmed that proper PPE should have been used.
Surveyors found unsealed floor drains and a large uncovered hole in the kitchen and dry storage areas, which allowed rodent entry as evidenced by droppings. Pest control recommendations to seal gaps and cracks had not been completed, and clutter near the dumpster contributed to the issue. The ice machine contained visible grime and debris, and cleaning procedures did not include scrubbing internal parts as required. Monthly inspections failed to identify these deficiencies, and the facility's sanitation policies were either outdated or not provided.
The facility did not follow pest control recommendations or address unsanitary conditions in the kitchen, including unsealed drains, large uncovered holes, and cluttered garbage areas. These inactions led to rodent infestation, as evidenced by droppings found in food preparation and storage areas, resulting in the kitchen's closure by the health department.
A resident with Alzheimer's and dementia was not protected from another resident with a cognitive communication deficit and aphasia, who hit him, causing a nosebleed. Despite the incident, the facility did not update care plans to separate the residents or prevent further altercations, as required by policy. The resident expressed feeling unsafe, and the facility's leadership acknowledged the need for separation but did not act on it.
The facility failed to monitor and document temperatures for medication storage areas, did not date opened multi-dose medications, and improperly managed discharged residents' medications. These deficiencies were observed during interviews and inspections, highlighting lapses in adherence to facility policies and potential risks to resident safety.
The facility failed to maintain food at a palatable temperature, as observed during a Resident Council Meeting where most members reported food was not hot enough. Residents also noted issues with raw and cold food items. Temperature checks revealed that food items were below the required temperature, not meeting the facility's expectations or FDA guidelines.
The facility failed to store food items properly, including grilled cheese, soy sauce, and food thickener, risking contamination. Grilled cheese was inadequately covered, soy sauce was not refrigerated as required, and a cracked lid on a food thickener bin posed a contamination risk. The Dietary Manager acknowledged these storage issues, which did not meet the facility's standards.
The facility's QAPI plan, overseen by the QAA committee, failed to identify issues with call light response times and food concerns before a recertification survey. The ADM and aDON were unaware of these issues, which were highlighted during resident interviews and council meetings. The DON stressed the importance of addressing food concerns to maintain residents' quality of life.
A resident with severe cognitive impairment and dependency on staff was unsafely discharged to an independent living facility instead of a hospice house, without proper evaluation or referral for home health services. The facility's discharge policy did not address the needs of cognitively impaired residents, leading to the resident's admission to an acute care hospital.
The facility failed to implement nail care plans for two residents, one with parkinsonism and another with hemiplegia, leading to unmet treatment goals. Both residents were observed with long, untrimmed fingernails despite care plans specifying nail trimming interventions. The facility's policy on comprehensive care plans was not followed, as acknowledged by the acting DON and ADON.
A facility failed to follow its medication administration protocols for a resident with a g-tube. An LN used bathroom sink water instead of warm, purified water to mix crushed medications, leading to a clogged g-tube. The facility's policy requires using purified water and fully dissolving medications to ensure proper administration.
Two residents in the facility, one with parkinsonism and another with hemiplegia, did not receive proper nail care despite requiring maximal assistance with personal hygiene. Observations revealed long fingernails, with one resident having black material underneath. The care plans, which included nail trimming, were not followed, and staff were unclear about responsibilities. Interviews with the acting DON and ADON confirmed the expectation for staff to maintain residents' nails for safety and hygiene.
A resident with chronic obstructive pulmonary disease and dementia was inaccurately assessed as a non-smoker, despite records and staff interviews confirming the resident's smoking habit. This discrepancy in the smoking assessment could potentially place the resident at risk for injury, as the facility's policy requires accurate evaluation and re-evaluation of smoking status.
A resident with functional quadriplegia and a urinary tract infection had a urinary catheter, but the facility staff failed to monitor and document urine output as per policy. Observations noted white sediments in the catheter tubing, and interviews revealed no physician's order for urine output monitoring, despite the facility's policy requiring it.
A resident with COPD and CHF was left without continuous oxygen for 30 minutes after being transferred from a wheelchair to a bed. The oxygen machine was found turned off despite the nasal cannula being in place. A licensed nurse restarted the oxygen at the ordered rate, acknowledging the responsibility of staff to ensure oxygen is maintained as ordered.
A resident receiving heparin injections for blood clot prevention was not monitored for signs of bleeding or bruising, despite facility policy requiring such monitoring. The resident, with functional quadriplegia, had been receiving the medication without appropriate oversight, as confirmed by staff interviews and record reviews.
A facility failed to monitor the correct target behavior for an antidepressant prescribed to a resident with schizoaffective disorder. The medication, mirtazapine, was ordered for depression but incorrectly listed auditory hallucinations as a target behavior. This discrepancy was confirmed by a nurse and acknowledged by the nursing leadership, highlighting a failure to adhere to the facility's policy on psychotropic medication use.
A resident was mistakenly given insulin without a physician's order due to a nurse confusing them with another resident with a similar profile. The error was discovered when the resident's family reported it, and the facility's protocol for verifying resident identity was not followed. Although the resident experienced no ill effects, the incident highlights a failure in the medication administration process.
A facility failed to ensure proper infection control during medication administration for two residents. An LN did not consistently perform hand hygiene after glove removal while administering medications to a resident with a g-tube. Another LN failed to perform hand hygiene before administering medications to a resident with epilepsy. The facility's policy on infection control was not followed, as confirmed by the acting DON and ADON.
The facility failed to ensure proper drainage from the dishwashing sink, leading to water draining onto the floor instead of into the drain hole. This issue was observed during an interview with a Dietary Aide, who was unsure of how long the problem had persisted. The Dietary Manager also confirmed the improper drainage and manually adjusted the pipe. The facility's policy emphasized the importance of keeping floors clean and dry to prevent accidents.
The facility failed to maintain accurate medical records for two residents, leading to missing personal items and inadequate communication with a resident's family. One resident's inventory forms lacked signatures, resulting in unaccounted belongings. Another resident's responsible party was not properly informed after the resident expired, and there was no physician's order to release the body to the mortuary. Staff interviews revealed inconsistencies in inventory management and communication processes.
A facility failed to follow a physician's order to monitor a COVID-19 positive resident's vital signs every four hours. The resident, diagnosed with emphysema, had a significant gap of seven and a half hours between recorded vital signs, exceeding the ordered interval. Staff interviews confirmed that CNAs and LNs shared responsibility for vital sign monitoring, but LNs were ultimately responsible. The lack of documentation indicated vital signs were not obtained as required, potentially delaying the identification of changes in the resident's condition.
A resident with schizoaffective disorder left the facility unnoticed and was fatally injured in an accident. The facility failed to implement its policies on accidents and supervision, as staff did not consistently obtain physician's orders for out on pass activities or document the resident's departures and returns. Miscommunication among staff led to assumptions about the resident's whereabouts, delaying the initiation of a search procedure.
A resident with schizoaffective disorder frequently left the facility unnoticed, leading to a fatal accident. Despite being aware of the resident's behavior, staff did not create a care plan to address it, violating the facility's policy for comprehensive, person-centered care plans.
The facility failed to protect residents' privacy by allowing male and female residents to share a bathroom and shower area, leading to discomfort. Observations and staff interviews confirmed that the shower curtain did not fully close, compromising privacy, and the facility's policy on resident rights was not followed.
The facility failed to ensure only authorized personnel had access to the medication storage cart's keys. An observation revealed keys left in an unlocked and unattended med cart, which were later taken by an unknown staff member. The facility's policy requires med carts to be locked and keys taken by the nurse when unattended.
Failure to Administer Anticoagulant as Ordered and Notify MD When Medication Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed anticoagulant medication, Eliquis, as ordered for a resident with a history of right hip prosthesis infection and injury of the right iliac vein. The resident was admitted with an order for Eliquis 5 mg, two tablets by mouth twice daily for DVT. The electronic MAR showed that on one evening the medication status was documented as “Pending delivery,” and on another evening it was documented as “Medication not available,” resulting in missed scheduled doses. The facility’s own medication administration policy required that medications be administered in accordance with prescriber orders, including any required time frame. Nursing documentation indicated that, in the early morning hours, the resident called 911 from her room, reporting to the nurse and the 911 operator that she had not received her Eliquis for days for DVT and was experiencing pain in her right lower limb. A nurse practitioner progress note later documented that the resident complained of leg pain, was worried she might have missed her Eliquis dose, and called 911 to be taken to the emergency room. A subsequent nurse practitioner discharge summary noted that during a recent hospital visit the resident was given Eliquis for DVT. Interviews with multiple licensed nurses revealed that when medications are not available, staff are expected to check with the pharmacy, search medication rooms and carts, and, if still unavailable, notify the physician for further direction or possible order adjustments. One nurse stated uncertainty about the availability of oral medications in the e-kit and described that staff might obtain medication from another resident with the same medication until delivery. Another nurse reported being unable to locate documentation that the physician had been notified about the missed Eliquis doses. The DON stated that the Eliquis had been delivered by the pharmacy on the day of admission prior to the scheduled administration time and that staff should have notified the physician when the medication was not administered, emphasizing that the resident had a confirmed DVT diagnosis and that the medication should have been administered as ordered.
Medications Left at Bedside Without Ensuring Administration
Penalty
Summary
The deficiency involves a failure to ensure complete and safe medication administration for a resident when ordered medications were left at the bedside and not verified as taken. The resident, who had diagnoses including congestive heart failure and anxiety disorder and physician orders for morning doses of Furosemide 40 mg and Lorazepam 0.5 mg, was observed lying in bed with eyes closed while two white, round pills remained in a medication cup on the bedside table. A nurse confirmed the presence of the pills and identified that another licensed nurse was the assigned medication nurse for the resident. Review of the Medication Administration Record and the medication cart, along with the photograph of the pills, established that the pills were the resident’s scheduled morning doses of Lorazepam and Furosemide. The assigned nurse stated she had administered the medications at 9:34 a.m. but acknowledged that she left the Lorazepam and Furosemide at the resident’s bedside when she went to assist the resident’s roommate and did not ensure the resident actually took the medications. Facility staff, including another licensed nurse, the director of staff development, and the DON, all stated that complete medication administration requires ensuring residents safely and fully swallow medications, including checking the mouth, and that medications should not be left at the bedside or on a bedside table. Facility documents, including a lesson plan on nursing documentation and the policy on administering medications, indicated that residents must take and swallow medications before staff leave the room and that no medications should be left by the bedside, and that medications are to be administered in a safe and timely manner as prescribed.
Failure to Identify and Care Plan Behavioral Triggers and Wandering Led to Resident‑to‑Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by not identifying, assessing, and care planning for known behavioral triggers and wandering behaviors. One resident with traumatic brain injury, PTSD, bipolar disorder, and Alzheimer’s dementia had documented triggers related to perceived theft, other residents entering his room or closet, and residents being near or touching the meal carts. Despite this, his behavioral triggers were not identified in his care plan, and staff assigned to him, including CNAs and licensed nurses, reported they were unaware of his specific triggers or PTSD diagnosis. The resident was also allowed to wear tape on his jacket labeling himself as an LVN, which staff stated could empower him and cause other confused residents to approach him as if he were staff, potentially provoking aggressive responses. This failure to manage the resident’s behaviors led to multiple resident‑to‑resident altercations. On one occasion, another resident was standing near the food cart when the aggressive resident pushed him aside, causing the resident to lose his balance and fall to the ground. On another date, a cognitively intact resident seated in a wheelchair in the dining room was approached by the aggressive resident, who attempted to pull her wheelchair backwards. When she told him to stop, he punched her in the mouth with a closed fist, causing a laceration to her upper inner lip, pain, and distress; she later reported that a tooth was loosened and that staff were not close enough to intervene before she was struck. Staff witnesses and leadership consistently characterized these acts of pushing and punching as physical abuse. The same aggressive resident also confronted a highly confused, cognitively impaired resident with dementia and schizophrenia who wandered and entered other residents’ rooms. Staff documented and reported that this wandering resident frequently went into others’ rooms, slammed doors, and was hard to redirect despite calm approaches and explanations. On the day of another altercation, staff observed that the wandering resident had been in the aggressive resident’s room most of the day and was not redirectable, and later put on the aggressive resident’s clothing. When the aggressive resident encountered him, he yelled at and grabbed the wandering resident’s arm; before staff could intervene, the wandering resident struck him in the face, causing him to fall to the floor and be sent to the hospital for evaluation. The facility’s own policies required identification of behaviors that could provoke reactions, assessment of triggers, and care plan changes after altercations, but interviews and record review showed that neither the aggressive resident’s triggers nor the wandering resident’s room‑entering behavior were identified, assessed, or incorporated into their care plans, contributing to repeated incidents of resident‑to‑resident abuse on the secured unit. In addition, the facility did not fully address the impact of the abuse on affected residents. The cognitively intact resident who was punched in the mouth reported significant pain lasting a long time and fear of the aggressive resident, stating she would not feel safe if he remained on the unit and that she knew he had hit other residents before. She was told by staff that the aggressive resident was no longer in the facility and was gone, rather than being informed of a specific plan to keep her safe from him. There was also no documentation that she was evaluated by a physician or dentist after being punched in the mouth, despite her oral injury and pain. Another roommate of the aggressive resident reported being afraid of him and stated that the aggressive resident had threatened to kill him, which staff considered believable given their knowledge of his prior aggressive acts. The facility’s own leadership and clinical staff acknowledged that unmanaged behaviors, such as the aggressive resident’s responses to perceived theft and control of food carts, and the other resident’s wandering into rooms and rummaging, could lead to altercations and abuse. They further acknowledged that these behaviors and triggers were not identified, assessed, or incorporated into individualized care plans, and that staff on the secured unit were not consistently aware of which residents had been involved in altercations with the aggressive resident. As a result, residents on the secured unit, including those with cognitive impairment and mental disorders, were exposed to repeated episodes of physical abuse and altercations stemming from unaddressed behavioral triggers and unsafe wandering into other residents’ rooms.
Failure to Provide Required Written Notice of Room Change and New Roommate
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of a room change and new roommate assignment for two residents. One resident with Alzheimer’s disease and unspecified dementia, documented in a history and physical as not having the capacity to understand and make decisions, was admitted with a responsible party designated as the decision maker. Facility census records showed this resident was in one room and another resident was in a different room on the same date. A progress note later documented that the cognitively impaired resident was moved into the other resident’s room. During interview and record review, the ADON confirmed that the responsible party should have been notified prior to the room change and that there was no documentation that this notification occurred. The second resident, who was already occupying the room into which the first resident was moved, did not receive written notice that a new roommate would be assigned. The ADON stated that residents should be notified about getting a roommate and that it was the Social Worker’s responsibility to notify the responsible party and the potential roommate of a room change and to document that conversation. The Social Service Assistant confirmed that the room change should have been documented on a room change form and in a progress note, and that written notification should have been provided to both residents, but acknowledged this was missed. The facility’s policy on room change/roommate assignment required advance notice to all parties and their representatives and documentation of the room change in the medical record, which was not followed in these instances.
Failure to Thoroughly Investigate Resident‑to‑Resident Abuse and Address Behavioral Triggers
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate two resident‑to‑resident physical abuse incidents and to identify and address contributing behavioral factors. In the first incident on 12/25/25, a resident with anxiety was seated in a wheelchair in the dining room when another resident with traumatic brain injury, PTSD, bipolar disorder, and Alzheimer’s dementia approached and attempted to pull the wheelchair backward. When the seated resident told him to stop, he struck her in the face without apparent provocation, causing a laceration to her upper inner lip and pain that she reported lasted a long time. The injured resident later stated she would feel afraid and unsafe if the aggressor were on the unit because of his violent nature, and she was told by staff that he was no longer in the facility. Interviews and record review showed that the aggressive resident had known behavioral triggers, including becoming agitated when other residents went into his room or closet or were around the meal carts, and believing he was a licensed nurse who should control access to the food carts. The ADON and DSD stated that these triggers were known and that residents with unmanaged behaviors could have altercations and incidents of abuse. However, the IDT note dated 12/26/25 for the 12/25/25 altercation did not identify these behavioral triggers as contributing factors, and the resident’s care plan did not include these specific triggers or related interventions. The ADON acknowledged that after a prior incident on 11/14/25, when the same resident pushed another resident away from the food carts causing a fall, his behavior and triggers were still not identified and care planned, and that the investigation into the 12/25/25 incident did not result in corrective action to prevent further abuse. The ADON also confirmed there was no documentation that the injured resident was informed of how she would be protected from the aggressor. In the second incident on 12/30/25, another resident with unspecified dementia and schizophrenia, who was documented as going into other residents’ rooms and slamming doors and being hard to redirect, wandered into the aggressive resident’s room and put on his clothing. Staff, including a CNA, reported that this confused resident frequently wandered into other residents’ rooms, that he had been in the aggressor’s room most of the day and refused redirection, and that this behavior would have triggered the aggressor’s aggression. The altercation occurred when the aggressive resident approached the confused resident in the hallway, yelled at him, and grabbed his arm, leading the confused resident to swing and strike him in the face, causing him to fall. Despite this pattern, the IDT note dated 12/31/25 for the 12/30/25 altercation did not identify the confused resident’s wandering into other residents’ rooms as a contributing factor, and his care plan did not address this wandering behavior with resident‑specific interventions. The ADON and administrator, who served as the abuse preventionist, acknowledged that the investigations into both incidents did not identify the behavioral triggers and wandering as contributing factors and did not include corrective actions, and that the investigative summaries did not clearly verify the incidents or specify what corrective action was taken, contrary to the facility’s policy requiring thorough investigations and follow‑up reports with sufficient information and corrective actions when allegations are verified. The facility’s own policy on Abuse, Neglect, Exploitation or Misappropriation‑Reporting and Investigating, revised September 2022, required that all allegations be thoroughly investigated and that follow‑up investigation reports provide sufficient information to describe the results of the investigation and indicate any corrective actions taken if the allegation was verified. The policy also required that the follow‑up report provide as much information as possible and that the resident and/or representative be notified of the outcome immediately upon conclusion of the investigation. In these two incidents, the administrator and ADON acknowledged that the investigations were not thorough enough, did not identify key contributing behaviors such as the aggressor’s triggers and the other resident’s wandering, did not include corrective actions, and did not document communication to the abused resident about how she would be kept safe, leading to the cited deficiency for failure to thoroughly investigate alleged abuse and respond appropriately.
Failure to Assess and Care Plan PTSD Triggers Leading to Resident‑to‑Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate behavioral health treatment and services, including trauma‑informed care, to a resident with diagnosed mental disorders and PTSD. The resident was admitted with traumatic brain injury, PTSD, bipolar disorder, and Alzheimer’s dementia. Hospital discharge instructions included a safety plan that identified a specific personal red flag: the resident becomes angry or aggravated when people are perceived as stealing from him. Despite this, the facility did not complete a PTSD‑specific assessment to identify individualized triggers, and the written care plans for psychosocial, mood, and behavioral issues remained generic and non‑resident‑specific. Multiple documented incidents show the resident’s aggression toward other residents in situations consistent with his known concerns about theft and control. In one incident, the resident pushed another resident standing near the food cart, causing that resident to lose balance and fall. In another, the resident approached a resident seated in a wheelchair in the dining room, attempted to pull the wheelchair backward, and then struck the resident in the face without apparent provocation. In a third incident, the resident yelled at another resident in the hallway and grabbed his arm; before staff could intervene, the other resident struck him, causing him to fall to the floor. Staff interviews revealed that the resident was triggered when other residents went into his room or closet, wore his clothing, were near the food carts, or were yelling, and that he was preoccupied with thoughts of theft and believed others were stealing from him. The resident’s care plans for PTSD, mood disorder, and behavior referenced broad interventions such as avoiding triggers, helping the resident identify triggers, documenting behavioral episodes, and observing for potential triggers, but did not list the specific, known triggers identified by staff and in prior documentation. Care plans created after each altercation only directed staff to observe and document changes in behavior and potential triggers, again without naming the resident’s known triggers. Several staff members, including CNAs and a nurse, stated they were not aware of the resident’s PTSD diagnosis or specific behavioral triggers, even though they acknowledged that all staff should know these triggers to prevent aggression. The resident was also observed wearing medical tape on his jacket labeling himself as an LVN, and multiple staff members stated this was unsafe and could empower him or cause other residents to approach him as if he were staff, potentially contributing to aggressive responses. The facility’s own policies on trauma‑informed care and behavioral assessment required trauma screening, identification of triggers, and individualized care plans, but the resident’s record lacked a PTSD assessment and did not contain resident‑specific triggers or interventions addressing his behavior.
Failure to Individualize Dementia Care and Care Plan for Wandering Behavior
Penalty
Summary
The deficiency involves the facility’s failure to provide individualized dementia care and care planning for a resident with dementia and schizophrenia whose behavior included wandering into other residents’ rooms. Resident 6 was admitted and later readmitted with diagnoses of unspecified dementia and schizophrenia, was documented as lacking capacity to make decisions, and had a court-appointed decision maker. An MDS assessment showed significant cognitive impairment, and the history and physical confirmed the resident did not have capacity to understand and make decisions. Staff documentation, including an SBAR summary, noted that the resident was going into another resident’s room and slamming doors, and that the resident was hard to redirect despite calm approaches, explanations, and encouragement. On the day of the altercation, nursing documentation indicated that Resident 5 was ambulating down the hallway when he approached Resident 6, began yelling, and grabbed Resident 6’s arm. Before staff could intervene, Resident 6 struck Resident 5 in the face, causing Resident 5 to fall to the ground. Staff interviews revealed that Resident 6 frequently wandered into other residents’ rooms, was very confused, and was easily startled, reacting physically when grabbed. One CNA reported that Resident 6 had been inside Resident 5’s room most of the day, that she had redirected him multiple times without success, and that she informed a licensed nurse that the resident was not responding to redirection. Staff also reported that Resident 6 had put on Resident 5’s clothing and that this situation would have triggered Resident 5’s aggression. Despite these known behaviors and staff observations, a review of Resident 6’s care plans for elopement and cognitive impairment related to dementia showed that the behavior of wandering into other residents’ rooms was not identified or addressed with individualized interventions. The Director of Staff Development and the Assistant Director of Nursing acknowledged that Resident 6 was known to wander into other residents’ rooms and that such behavior, including rummaging or taking things, could lead to altercations and incidents of abuse. They confirmed that even after the altercation between Resident 6 and Resident 5, Resident 6’s wandering into other residents’ rooms had not been identified, assessed, or incorporated into the resident’s care plan with resident-specific interventions, contrary to the facility’s dementia and resident-to-resident altercation policies.
Inaccurate Behavioral Documentation for Resident With Psychiatric and Cognitive Disorders
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one resident with traumatic brain injury, PTSD, bipolar disorder, and Alzheimer’s dementia. The resident’s interdisciplinary team note documented that the resident struck another resident in the face in the dining room without apparent provocation. A nurse’s note later documented that the same resident approached another resident in the hallway, yelled, grabbed the other resident’s arm, and was then struck and knocked to the floor. A psychiatric progress note also stated that staff reported the resident had been anxious, aggressive at times, and continued to have mood swings and aggression. Despite these documented incidents and provider observations, the resident’s December medication administration record (MAR) behavior monitoring for agitation, irritability, and hypervigilance was incomplete and inaccurate. One day’s behavior monitoring entry was left blank, and on the days when the resident was involved in physical altercations, the MAR documented zero episodes of agitation or irritability. During interviews, a licensed nurse and the ADON acknowledged that the MAR entries were incorrect and that nursing notes did not reflect the anxiety, aggression, or mood swings described in the psychiatric note. This resulted in a medical record that did not accurately represent the resident’s behavioral condition, contrary to the facility’s policy requiring objective, complete, and accurate documentation of changes in a resident’s condition.
Failure to Develop Discharge Care Plan for Resident with Severe Cognitive Deficits
Penalty
Summary
The facility failed to develop a discharge care plan for one of three sampled residents following re-admission. The resident in question had a history of cerebrovascular disease and was assessed with severe cognitive deficits, as indicated by a BIMS score of 2 out of 15. Despite the resident's complex needs, there was no evidence of a current or revised discharge care plan after re-admission. The Social Service Designee (SSD) initially planned for the resident to be discharged to a sister facility in another state, but later learned from the resident's family member that the preferred discharge location was closer to the family in California. However, the SSD was unable to locate any updated discharge care plan reflecting this change or the resident's needs. Interviews with facility staff, including the SSD and the Director of Nursing (DON), confirmed that discharge planning and care plans were not initiated or updated in a timely manner. The DON acknowledged that discharge care plans should be developed and revised based on the resident's condition, care needs, and input from the interdisciplinary team (IDT), as well as discussed with the resident or their representative. A review of facility policy also indicated that comprehensive, person-centered care plans are required to be developed by the IDT. The absence of a discharge care plan following the resident's re-admission constituted a deficiency in meeting regulatory requirements for care planning.
Failure to Update and Revise Person-Centered Discharge Care Plan
Penalty
Summary
The facility failed to update and revise a person-centered discharge care plan for one of three sampled residents. The resident, who had a history of Diabetes Mellitus and no cognitive deficits as indicated by a perfect BIMS score, was re-admitted to the facility and had a discharge care plan initiated at the time of re-admission. However, the discharge care plan was not revised or updated as the resident's condition and planning needs changed. There was no documentation of revised discharge goals or updated interventions for a safe transition since the baseline care plan was initiated, and no interdisciplinary team (IDT) review was completed during the scheduled care conference. Interviews and record reviews revealed that the Social Service Designee (SSD) acknowledged the discharge care plan was not person-centered and had not been updated within the required timeframe or as the resident's needs changed. The SSD also confirmed that the care plan was not reviewed by the IDT and was not discussed with the resident or their representative. The Director of Nursing (DON) further stated that discharge care plans must be continuously updated and coordinated with the IDT, and acknowledged that this had not occurred for the resident in question.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that two medication carts, located at Station 2 and Station 3, were left unlocked and unattended during an unannounced visit. At Station 2, a resident in a wheelchair was found sitting next to the unattended cart, which had an open Control Drug Record and an open computer displaying a medication administration record. The nurse responsible for the cart admitted to leaving it unlocked and the computer open after assisting a resident in another room. At Station 3, another medication cart was found unlocked with no staff present, and prescription bottles along with a cup containing four unlabeled medications were found in the top drawer. The nurse responsible for this cart also acknowledged forgetting to lock it before leaving the area. Staff interviews confirmed that the facility's policy requires medication carts to be locked and secured when not in use or out of the nurse's view. The Assistant Director of Nursing stated that the expectation is for all medication carts to be locked and acknowledged the potential for unauthorized removal of medications. Facility policies reviewed by surveyors also specified that all compartments containing medications must be locked when not in use. The Director of Nursing was unavailable for interview during the survey.
Failure to Provide Scheduled Showers for Resident Needing ADL Assistance
Penalty
Summary
A deficiency occurred when a resident, admitted with generalized weakness, major depressive disorder, and cognitive communication deficit, was not provided a shower on scheduled shower days during the first week of admission. The resident's care plan indicated a need for assistance with activities of daily living (ADLs) and specified that the resident was at risk for ADL/mobility decline. Despite being scheduled for showers twice a week, documentation showed that the resident did not receive or was not offered a shower on the first two scheduled days after admission. Interviews with staff confirmed that showers were to be offered and refusals documented, but there was no record of showers being offered or provided on those days. Review of the facility's records and interviews with the CNA, Charge Nurse, ADON, and DON confirmed that the resident should have received showers on the scheduled days, and that documentation was lacking for those dates. The facility's ADL policy required appropriate care and services, including hygiene, but there was no specific policy for resident showers. The lack of documentation and failure to provide or offer showers as scheduled led to the deficiency.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not provided with adequate preventive care to avoid the formation of new ulcers.
Failure to Ensure Staff Use Required PPE for Transmission Based Precautions
Penalty
Summary
Staff failed to use appropriate Personal Protective Equipment (PPE) when entering rooms placed on Transmission Based Precautions (TBP). Specifically, a housekeeper entered a TBP room without wearing the required eye protection while cleaning, despite a sign at the entrance instructing all visitors to wear eye protection. Additionally, a certified nursing assistant entered another TBP room and interacted with a resident without wearing eye protection, as directed by the posted signage. During interviews, the certified nursing assistant stated she forgot to put on eye protection before entering the TBP room. The housekeeper reported not wearing eye protection because he believed the facility had run out of the necessary supply. The Director of Nursing confirmed that staff should have worn the correct PPE, including eye protection, in accordance with the facility's policy, which requires personnel to use eye protection upon entry to a resident's room under TBP.
Unsanitary Kitchen Conditions and Inadequate Ice Machine Cleaning
Penalty
Summary
Surveyors identified unsanitary conditions in the facility's kitchen, including unsealed and uncovered floor drains and a large floor hole in the dry storage room, which were acknowledged by the Registered Dietitian and Director of Food and Nutrition Services. These openings were found to facilitate rodent entry, as evidenced by rodent droppings discovered behind the oven and in the entry room to the dry storage area during a county environmental health inspection. Pest control company reports from January to May documented ongoing recommendations to seal gaps, cracks, and broken tiles in the kitchen, but these repairs remained pending. The Maintenance Director confirmed that not all pest control recommendations had been completed and acknowledged that clutter near the garbage dumpster could attract rodents. Additionally, the ice machine in the kitchen was found to have black, brown, and grayish grime and debris inside the grid curtain, water tray, and ice chute. The Maintenance Director stated that monthly cleaning was performed using descaler and sanitizer chemicals, but admitted that a scrub brush was not used to clean between the metal flaps, leaving visible slime and debris. The Registered Dietitian and Director of Food and Nutrition Services agreed that the ice machine should be visibly clean, especially since the ice is used for resident consumption and food preparation. Record reviews revealed that the facility's Registered Dietitian had completed monthly inspection checklists without identifying the issues with uncovered floor holes, drains, or the cleanliness of the ice machine. The facility's kitchen sanitation policy was not provided, and the pest control policy on file was outdated. The facility's policy on ice machine cleaning required cleaning per manufacturer guidelines and monitoring by the Registered Dietitian, but these procedures were not adequately followed, as evidenced by the observed grime and debris.
Failure to Maintain Pest-Free Kitchen Environment
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen, as evidenced by multiple observations and interviews. The pest control company's recommendations to seal gaps, cracks, and broken tiles in the kitchen area were not completed, leaving large uncovered openings and holes. These unaddressed structural issues allowed rodents to enter the kitchen, as confirmed by the presence of rodent droppings found behind the oven and in the entry room to the dry storage area. The kitchen staff and maintenance director acknowledged that rodents had been seen in the kitchen, particularly near the floor drain behind the ice machine, and that the open holes and drains made it easier for pests to access the area. During inspections, the local health department identified multiple violations, including evidence of rodent infestation and unsanitary conditions such as an unsealed floor drain and a large uncovered hole in the dry storage room. The garbage area outside the facility was also found to be cluttered with cardboard boxes, worn appliances, equipment, linens, bins, and crates, which could attract and harbor pests. The facility's pest control reports from January to May indicated repeated recommendations to seal gaps and repair broken tiles, but these actions remained pending and unaddressed over several months. The failure to implement the pest control company's recommendations and maintain sanitary conditions in the kitchen led to the closure of the kitchen by the local health department due to the risk of food contamination from rodent activity. The facility's own policy required ongoing pest control and daily removal of garbage, but these standards were not met, resulting in unsanitary conditions and the potential for foodborne illness.
Failure to Protect Resident from Alleged Perpetrator
Penalty
Summary
The facility failed to take appropriate action to protect a resident, identified as Resident 5, from an alleged perpetrator, Resident 9, following a reported altercation. Resident 5, who has Alzheimer's Disease and dementia, was involved in an incident where Resident 9, who has a cognitive communication deficit and aphasia, wandered into Resident 5's room and hit him on the nose, causing a nosebleed. Despite this incident, the facility did not update the care plans to separate the two residents or prevent further altercations, as confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The facility's policy requires thorough investigation and documentation of such incidents, but the care plans for both residents did not reflect necessary changes to prevent future occurrences. Observations and interviews revealed that Resident 5 did not feel safe and still encountered Resident 9, who was known to have episodes of aggression. The ADON and DON acknowledged that the residents should not share a bathroom to prevent further altercations, yet no action was taken to separate them. The facility's policies on abuse and resident-to-resident altercations emphasize the need for investigation and care plan adjustments, which were not adequately followed in this case, leaving Resident 5 and potentially other residents at risk for further abuse.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to consistently monitor and document the temperature for medication refrigerators, a utility room, and a utility refrigerator, as observed during a joint interview with a Licensed Nurse (LN) and the acting Director of Nursing (aDON). The temperature logs for these areas had multiple missed entries from July 2024 through December 2024. LN 14 acknowledged the importance of maintaining proper temperatures to ensure the safety and potency of medications and tube feedings. The facility's policy requires medications to be stored under proper temperature conditions, but this was not adhered to, as evidenced by the missed temperature log entries. Additionally, the facility did not date an opened multi-dose vial (MDV) of flu vaccine and an opened inhaler, which is against the facility's policy that requires opened multi-dose medications to be dated and discarded within 28 days. During an observation in the medication room, the aDON noted the absence of an opened date on the flu vaccine vial, and LN 31 admitted to forgetting to label the inhaler with the opened date. This oversight could lead to the administration of expired medications, compromising resident safety. Furthermore, the facility improperly managed discharged residents' medications by keeping them for more than 30 days and commingling them with active residents' medications. An observation revealed an unlocked locker containing an overfilled plastic bag with bottles of personal medications belonging to both active and inactive residents. The aDON confirmed that the medications of a discharged resident should have been separated and returned to the resident upon discharge. Additionally, loose medications were found in a medication cart, which LN 43 could not identify, posing a risk to resident safety and potential drug diversion.
Deficiency in Food Temperature Maintenance
Penalty
Summary
The facility failed to ensure that food served during lunch was at a palatable temperature for the residents. This deficiency was identified through observations, interviews, and record reviews. During a Resident Council Meeting, seven out of eight members expressed that the food was not hot enough. Additionally, residents reported issues with the food, such as raw meatballs and cold hamburgers, scrambled eggs, sausage, and bacon. On a specific day, the temperature of food items was measured, revealing that the eggrolls and meatballs were significantly below the required temperature, with readings of 97 F and 97.4 F, respectively. The Dietary Manager and Registered Dietician confirmed that the food was warm but not hot, which did not meet the facility's expectations for hot food temperatures. The Dietary Manager stated that the expectation for hot foods was to maintain a temperature close to 135 F for main entrees and hot sides, and 140 F for soups and hot cereal. The 2022 FDA Food Code requires hot foods to be maintained at 135 degrees F or above. The failure to maintain these temperatures could prevent residents from eating their meals and receiving their daily nutrition. The report highlights the importance of serving food at a palatable temperature to promote residents' nutrition and satisfaction with their meals, thereby supporting their health and well-being.
Improper Food Storage Practices
Penalty
Summary
The facility failed to appropriately store certain food items, which could lead to residents receiving spoiled or contaminated food. During an initial tour of the kitchen, a tray of prepared grilled cheese sandwiches was found in the walk-in refrigerator, covered only partially with wax paper and not sealed properly, leaving the sides exposed to air. The Dietary Manager (DM) acknowledged that the grilled cheese should have been sealed with plastic wrap. Additionally, an opened soy sauce container, which required refrigeration after opening, was found in the dry storage room past its use-by date. Furthermore, a food thickener bin was observed with a crack in its lid, creating a potential entry point for pests. The DM confirmed that the facility's expectations for food storage were not met. Foods prepared in advance should be sealed and labeled with preparation and use-by dates to prevent contamination. The soy sauce should have been stored according to the manufacturer's guidelines to prevent spoilage. The cracked lid on the food thickener bin did not meet the facility's standards for dry storage, which require seamless containers with tight covers to prevent contamination. These observations were supported by the facility's documented procedures for refrigerated and dry storage, which emphasize the importance of proper sealing and labeling to maintain food quality and safety.
QAPI Plan Fails to Identify Deficiencies in Call Light Response and Food Concerns
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) plan, developed by the Quality Assessment and Assurance (QAA) committee, failed to identify deficient practices prior to their recertification survey. These deficiencies included issues with call light response times from staff and food concerns identified through resident interviews and during the resident council meeting. This oversight had the potential to cause the facility to overlook trends in residents' health and quality of life. During a joint interview with the Administrator (ADM) and the Acting Director of Nursing (aDON), it was revealed that they were unaware of the call light issues and food concerns. The ADM expressed that the expectation was for the QAA committee to have identified these trends before they were pointed out by the surveyors. Additionally, the Director of Nursing (DON) emphasized the importance of identifying residents' food concerns to ensure the highest quality of life for all residents in the facility.
Unsafe Discharge of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure a safe discharge for a resident, identified as Resident 80, who was cognitively impaired and dependent on staff for activities of daily living. Resident 80 was discharged to what was believed to be a hospice house, but was actually an independent living facility, without proper evaluation or confirmation of the facility's capability to provide necessary care. The discharge plan was made by the interdisciplinary team, but there was no documentation that the hospice house owner evaluated Resident 80's needs or that the facility was suitable for his care. Additionally, Resident 80 was not referred for home health services as planned. The facility's policy on discharging residents did not address the safe discharge of cognitively impaired and dependent residents. Interviews with staff revealed that Resident 80 had a history of hallucinations, agitation, and was bedbound and incontinent. The attending physician had noted that Resident 80 lacked the capacity to make decisions. Despite these needs, the social service director was unaware that the hospice house was actually an independent living facility, and the resident's insurance benefits were exhausted, making him ineligible for hospice care. This oversight led to Resident 80 being admitted to an acute care hospital shortly after discharge.
Failure to Implement Nail Care Plans for Two Residents
Penalty
Summary
The facility failed to implement care plans related to nail care for two residents, which had the potential to not meet their treatment goals and needs. Resident 90, who was readmitted with parkinsonism and required assistance with personal care, was observed with long fingernails on his contracted right hand during two separate observations. Despite the care plan indicating that a nurse should trim the nails, this intervention was not carried out. The acting Director of Nursing and the Assistant DON acknowledged that the care plan should have been followed and verified. Similarly, Resident 131, who was readmitted with hemiplegia and hemiparesis and lacked the capacity to make decisions, was observed with long, dirty fingernails. The care plan for Resident 131 specified that nails should be trimmed according to the bathing schedule, but this was not implemented. The Certified Nursing Assistant was unaware of who was responsible for trimming the resident's nails. The facility's policy on comprehensive, person-centered care plans emphasizes the need for measurable objectives and timetables to address residents' physical and functional needs, which were not adhered to in these cases.
Failure to Follow Medication Administration Protocols for G-Tube
Penalty
Summary
The facility failed to adhere to its policy and procedure for administering medications through a gastrostomy tube (g-tube) for a resident. During a medication pass observation, a Licensed Nurse (LN 12) was seen preparing medications for a resident with a g-tube by crushing tablets and mixing them with water from the bathroom sink, rather than using warm, purified water as required by the facility's guidelines. LN 12 did not fully dissolve the crushed medications, which led to the g-tube becoming clogged. Despite attempts to clear the obstruction using a declogger, the process was not initially successful, and some medication remained undissolved in the cup. The resident involved had been readmitted to the facility with a g-tube for medication and nutrition. The facility's policy, revised in 2018, clearly states that warm, purified water should be used for diluting medications and flushing the g-tube. The acting Director of Nursing and the Assistant DON confirmed that LN 12 did not follow the expected procedures, which included using a spoon to fully dissolve the medications. This oversight had the potential to prevent the resident from receiving the correct dosage of medication and risked clogging the g-tube.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with nail care for two residents, Resident 90 and Resident 131, who were unable to perform activities of daily living independently. Resident 90, who was readmitted with diagnoses including parkinsonism, required maximal staff assistance for personal hygiene. Despite this, observations on two separate occasions revealed that Resident 90 had long fingernails on his contracted right hand. The care plan for Resident 90 indicated that nurses were responsible for trimming nails, but this was not adhered to, as confirmed by a Licensed Nurse during a record review and interview. Resident 131, who was readmitted with hemiplegia and hemiparesis, also required maximal staff assistance for personal hygiene. Observations showed that Resident 131 had long fingernails with black material underneath, indicating a lack of proper nail care. The care plan for Resident 131 specified that nails should be trimmed according to the bathing schedule, but this was not followed. A Certified Nursing Assistant was unaware of who was responsible for trimming Resident 131's nails, highlighting a gap in communication and responsibility. Interviews with the acting Director of Nursing and the Assistant DON confirmed that the expectation was for nursing staff to maintain residents' nails for safety, infection prevention, and hygiene. The facility's policy on activities of daily living emphasized the need for appropriate care and services for residents unable to perform these tasks independently. However, the care plans for both residents were not implemented as required, leading to the observed deficiencies in nail care.
Inaccurate Smoking Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate smoking assessment for a resident, identified as Resident 54, which had the potential to place the resident at risk for injury. Resident 54 was admitted with diagnoses including chronic obstructive pulmonary disease and dementia, with a moderately impaired cognitive status as indicated by a BIMS score of 09. Despite the resident's admission record and facility smoking list indicating that the resident was a smoker, the smoking assessment inaccurately stated that the resident denied smoking or using tobacco products. Interviews conducted with Resident 54, a licensed nurse, and a hospitality aide confirmed that the resident was indeed a smoker and regularly went to the designated smoking area. The facility's smoking policy requires that a resident's smoking status be evaluated upon admission and re-evaluated quarterly or upon significant changes in physical or cognitive status. The discrepancy between the resident's smoking assessment and other records, as well as staff interviews, highlights a failure in accurately assessing and documenting the resident's smoking status.
Failure to Monitor Urine Output for Resident with Catheter
Penalty
Summary
The facility staff failed to monitor and document urine output for a resident with a urinary catheter, as per the facility's policy. This deficiency was identified for a resident who was readmitted with diagnoses including functional quadriplegia and a urinary tract infection. During an observation, the resident was found to have a urinary catheter with white sediments in the tubing, and there was no documentation of urine output measurement. Interviews with the licensed nurse and the acting Director of Nursing revealed that there was no physician's order to monitor the resident's urine output, although it was acknowledged that measuring urine output is necessary to ensure catheter functionality. The facility's policy on catheter care, revised in August 2022, requires observing urine levels for noticeable changes and following procedures for measuring and documenting input and output, which was not adhered to in this case.
Failure to Restart Resident's Oxygen Supply After Transfer
Penalty
Summary
The facility failed to restart a resident's continuous oxygen supply after transferring her from a wheelchair to a bed. The resident, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF), was observed with a nasal cannula in place, but the oxygen machine was turned off. This oversight was discovered during an observation at 3:09 P.M., and the oxygen was subsequently restarted by a licensed nurse at the ordered rate of 2 liters per minute. The resident's care plan indicated the need for continuous high-concentration oxygen due to her CHF diagnosis. A review of the nurse's notes revealed that the resident was without supplemental oxygen for approximately 30 minutes. The facility's policy on oxygen administration, dated 2001, outlines the steps for ensuring proper oxygen delivery, including turning on the oxygen and adjusting the delivery device for comfort and proper flow. The licensed nurse acknowledged the expectation for staff to check oxygen after transfers and ensure it is maintained as ordered.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication, specifically in the case of a resident receiving heparin, an anticoagulant. The resident, who was readmitted to the facility with functional quadriplegia, had a physician's order for heparin injections every eight hours to prevent blood clots. However, there was no accompanying order or documentation for monitoring the resident for signs and symptoms of bleeding or bruising, which are known side effects of heparin. During a review of the resident's clinical record and interviews with the licensed nurse and the acting Director of Nursing, it was confirmed that the resident had been receiving heparin since the previous year without appropriate monitoring for adverse effects. The facility's policy on adverse consequences and medication errors emphasizes the importance of monitoring medication usage to prevent and detect medication-related problems, including side effects. Despite this policy, the necessary monitoring for the resident's safety was not conducted, leading to a deficiency in care.
Failure to Monitor Correct Target Behavior for Antidepressant Use
Penalty
Summary
The facility failed to appropriately identify and monitor the target behavior for the use of the antidepressant medication, mirtazapine, prescribed to Resident 45. The resident was readmitted with a diagnosis of schizoaffective disorder, which includes symptoms such as hallucinations and mood disorders. The physician's order for mirtazapine indicated it was for depression, evidenced by verbalizing sadness, but also incorrectly listed auditory hallucinations as a target behavior. This discrepancy was noted during a review of the resident's clinical record and confirmed by Licensed Nurse 11, who acknowledged that monitoring the correct target behavior is crucial to ensure the medication's appropriateness for its intended use. During interviews, both the acting Director of Nursing and the Assistant Director of Nursing confirmed that the expectation was for nurses to monitor the appropriate target behavior for antidepressant use. The facility's policy on psychotropic medication use, revised in July 2022, states that residents should not receive medications that are not clinically indicated for a specific condition. The failure to monitor the correct target behavior for Resident 45's antidepressant medication had the potential to lead to unnecessary psychotropic medication use and its associated side effects, impacting the resident's psychological and mental well-being.
Medication Error Due to Resident Misidentification
Penalty
Summary
The facility failed to prevent a significant medication error involving Resident 390, who was administered insulin without a physician's order. Resident 390, who was admitted with diagnoses including Type 2 Diabetes Mellitus, morbid obesity, cerebral infarction, and aphasia, was mistakenly given a shot of insulin by Licensed Nurse 26 (LN26). The error occurred because LN26 confused Resident 390 with another resident who had a similar profile and was new to the facility. LN26 checked the medication administration record (MAR) for the wrong resident and administered 9 units of Aspart insulin based on the incorrect order. The error was discovered when Resident 390's daughter (DOR) reported the incident to the head nurse after noticing the administration of insulin, which was not ordered for her mother. The facility's process for insulin administration, as described by LN24 and the Unit Manager Nurse (UMN), involves verifying the resident's identity through an ID band or confirmation by two nurses if the resident is confused. However, this protocol was not followed, leading to the administration of insulin to the wrong resident. The facility's policy on medication errors requires notifying the physician, responsible party, and charge nurse, and monitoring the resident for adverse effects. Although Resident 390 did not experience any ill effects from the insulin administration, the incident highlights a failure in the facility's medication administration process. The error was documented by LN25, who was informed by the resident's family, but LN26, who made the error, did not document it herself. The Assistant Director of Nursing (ADON) and Acting Director of Nursing (aDON) emphasized the importance of correctly identifying residents before administering medications to prevent such errors.
Inconsistent Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed during medication administration for two residents. A Licensed Nurse (LN) was observed not performing hand hygiene consistently after removing gloves while administering medications to a resident with functional quadriplegia and a gastrostomy tube. The LN handled various items and performed tasks such as filling cups with water, adjusting the g-tube, and using a declogger without performing hand hygiene between glove changes. This inconsistency in hand hygiene was acknowledged by the LN during an interview, who admitted the importance of hand hygiene for infection control. Another incident involved a different LN who did not perform hand hygiene before administering medications to a resident with epilepsy and encephalopathy. Although the LN performed hand hygiene after the medication administration, the failure to do so beforehand was noted. The facility's policy on administering medications, which includes following infection control procedures like handwashing, was not adhered to in these instances. The acting Director of Nursing and the Assistant DON confirmed the expectation for nurses to perform hand hygiene before and between tasks to prevent infection.
Improper Drainage in Dishwashing Area
Penalty
Summary
The facility failed to ensure that water from the dishwashing sink drained appropriately into the drain hole, which had the potential to cause accidents in the dishwashing area and preventable flooding of the kitchen. During an observation and interview with a Dietary Aide (DA), it was noted that water was draining directly onto the floor beneath the dishwasher sink from the sink pipe, rather than into the drain hole. The DA was unsure how long this issue had been occurring but acknowledged that the expectation was for the drain water to empty directly into the drain hole to ensure the safety of staff washing dishes, as they could slip on the water. Further observation and interview with the Dietary Manager (DM) revealed that the DM was also unaware of how long the pipe had been draining onto the floor. The DM manually adjusted the pipe to ensure it emptied into the drain hole. The facility's dietary policy on accident prevention and safety precautions emphasized the importance of keeping floors clean, dry, and free of obstructions, and specified that equipment discharging liquid waste should drain through an air gap into an open floor sink.
Deficiencies in Documentation and Communication for Resident Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for two residents, leading to deficiencies in safeguarding resident-identifiable information and maintaining medical records. For Resident 3, the inventory of personal items was not signed by the resident or facility staff upon transfer to the hospital, resulting in missing items such as a cell phone, cash, a gold necklace, and a green card. The inventory forms for multiple dates lacked signatures and documentation indicating whether Resident 3's belongings remained in the facility or were returned to the resident. For Resident 7, the facility did not document follow-up attempts to contact the responsible party after the resident expired. The progress notes indicated that a code blue was called, and the resident expired, but there was no documentation of further attempts to reach the emergency contact after an initial unsuccessful call. Additionally, there was no physician's order documented to release Resident 7's body to the mortuary, which is a required procedure for discharging a resident from the facility. Interviews with facility staff, including CNAs, LNs, and the ADON, revealed inconsistencies in the process of inventory management and communication with residents' families. The facility's policies and procedures were reviewed, highlighting the requirement for signatures on inventory forms and notification of responsible parties in the event of significant changes in a resident's condition. However, these procedures were not followed, leading to the deficiencies identified in the report.
Failure to Monitor Vital Signs for COVID-19 Positive Resident
Penalty
Summary
The facility failed to adhere to a physician's order for monitoring vital signs every four hours for a resident who tested positive for COVID-19. The resident, who had a diagnosis of emphysema, was admitted to the facility and later tested positive for COVID-19. The physician's order required that the resident's vital signs, including blood pressure, pulse rate, temperature, respiration rate, and oxygen saturation level, be monitored every four hours. However, a review of the resident's electronic health record revealed that there was a significant gap of seven and a half hours between the recorded vital signs, which exceeded the four-hour interval specified by the physician. Interviews with facility staff, including certified nursing assistants and licensed nurses, confirmed that the responsibility for taking and documenting vital signs was shared between CNAs and LNs, with LNs ultimately responsible for ensuring compliance with the physician's orders. The assistant director of nursing acknowledged that the lack of documentation indicated that vital signs were not obtained as required. This failure to monitor and document vital signs as ordered potentially delayed the identification of changes in the resident's condition, which could have impacted the timely transfer of care to the hospital.
Failure to Implement Safety and Supervision Policies Leads to Resident's Fatal Accident
Penalty
Summary
The facility failed to implement its policies related to accidents and supervision, specifically concerning a resident who left the facility unnoticed and was subsequently involved in a fatal accident. The resident, who had a diagnosis of schizoaffective disorder and was admitted for rehabilitation, was last seen at the nurse's station in stable condition. However, the facility did not initiate a search procedure or announce a code green until approximately 12 hours after the resident was last seen, resulting in a significant delay in response. Interviews and record reviews revealed that the staff did not consistently obtain a physician's order for the resident's out on pass (OOP) activities, nor did they adequately document the resident's departures and returns. The lack of communication among staff members led to assumptions about the resident's whereabouts, with some staff believing the resident had signed out or was in his room. This miscommunication and failure to follow protocol contributed to the resident leaving the facility unnoticed. The facility's policies on safety and supervision, elopements, and signing residents out were not adhered to, as evidenced by incomplete documentation and the absence of a timely response to the resident's disappearance. Staff interviews indicated a lack of awareness and adherence to the procedures for managing residents who leave the facility, which ultimately resulted in the resident's tragic accident and death.
Failure to Develop Care Plan for Resident's Wandering Behavior
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who had multiple episodes of leaving the facility unnoticed by staff. This deficiency was identified following an incident where the resident, diagnosed with schizoaffective disorder, left the facility and was subsequently hit by a pickup truck, resulting in their death. Despite being alert, oriented, and ambulatory, the resident's tendency to leave the facility was known to staff, yet no care plan was created to address this behavior. Interviews with various staff members, including CNAs and LNs, revealed that the resident frequently went out of the building, sometimes not returning until the next day. However, none of the staff members interviewed had developed a care plan for the resident's behavior of leaving the facility. The facility's policy required a comprehensive, person-centered care plan to be developed by the interdisciplinary team, but this was not done for the resident, contributing to the tragic outcome.
Failure to Ensure Resident Privacy in Shared Bathrooms
Penalty
Summary
The facility failed to protect residents' privacy by allowing male and female residents to share a bathroom and shower area, which made the residents uncomfortable. Resident 5, who required assistance with personal care, and Resident 6, who had abnormalities of gait and mobility, both expressed discomfort with the shared bathroom arrangement. Observations revealed that the shower curtain separating the male and female sides of the bathroom was approximately 12 inches short and did not fully close, compromising privacy during showering and bathroom use. Interviews with staff, including a CNA, licensed nurses, and the social service director, confirmed that the shared bathroom arrangement was inappropriate and did not provide adequate privacy for the residents. The facility's policy on resident rights, which emphasizes treating residents with respect and ensuring their privacy, was not adhered to in this case. The director of nurses also acknowledged that male and female residents should not share bathrooms for privacy reasons.
Unauthorized Access to Medication Cart Keys
Penalty
Summary
The facility failed to ensure only authorized personnel had access to the medication storage cart's keys. During an observation, keys were found in the lock of an unattended and unlocked med cart. After two minutes, an unknown staff member took the keys. Licensed Nurse 1 admitted to making an error by not locking the cart and taking the keys with him. The Director of Nursing confirmed that the facility's policy requires nurses to lock the med cart and take the keys when leaving it unattended. The facility's policy, revised in November 2020, mandates that drugs and biologicals be stored in locked compartments and only accessible to authorized personnel.
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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