Santa Clarita Post-acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newhall, California.
- Location
- 23801 Newhall Avenue, Newhall, California 91321
- CMS Provider Number
- 055728
- Inspections on file
- 47
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Santa Clarita Post-acute Care Center during CMS and state inspections, most recent first.
Staff failed to verify the internal temperature of grilled chicken used as a substitute entrée for several residents who avoided pork, despite a facility policy requiring Food and Nutrition Services staff to take food temperatures on the tray line before service. On the observed lunch meal, a cook checked temperatures of other foods but plated and distributed grilled chicken, and later pureed a portion for a diet-changed resident, without taking its temperature. Multiple residents with conditions such as Alzheimer’s disease, dysphagia, DM, COPD, CKD, and cancer, and with documented pork dislikes or specific diet textures, were affected by this practice, while the Dietary Supervisor and DON both confirmed that required temperature checks were not performed as outlined in the meal service policy.
Licensed nurses did not monitor or document the medical status of two residents after changes of condition, including one with diabetes, anemia, and COPD, and another with gastrointestinal issues. One resident also received oxygen therapy at a rate higher than the physician's order. The DON confirmed that required monitoring and documentation were not completed according to facility policy.
Staff failed to follow COVID-19 infection control protocols when a CNA removed and disposed of PPE, including an N95 mask, inside a COVID-19 isolation room, and an LVN did not wear an N95 mask properly or perform hand hygiene after touching the mask and using shared equipment. These actions were not in accordance with facility policies requiring proper use of N95 respirators and hand hygiene during a respiratory outbreak.
A resident with severe cognitive impairment and high fall risk, who required the call light to be within reach per their care plan, was found with the call light rolled up and out of reach. The DON confirmed the call light was not accessible, contrary to facility policy and the resident's care plan.
A resident with diabetes, depression, and epilepsy was served a meal containing fish despite a physician order and documented preference for no fish. The resident's care plan did not include this dietary preference, and staff were unaware until notified by a family member. The nutrition care plan was not individualized as required by facility policy.
A resident with hypotension and heart failure did not receive their midodrine HCl 10 mg tablet as prescribed, and a midodrine pill was found on the hallway floor. The LVN believed the medication was given but failed to document it correctly and did not ensure the resident swallowed the pill, contrary to facility policy requiring timely administration and documentation.
A resident with multiple medical conditions and a physician order for a no fish diet was served fish after their dietary preference was not communicated to the dietary department or documented on the Diet Communication Form. Staff were unaware of the restriction, and the meal ticket did not reflect the resident's preference, resulting in the resident receiving a meal that did not accommodate their documented dietary needs.
A resident with multiple medical and psychiatric diagnoses reported to an LVN that another resident touched his legs, making him feel scared and uncomfortable due to wounds in the area. The LVN relayed the concern to the SSA, but the SSA did not follow up with the resident or document the complaint, resulting in a failure to investigate and record the grievance as required by facility policy.
A resident with multiple chronic conditions, who was dependent on staff for care, repeatedly refused to have her incontinence brief checked by a CNA. Despite the resident's clear verbal refusals, the CNA continued to attempt care, pulling the blanket and proceeding until another CNA intervened. Staff interviews and facility policy confirmed that the resident's right to refuse care was not honored, resulting in a violation of her rights to dignity and self-determination.
Two residents in an RNA feeding program were assisted with eating in a rehab therapy room instead of a homelike setting, contrary to facility policy. Additionally, a resident with a tibia fracture had an unclean and damaged floor mat, which was not addressed by housekeeping or staff. These deficiencies were identified through observations and interviews, highlighting the facility's failure to maintain a homelike environment.
The facility improperly used physical restraints on four residents without obtaining necessary physician orders, informed consent, or developing care plans. Beds were placed against walls and wedge pillows were used under fitted sheets, restricting residents' movement without proper documentation or consent.
A facility failed to implement comprehensive care plans for four residents, leading to deficiencies in medication management. One resident lacked a care plan for methenamine hippurate, risking antibiotic resistance. Two residents did not receive non-pharmacological interventions for trazodone and Haldol, as outlined in their care plans. Another resident's care plan lacked measurable goals for sleep monitoring with trazodone, preventing assessment of medication effectiveness.
Two residents in the facility did not receive insulin injections with proper site rotation, as required by physician's orders and professional standards. This failure was identified through record reviews and staff interviews, revealing repeated use of the same injection sites, which could lead to complications such as bruising and lipodystrophy.
The facility failed to limit the use of psychotropic medications for several residents, neglecting to set stop dates or durations for lorazepam and Ativan, and did not implement non-pharmacological interventions for residents using trazodone and Haldol. Additionally, the facility did not monitor the effectiveness of these medications by tracking symptoms or sleep patterns, potentially leading to unnecessary medication use.
A facility failed to maintain a medication error rate below five percent, resulting in a 6.9% error rate due to two errors affecting a resident. Medications were administered outside the prescribed timeframe, contrary to facility policy, leading to a medication error as defined by the facility's guidelines.
Two residents in the facility experienced significant medication errors due to the failure to rotate insulin injection sites as per physician's orders and manufacturer's guidelines. This non-compliance with established protocols led to repeated insulin administration in the same areas, increasing the risk of complications such as bruising and lipodystrophy.
The facility failed to ensure safe food storage and preparation practices, as observed during a survey. Food items in the walk-in refrigerator were not labeled according to policy, posing a risk of serving expired or allergenic foods. Additionally, used towels were improperly stored on a meat slicer, risking cross-contamination. The walk-in freezer also showed signs of improper temperature maintenance, with ice build-up indicating potential thawing and refreezing of stored meat.
The facility failed to properly dispose of garbage and refuse, with trash bags left outside dumpsters, potentially attracting pests and spreading infection. Staff acknowledged the importance of proper disposal, and the facility's policy requires waste to be stored in a manner inaccessible to pests.
A facility failed to maintain a resident's dignity by not providing a privacy cover for their urinary drainage bag. The resident, who required assistance with daily activities and had an indwelling catheter, was observed with an uncovered drainage bag. Both the Quality Assurance Nurse and the DON confirmed the absence of the cover, acknowledging it as a dignity issue. Facility policy mandates covering urinary catheter bags to promote resident dignity.
A resident with impaired cognition and high fall risk had their call light placed out of reach, contrary to their care plan and facility policy. The RN and DON confirmed the oversight, which could delay care. The facility's policy requires call lights to be accessible to residents at all times.
The facility failed to maintain privacy during medication administration for two residents, as privacy curtains were left open, potentially exposing their treatment to unauthorized individuals. Both residents had significant medical histories, and the LVNs involved acknowledged the oversight. The DON emphasized the importance of maintaining privacy, as outlined in the facility's policies.
A resident with significant weight loss and multiple health issues did not have their care plan updated to include a prescribed nutritional intervention, LiquaCel, despite a recommendation and order for its administration. The oversight was acknowledged by the DON, who noted the importance of updating care plans to reflect current interventions.
A resident with a stage 4 sacral ulcer did not receive consistent care as per their care plan, which required turning every two hours. Staff failed to document the resident's position and refusals to turn, and improper equipment was used, potentially worsening the resident's condition. Interviews confirmed lapses in care and documentation.
The facility failed to ensure a safe environment for a resident by improperly placing fall mats, leading to potential injury risks. Additionally, the facility did not accurately complete a fall risk assessment or conduct necessary IDT meetings for another resident after fall incidents, failing to adhere to protocols for resident safety.
A facility failed to provide proper care for a resident with a urinary catheter, leading to a potential risk of UTI. The resident's catheter tubing had a loop, preventing urine from flowing freely, which was confirmed by the QAN. The DON stated that catheter tubing should be free of loops to prevent urine backup. This failure violated the facility's policy on catheter care.
A facility failed to properly label a water flush bag for a resident with a feeding tube, leading to potential risks of over or under hydration. The resident, with severe cognitive impairment and other medical conditions, had a water flush bag labeled only with the date and time, missing critical information such as the resident's name, room number, and infusion rate. This oversight was confirmed by staff and did not comply with the facility's policy, posing a risk of nutritional imbalance and infection.
The facility failed to provide proper respiratory care for two residents. A resident's suction canister was not labeled with the date it was last changed, and another resident's oxygen tubing was found unlabeled and touching the floor. Additionally, the nebulizer mask and tubing were not stored correctly. These practices deviate from the facility's policy, which requires labeling and changing of equipment every seven days to prevent infection.
The facility failed to reconcile a medication emergency kit containing controlled substances at every shift change and did not include verifying signatures on accountability logs for controlled substances awaiting disposal. This lack of adherence to policies increased the risk of medication diversion and accidental exposure.
A facility failed to ensure a licensed pharmacist provided a recommendation on the use of methenamine hippurate as a prophylaxis for UTI for a resident. The resident had been on the medication since September 2023 without monitoring for signs and symptoms of UTI. The facility did not conduct necessary monitoring or follow up with the attending physician regarding the prolonged use of the medication, despite having a policy on Antibiotic Stewardship.
A resident was prescribed methenamine hippurate for UTI prophylaxis without adequate monitoring for signs and symptoms of UTI, leading to its prolonged use without an end date. The facility's staff did not follow the antibiotic stewardship policy, and there was a lack of communication with the physician regarding the medication's continued use.
A resident receiving hospice care did not receive the scheduled hospice aide visits as per the hospice plan of care. The resident, with conditions including malignant neoplasm of the colon and respiratory failure, was supposed to have hospice aide visits twice a week. However, during a specific week, only one visit occurred, with no documentation explaining the missed visit. This inconsistency was acknowledged by the facility's DON, who noted the potential impact on the resident's care choices and well-being.
A facility failed to maintain an effective infection control program by not labeling a resident's urinal, risking cross-contamination, and improperly storing clean linens on the floor, potentially leading to contamination. Staff acknowledged these lapses, which violate the facility's infection control policies.
A resident with a history of hip dislocation and severe cognitive impairment experienced severe pain and possible hip displacement, leading to hospital discharge. The facility failed to report the incident to the State Survey Agency within the required timeframe, as per their abuse reporting policy.
The facility failed to make the most recent survey results accessible to residents and their representatives by not posting them in a prominent location. The survey results were removed due to wall painting, and a sign indicated they were available upon request. Interviews with residents and staff confirmed the deficiency, and the facility's policy required the results to be maintained in an area frequented by residents.
The facility did not meet the required room size of 80 square feet per resident in multiple bedrooms for 35 out of 38 rooms. Despite this, observations and interviews indicated that there was sufficient space for resident mobility and care provision. A resident and a CNA confirmed that the room sizes did not impede care, and the DON stated that the rooms provided enough space for comfort and privacy.
A facility failed to report an abuse allegation involving a resident within the required two-hour timeframe. The resident, admitted with a femur fracture and severe obesity, alleged an attempted assault. The facility did not notify the SSA or conduct an investigation promptly, potentially risking further harm to the resident.
A resident with a fracture and severe obesity alleged sexual abuse by a woman at the facility. The facility failed to report the incident to the State Survey Agency and did not conduct an investigation, violating their policy requiring immediate reporting and a written report within five days.
A facility failed to develop a care plan for a resident with a severe pressure ulcer who developed a productive cough. Despite the resident's inability to make medical decisions, no care plan was created to address the new condition, as confirmed by an LVN and the DON. The facility's policy requires comprehensive care plans, highlighting a deficiency in adhering to this standard.
A resident with a severe pressure ulcer and unable to make medical decisions experienced a change in condition, specifically a productive cough. The facility failed to document the resident's condition every shift for 72 hours as required. Nursing staff admitted to forgetting to document due to being busy, and the DON emphasized the importance of monitoring and documentation to prevent delays in care.
A resident developed a pressure ulcer, but the LTC facility failed to notify the physician and the family, delaying treatment. The resident, at risk for PU due to existing conditions, was not reported to the physician by the staff, and the family was unaware until after discharge. This violated the facility's policy requiring notification of significant changes in a resident's condition.
A resident at risk for pressure ulcers developed a stage 2 ulcer due to the facility's failure to notify the physician, provide treatment, inform the family, and develop a care plan. The resident's Braden Scale assessment was also inaccurately documented, contributing to the lack of appropriate care.
A resident was discharged with an IV catheter still in place after completing IV fluid hydration, contrary to the facility's policy. The resident, who had dementia and other health issues, received IV fluids due to poor oral intake. The catheter was not removed as required, leading to its discovery at a Board and Care facility, where staff had to intervene.
A facility failed to maintain accurate medical records for a resident with dementia and other health issues. The SBAR Communication Form did not correctly document the date and time when the physician and family were notified about the resident's condition. Discrepancies included incorrect times and missing entries, which were acknowledged by the Director of Staff Development and the DON, who emphasized the importance of accurate documentation.
A resident at risk for pressure ulcers developed a Stage 3 ulcer on the right heel due to the facility's failure to offload the heel and provide a Low Air Loss Mattress. The resident's care plan lacked specific interventions, and skin inspections were not consistently documented. Staff interviews confirmed the care plan was incomplete and not individualized, leading to the ulcer's development.
A resident with a urinary indwelling catheter was found with the catheter tubing unsecured, contrary to the facility's policy. The resident, who had a history of stage 4 pressure ulcer, diabetes, and dementia, was dependent on staff for toileting hygiene. The facility's policy required the catheter to be secured to prevent complications, but this was not adhered to, resulting in a deficiency.
During a COVID-19 outbreak, several staff members, including a Medical Records Assistant and LVNs, failed to adhere to the facility's infection control measures by not wearing N95 masks properly. The Medical Records Assistant was seen without a mask, while LVNs had their masks hanging around their necks, exposing their noses and mouths. The Director of Staff Development Assistant also removed her mask in the DON's office, contrary to the facility's policy. These actions risked spreading COVID-19 among residents and staff.
Failure to Verify Grilled Chicken Temperatures Before Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and sanitary food preparation practices by not verifying the internal temperature of grilled chicken before service. The facility’s menu for a specified week listed BBQ pork as the lunch entrée on a particular date, and grilled chicken was used as a substitute for residents who did not consume pork. During kitchen observations on that date, the cook (CK 1) was seen checking internal temperatures of foods on the tray line but did not check the internal temperature of the grilled chicken before plating and distribution. CK 1 later acknowledged in an interview that she did not check the temperature of the grilled chicken and recognized that failure to do so could result in residents becoming ill. Several residents were identified as receiving or potentially receiving the substituted grilled chicken. One resident with Alzheimer’s disease, type 2 DM, and HTN was on a regular, easy-to-chew diet with meat to be cut up and had documented dislikes of pork, ham, bacon, and sausage. Another resident with dysphagia, type 2 DM, and HTN had orders for a CCHO, NAS, minced and moist diet with mildly thick liquids for lunch only for oral gratification. A third resident, admitted with pancreatic cancer and muscle wasting/atrophy, had a regular puree diet with mildly thick liquids and documented dislikes of bacon, ham, and pork. A fourth resident with dysphagia, COPD, and CKD was on a CCHO, NAS, regular texture diet with thin liquids and had documented dislikes of pork chops and pork. These residents’ diet orders and documented dislikes made them candidates for the grilled chicken substitution instead of the scheduled pork entrée. On the observed lunch service date, CK 1 placed grilled chicken onto plates and into meal carts for distribution at specific times without verifying the internal temperature. Later, CK 1 placed a piece of grilled chicken into a blender to prepare a puree for a resident whose diet had been changed, again without prior temperature verification. The Dietary Supervisor stated in an interview that food temperatures should be taken at the tray line prior to service and that failure to do so means food may not be at required limits. The DON stated that food temperatures are to be taken before food goes out and that if not done, food may arrive at the wrong temperature, with potential for residents not eating, weight loss, hunger, gastrointestinal issues, and foodborne illness. Review of the facility’s “Meal Service” policy, last reviewed on a specified date, showed that Food and Nutrition Services staff are required to take food temperatures prior to meal service, with hot foods such as meats to be served at 160°F–180°F and hot entrées to be above 120°F at delivery, which was not followed for the grilled chicken.
Failure to Monitor and Document Residents After Change of Condition and to Follow Oxygen Therapy Orders
Penalty
Summary
Licensed nurses failed to monitor and document the medical status of two residents following changes of condition (COC). For one resident with diagnoses including type 2 diabetes mellitus, anemia, and COPD, there was no documented evidence of monitoring after COCs related to low hemoglobin and hematocrit levels, a mass on the left arm, and later, high blood urea nitrogen, low potassium, and high ammonia levels. The facility's records showed that required monitoring every shift for 72 hours post-COC was not performed or documented on several shifts following these events. Additionally, the same resident had a physician's order for continuous oxygen therapy at two liters per minute via nasal cannula. However, documentation revealed that oxygen was administered at three liters per minute, contrary to the physician's order. This deviation from the prescribed oxygen therapy was acknowledged by both the LVN and the DON during interviews and was not in accordance with the facility's policy and procedure for oxygen administration. For another resident admitted with gastro-esophageal reflux disease, anemia, and hypertension, there was a failure to monitor and document the resident's gastrointestinal status after a COC involving two days of diarrhea. Progress notes indicated missing documentation for several shifts over a three-day period following the COC. The DON confirmed that monitoring and documentation were not completed as required by facility policy, which mandates monitoring and documentation of residents' progress and responses to treatment after a COC.
Failure to Adhere to COVID-19 Infection Control Protocols
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols related to COVID-19. One certified nursing assistant (CNA) was observed exiting a COVID-19 isolation room without wearing an N95 mask. The CNA reported that she had removed and disposed of all personal protective equipment, including the N95 mask, inside the isolation room, contrary to facility policy which requires PPE to be removed and replaced outside the isolation room. The resident in the isolation room had a diagnosis of COVID-19 and other medical conditions, with intact cognition, and had recently tested positive for COVID-19. Additionally, a licensed vocational nurse (LVN) was observed at a nurse station not wearing the N95 mask properly; the mask was under the chin and not covering the nose and mouth. The LVN also touched the outside of the mask and then used the computer keyboard without performing hand hygiene. Both the Director of Staff Development and the Director of Nursing confirmed that N95 masks should be worn properly in all patient care areas, including nurse stations, and that hand hygiene should be performed after handling soiled masks. Facility policies reviewed indicated that staff must wear well-fitted N95 respirators during respiratory outbreaks and perform hand hygiene after handling soiled equipment or contaminated objects.
Call Light Not Accessible for High Fall Risk Resident
Penalty
Summary
A resident with a history of hemiplegia and hemiparesis following cerebrovascular disease, as well as type 2 diabetes mellitus and essential hypertension, was identified as having severely impaired cognitive skills and a high risk for falls. The resident's care plan specifically required that the call light be kept within reach and that staff encourage its use for assistance, with prompt responses to all requests. However, during an observation, the call light was found rolled up and hung on the wall at the head of the resident's bed, out of the resident's reach. The Director of Nursing confirmed that the call light was not accessible to the resident and acknowledged that the call light is a primary means for residents to communicate with staff. Facility policy also required that call lights be accessible to residents when in bed, on the toilet, or in the shower. The failure to ensure the call light was within reach represented a lack of reasonable accommodation for the resident's needs and preferences, as outlined in both the care plan and facility policy.
Failure to Individualize Nutrition Care Plan for Resident Food Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with multiple diagnoses, including type 2 diabetes mellitus, depression, and epilepsy. Upon admission, the resident's physician order specified a controlled carbohydrate, no added salt, regular texture diet with no fish. However, the facility's menu included fish for lunch, and the resident was served a meal containing fish. The resident's food preference for no fish was not documented on the meal ticket, and the Certified Nursing Assistant (CNA) was unaware of this preference until informed by a family member. The CNA then returned the tray to the kitchen for replacement. Further review revealed that the resident's care plan did not address the food preference for no fish, and the care plan on nutrition was not individualized. Both the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the resident's food preference should have been identified and documented during the admission process, and that the care plan should have been updated to reflect this preference. The facility's policy required comprehensive, person-centered care plans based on thorough assessments, but this was not followed in the resident's case.
Failure to Ensure Proper Administration and Documentation of Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cerebral palsy, hypotension, and heart failure did not receive their midodrine HCl 10 mg tablet as prescribed. The physician's order required the medication to be administered three times daily for hypotension, and the care plan reflected this intervention. On the day in question, the medication was documented as administered at 11:08 a.m., two hours after it was actually given at 9:08 a.m. During an observation, a white round pill identified as midodrine was found on the hallway floor outside the resident's room. The Director of Staff Development confirmed the pill's identity and noted that the nurse should ensure residents swallow their medications. Further review of the Medication Administration Record (MAR) with the LVN revealed that the medication was marked as not given, despite the bubble pack for that dose being empty. The LVN stated he believed he had given the medication with applesauce but acknowledged that documentation should occur before moving to the next resident. The facility's policy required medications to be administered and documented in a safe and timely manner, with the MAR initialed after each administration and before proceeding to the next medication. The failure to ensure the medication was properly administered and documented constituted a significant medication error.
Failure to Honor Resident's No Fish Dietary Preference
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus, depression, and epilepsy was admitted to the facility with a physician order specifying a controlled carbohydrate, no added salt, regular texture, and no fish diet. Despite this order, the resident's food preference for no fish was not documented on the Diet Communication Form, and the dietary department was not informed. On the day following admission, the facility's menu included fish for lunch, and the resident was served a meal containing fish. The meal ticket on the resident's tray did not indicate the no fish preference, and staff members, including a CNA and an LVN, were unaware of the resident's dietary restriction at the time the meal was served. The deficiency was further evidenced by interviews and record reviews showing that the resident's food preference was communicated by a family member to nursing staff on the night of admission, but this information was not relayed to the dietary department or reflected in the resident's dietary documentation. The dietary supervisor only updated the Diet Communication Form after being informed of the issue by the family member. The facility's policy required that dietary profiles include diet orders and food dislikes, but this was not followed, resulting in the resident being served a meal that did not accommodate their documented preference.
Failure to Investigate and Document Resident Grievance
Penalty
Summary
A resident with multiple sclerosis, schizophrenia, and bipolar disorder, who was assessed as having intact cognitive skills and the capacity to make decisions, reported an incident in which another resident touched his legs, causing him to feel scared and uncomfortable due to existing wounds in the area. The resident communicated this concern to an LVN, who then relayed the complaint to the Social Services Assistant (SSA). However, the SSA did not ask the resident about the complaint during their interaction and did not document the concern. A review of the facility's grievance policy indicated that all grievances and complaints must be investigated and documented, including the resident's account of the incident. The Director of Nursing confirmed that the complaint was not verified or investigated, and there was no documentation of the incident as required by policy. This failure to investigate and document the resident's grievance constituted a violation of the facility's procedures for addressing resident complaints.
Resident's Right to Refuse Care Not Respected
Penalty
Summary
A deficiency occurred when a resident's right to refuse care was not respected by facility staff. The resident, who had diagnoses including bilateral primary osteoarthritis of the knee, muscle weakness, and chronic pain, was dependent on staff for several activities of daily living and was always incontinent. On the morning in question, the resident expressed to staff that she did not want to be touched or have her incontinence brief changed, repeatedly telling the certified nursing assistant (CNA) to leave her alone. Despite these clear refusals, the CNA continued to attempt to check the resident's incontinence brief, pulling the blanket and attempting to proceed with care. Interviews with the resident, the involved CNA, another CNA who witnessed the incident, and the Director of Nursing (DON) confirmed that the resident's refusals were not honored. The CNA admitted to not respecting the resident's wishes and acknowledged that she should have left the resident alone and reported the refusal to the licensed nurse. The second CNA corroborated that the resident was vocal in her refusal and that the CNA continued with the care attempt despite this. The DON also confirmed that the resident's rights were violated by the CNA's actions. Facility policy review indicated that residents have the right to refuse care and must be treated with dignity and respect. The failure to honor the resident's refusal of care was contrary to both facility policy and the resident's rights, as documented in the facility's own procedures and confirmed by staff interviews.
Failure to Provide Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, Resident 85 and Resident 34, who were part of the Restorative Nursing Assistant (RNA) feeding program. These residents were assisted with eating in the rehabilitation therapy room, which contained multiple walkers, a weighing scale, parallel bars, and electric bikes, rather than in a more appropriate setting like the bistro room. The bistro room was being used as an office and employee lounge, which was intended to be a temporary arrangement. This setting did not align with the facility's policy to provide a personalized, homelike environment. Additionally, the facility did not maintain a clean and safe environment for Resident 248, who had a fracture of the right tibia and required substantial assistance with activities of daily living. The resident's left floor mat was found to have dried black particles and a tear, which were not addressed by the housekeeping department or staff responsible for cleaning spills. This oversight was contrary to the facility's policy of maintaining a clean, safe, and homelike environment, as well as the manufacturer's guidelines for cleaning fall mats after each use. These deficiencies were identified through observations, interviews, and record reviews, highlighting the facility's failure to adhere to its policies and procedures regarding maintaining a homelike environment. The presence of institutional characteristics and unclean conditions in the residents' living spaces had the potential to violate their rights to a safe, comfortable, and homelike environment.
Improper Use of Restraints Without Orders or Consent
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, affecting four residents. For two residents, the facility did not have a physician's order, informed consent, restraint assessment, or care plan for the use of a bed placed against the wall, which was considered a restraint. The staff placed the beds against the wall to prevent falls and accommodate wheelchairs, but this restricted the residents' freedom of movement and was done without the necessary documentation and consent. For the other two residents, the facility used wedge pillows placed under the fitted sheets, which acted as restraints by preventing the residents from moving freely or getting out of bed. The staff used these pillows for repositioning but placed them in a way that the residents could not remove them, effectively restraining them without a physician's order, informed consent, or a care plan. This practice was acknowledged by the staff and the Director of Nursing as inappropriate and restrictive. The facility's policies and procedures require a physician's order, informed consent, and a comprehensive care plan for the use of physical restraints. However, these were not followed, leading to the improper use of restraints on the residents. The lack of adherence to these protocols resulted in the restriction of residents' freedom of movement and potentially increased the risk of harm.
Deficiencies in Care Plan Implementation and Medication Management
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in medication management and care. Resident 37 was prescribed methenamine hippurate for UTI prophylaxis, but no care plan was developed to ensure its safe use and prevent antibiotic resistance. This oversight was identified during a review of the resident's records, which showed moderate cognitive impairment and periods of confusion, highlighting the need for a structured care plan. Resident 7, who was prescribed trazodone for depression and insomnia, did not receive the non-pharmacological interventions outlined in their care plan. The care plan included various therapeutic and environmental interventions to address sleep issues, but these were not documented or implemented between February 1 and February 11, 2025. Similarly, Resident 53, who was on Haldol for schizoaffective disorder, did not receive the non-pharmacological interventions specified in their care plan for managing paranoia and verbal outbursts during the same period. Resident 55's care plan lacked measurable goals and monitoring for sleep hours despite being prescribed trazodone for major depressive disorder with insomnia. The absence of documented sleep monitoring from January 1 to January 30, 2025, meant that the effectiveness of trazodone could not be assessed, potentially leading to unnecessary medication use. Interviews with nursing staff and the Director of Nursing confirmed these deficiencies, emphasizing the importance of comprehensive care plans to maintain residents' well-being and limit unnecessary medication use.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards by not rotating insulin administration sites for two residents, leading to potential adverse effects. Resident 73, who was admitted with diagnoses including type 2 diabetes mellitus and congestive heart failure, had physician's orders to rotate insulin injection sites to prevent complications such as bruising and lipodystrophy. However, the Medication Administration Record (MAR) indicated that the insulin was repeatedly administered in the same areas, contrary to the physician's orders and manufacturer's guidelines. Similarly, Resident 63, who had type 2 diabetes mellitus and dementia, also received insulin injections without proper site rotation. The resident's care plan and physician's orders specified the need for site rotation to prevent skin complications. Despite these instructions, the Location of Administration Report showed repeated use of the same injection sites over several months. Interviews with the Director of Nursing and nursing staff confirmed the failure to rotate injection sites as per the guidelines and physician's orders. The facility's policy on insulin administration emphasized the importance of site rotation to avoid skin issues, yet this was not followed, leading to the identified deficiencies.
Failure to Limit Psychotropic Medication Use and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that the drug regimens for five of six sampled residents were free from unnecessary medications, as per the facility's policy and procedure. Specifically, the facility did not limit the use of lorazepam and Ativan for two residents to a 14-day period or specify a duration or stop date. This oversight was noted despite the facility's policy requiring a stop date for psychotropic medications to prevent unnecessary use. Additionally, the facility did not provide non-pharmacological interventions for residents using trazodone and Haldol, nor did it monitor the effectiveness of these medications by tracking symptoms or sleep patterns. Resident 71 was admitted with diagnoses including depression, dementia, and anxiety disorder. The resident was prescribed lorazepam without a stop date, which was against the facility's policy. Similarly, Resident 5, who was cognitively intact and diagnosed with hemiplegia, bipolar disorder, depression, and anxiety, was prescribed Ativan without a specified duration or stop date. These omissions were acknowledged by the facility's staff, who confirmed that the medications should have had a 14-day stop date or a specific duration to ensure they were not causing more harm than good. For Residents 7, 53, and 55, the facility failed to implement non-pharmacological interventions and monitor the effectiveness of psychotropic medications. Resident 7, diagnosed with depression and insomnia, was prescribed trazodone without documentation of non-pharmacological interventions. Resident 53, with schizoaffective disorder, was prescribed Haldol without monitoring the number of episodes of paranoia. Resident 55, using trazodone for depression-related insomnia, did not have a care plan goal for hours of sleep or documentation of sleep monitoring. These deficiencies in care planning and monitoring potentially led to the unnecessary use of psychotropic medications, as the facility did not assess the effectiveness of non-drug interventions or the medications themselves.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 6.9% error rate. This was due to two medication errors out of 29 opportunities, affecting one resident. The errors involved the administration of metoprolol and aspirin to Resident 196 at a time different from the physician's order. The medications were supposed to be given at 7:30 a.m. with food, but were administered at 9:39 a.m. without food, which was outside the facility's policy of a 60-minute window for medication administration. Licensed Vocational Nurse 5 (LVN 5) acknowledged the error during an interview, stating that the medications were administered later than the specified timeframe, which was confirmed by the Director of Nursing (DON). The facility's policy requires medications to be administered in a safe and timely manner, as prescribed, and within one hour of their prescribed time unless otherwise specified. The failure to adhere to these guidelines resulted in a medication error, as defined by the facility's policy, which includes administering medications at the wrong time.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. For one resident, the facility did not rotate the subcutaneous insulin administration sites as per the physician's orders and manufacturer's guidelines. This resident, who had type 2 diabetes mellitus and other health conditions, received insulin injections repeatedly in the same areas of the abdomen, contrary to the instructions to rotate sites to prevent complications such as bruising and lipodystrophy. The Minimum Data Set Nurse confirmed that the insulin administration sites were not rotated, which was a deviation from the physician's orders and standards of practice. Another resident also experienced similar issues with insulin administration. This resident, who had type 2 diabetes mellitus and cognitive impairments, received insulin injections without proper rotation of the administration sites. The facility's records showed multiple instances where the insulin was administered in the same areas, despite the physician's orders to rotate the sites. A Registered Nurse acknowledged that the staff failed to rotate the insulin administration sites, which is considered a medication error. The Director of Nursing confirmed that the facility's staff did not adhere to the physician's orders, manufacturer's guidelines, and professional standards regarding insulin administration. The facility's policies and procedures clearly defined medication errors as deviations from these standards, and the failure to rotate insulin administration sites was identified as such an error. The facility's documentation and interviews with staff highlighted the lack of compliance with established protocols, leading to the identified deficiencies.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. The Dietary Supervisor (DS) noted that food items in the walk-in refrigerator were not labeled according to facility policy. Specifically, a white bag containing a cookie and a small bowl of grapes were found unlabeled, which is against the facility's policy that requires all items removed from their original packaging to be labeled with contents, preparation date, and expiration date. This oversight could lead to serving expired or allergenic foods to residents. Additionally, the facility did not adhere to its policy regarding the storage of used cloths and towels. During the kitchen observation, two dry white towels, one with a dry brown substance, were found on top of a meat slicer. The DS stated that towels should be stored in a sanitization bucket when in use and not left on kitchen equipment, as this poses a risk of cross-contamination. The Director of Nursing (DON) confirmed that improper towel storage is an infection control issue that could lead to resident illness. The facility also failed to maintain the walk-in freezer temperature as per policy. The DS observed a build-up of ice around the freezer door gasket and on the ceiling, indicating that the freezer temperature was not consistently maintained. This could result in thawing and refreezing of stored meat, affecting its quality. The facility's policy requires freezers to be maintained at temperatures below zero degrees, and the presence of ice build-up suggests that this standard was not met.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a kitchen facility task. On two separate occasions, surveyors observed multiple large dumpsters outside the facility with trash bags placed on the ground behind them. The trash included disposable gloves, dirty rags, a Styrofoam cup, and a food wrapper. During interviews, staff members, including a janitor, the Infection Preventionist (IP), the Maintenance Supervisor (MS), and the Director of Nursing (DON), acknowledged that trash should be placed inside the dumpsters to prevent contamination and the attraction of pests. The janitor stated that the trash bags were left outside because the dumpsters were full, although they were found to be empty upon inspection. The IP, MS, and DON all emphasized the importance of keeping trash inside closed containers to prevent the spread of infection and the attraction of insects and rodents. The facility's policy and procedure, as well as the Food Code 2022, require that garbage and refuse be stored in a manner inaccessible to pests and that dumpsters be kept closed and free of surrounding litter.
Failure to Provide Privacy Cover for Urinary Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident, identified as Resident 249, by not providing a privacy cover for the resident's urinary drainage bag. Resident 249 was admitted with diagnoses including a urinary tract infection, unsteadiness on feet, and generalized muscle weakness, and required assistance with all activities of daily living. The resident had an indwelling catheter for urine retention, and the facility's policy required that urinary catheter drainage bags be covered to preserve the resident's dignity. During an observation, it was noted that Resident 249's urinary catheter drainage bag was hanging on the side of the bed without a privacy cover. The Quality Assurance Nurse confirmed the absence of the privacy cover and acknowledged that it should have been placed upon admission. The Director of Nursing also stated that the lack of a privacy cover was a dignity issue, as it could affect the resident's self-worth and self-esteem. The facility's policy emphasized the importance of promoting dignity and assisting residents in maintaining their sense of well-being.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure the call light was within reach for a resident, leading to a deficiency in accommodating the resident's needs and preferences. The resident, admitted with a fracture of the right tibia, unsteadiness on feet, and generalized muscle weakness, was identified as having severely impaired cognition and required substantial to total assistance with activities of daily living. The care plan for the resident, who was at high risk for falls, included an intervention to keep the call light and bed controls within easy reach to prevent falls. During an observation, the call light was found on the floor, out of the resident's reach, which was confirmed by RN 3. The RN acknowledged that the call light should have been clipped to the bed sheet and within the resident's reach to prevent delays in care. The Director of Nursing also confirmed that staff should ensure call lights are accessible to residents before leaving the room. The facility's policy on answering call lights emphasized the importance of ensuring call lights are accessible to residents in various locations, including from the bed and floor, and that timely responses to residents' requests and needs are essential.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to maintain resident privacy during medication administration, affecting two residents. During observations, it was noted that the privacy curtains between the beds of the residents and their roommates were left open while medications were being administered. This oversight occurred with two different Licensed Vocational Nurses (LVNs) administering medications to the residents. The failure to close the privacy curtains potentially exposed the residents' treatment and care to unauthorized individuals, which could lead to psychosocial harm. Resident 5, who was cognitively intact, had a history of hemiplegia, hemiparesis, bipolar disorder, depression, and anxiety. Resident 196, who had mild cognitive impairment and was feeling down and depressed, had diagnoses including hypertension, atrial fibrillation, and dysphagia. Both LVNs acknowledged their failure to ensure privacy during medication administration, and the Director of Nursing confirmed the importance of safeguarding resident dignity by maintaining privacy during medical care. The facility's policy and procedures emphasized the need to respect residents' private space and property at all times.
Failure to Update Care Plan for Nutritional Intervention
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident 6, to include updated interventions for nutrition. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, contractures, and visual loss, experienced a significant weight loss of 15% over 180 days. A nutrition assessment recommended the administration of LiquaCel, a protein supplement, to address this weight loss. However, the care plan, last revised on February 7, 2025, did not reflect this intervention, as confirmed by a registered nurse during a review. The Director of Nursing acknowledged that the care plan was not updated to include the LiquaCel intervention, which was ordered on February 12, 2025. The oversight was attributed to the licensed nurse who carried out the order but failed to update the care plan. The facility's policy requires that care plans be revised as residents' conditions change to ensure all staff are aware of current interventions. The failure to update the care plan had the potential to delay necessary interventions for the resident's nutritional needs.
Failure to Prevent and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, identified as Resident 12, who was at risk for developing pressure injuries and had a pre-existing stage 4 sacral ulcer. The resident's care plan required turning and repositioning every two hours to prevent further skin breakdown. However, the facility staff did not consistently adhere to this schedule, as evidenced by multiple entries in the Turn and Reposition Log that lacked documentation of the resident's position or indicated that the resident was not turned every two hours as required. Observations and interviews revealed that Resident 12 was often found in positions not aligned with the posted turning schedule, and staff failed to document the resident's refusal to turn or the reasons for such refusals. On several occasions, the resident was observed lying in the same position for extended periods, contrary to the care plan's directives. Additionally, the use of improper equipment, such as ordinary pillows instead of wedge pillows, was noted, which did not adequately relieve pressure on the resident's buttocks. Interviews with staff, including LVN 1, CNA 6, and the Director of Nursing, confirmed the lapses in following the care plan and documentation requirements. The staff acknowledged the importance of turning the resident every two hours and documenting any refusals to prevent the worsening of the pressure ulcer. The facility's policy and procedure on repositioning emphasized the need for accurate documentation and adherence to the care plan, which was not followed in this case.
Failure to Ensure Safe Environment and Accurate Fall Risk Assessment
Penalty
Summary
The facility failed to ensure a safe environment for Resident 19 by improperly placing fall mats in their room. During an observation, it was noted that a drawer was placed on top of the fall mat, and there was a gap between the bed and the mat, which could lead to the resident falling directly onto the floor. The Registered Nurse confirmed that the fall mat should be placed directly at the exit side of the bed to prevent injury, and the presence of furniture on the mat could cause significant harm if the resident were to fall. The Director of Nursing also acknowledged the improper placement of the fall mat and the potential for injury due to the furniture on top of it. For Resident 66, the facility failed to accurately complete a fall risk assessment and conduct an interdisciplinary team (IDT) meeting after fall incidents. The fall risk assessment on one occasion was not completed accurately, as it did not reflect the resident's history of falls, which should have resulted in a higher risk score. Additionally, there was no documentation of IDT meetings being conducted after fall incidents, which are necessary to determine the cause of falls and implement appropriate interventions. The Minimum Data Set Nurse and the Director of Nursing both confirmed the absence of these critical assessments and meetings. The facility's policies and procedures require that fall risk factors be documented and that IDT meetings be conducted after fall incidents to identify causes and implement interventions. However, these procedures were not followed for Resident 66, placing the resident at risk for further falls and potential injuries. The lack of accurate assessments and timely IDT meetings indicates a failure to adhere to established protocols designed to ensure resident safety.
Failure to Ensure Proper Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a potential risk of urinary tract infection (UTI). The resident, admitted with diagnoses including UTI, unsteadiness on feet, and generalized muscle weakness, required assistance with activities of daily living and had an indwelling catheter for urine retention. During an observation, it was noted that the resident's urinary catheter tubing had a loop while hanging on the side of the bed, which was verified by the Quality Assurance Nurse (QAN). The QAN confirmed that the loop in the catheter tubing could prevent urine from flowing freely, potentially causing a UTI. The Director of Nursing (DON) stated that urinary catheter tubing should be positioned properly to prevent loops or kinks, as improper positioning could lead to urine backing up into the bladder. The facility's policy on catheter care emphasized the importance of keeping the catheter and tubing free of kinks and ensuring proper drainage. Despite these guidelines, the staff failed to ensure the resident's catheter tubing was free of loops, which was a direct violation of the facility's policy and posed a risk for the resident's health.
Improper Labeling of Water Flush Bag for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure proper labeling and administration of a water flush bag for a resident with a feeding tube, identified as Resident 22. The resident, who was admitted with conditions including gastrostomy, acute kidney failure, and dysphagia, had a feeding tube in place. The resident's Minimum Data Set indicated severe cognitive impairment and highly impaired vision, affecting their ability to make decisions. During an observation, it was noted that the water flush bag was labeled only with the date and time, lacking the resident's name, room number, and the rate of infusion, which are necessary to ensure accurate administration and prevent over or under hydration. Interviews with the Registered Nurse and the Director of Nursing confirmed that the labeling was incomplete and did not comply with the facility's policy and procedure for enteral feedings. The facility's policy required that water flush bags be labeled with specific information, including the resident's name, room number, and rate of administration, to prevent errors. The failure to adhere to these protocols had the potential to result in altered nutritional status and gastrointestinal infection for the resident.
Deficient Respiratory Care Practices
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For Resident 22, the suction canister was not labeled with the date it was last changed. This oversight was observed during an interview with LVN 3, who acknowledged that the canister should be dated to prevent prolonged use, which could lead to the growth of microorganisms and potential respiratory infections. The Director of Nursing (DON) confirmed that the canister should be changed every seven days or as needed, according to the facility's policy. For Resident 346, the oxygen tubing was not labeled with the date it was last changed and was found touching the floor, while the nebulizer mask and tubing were not stored in a plastic bag with the resident's name and date. During an observation with CNA 3 and LVN 1, it was noted that the tubing was inside the trash can, and both staff members agreed that the tubing should be dated and stored properly to prevent infection. The DON reiterated that the tubing should be changed every seven days or as needed and should not be in contact with the floor or trash. The facility's policy on respiratory therapy and infection prevention, last reviewed in 2024, requires labeling and changing of oxygen cannula, tubing, and nebulizer equipment every seven days or as needed. The failure to adhere to these standards poses a risk of infection due to improper handling and storage of respiratory equipment.
Failure to Reconcile Controlled Substances and Verify Accountability Logs
Penalty
Summary
The facility failed to properly reconcile a medication emergency kit containing controlled substances in one of the inspected medication carts. During an observation and interview with a Licensed Vocational Nurse (LVN), it was revealed that the emergency kit was not reconciled as part of the controlled substances inventory at every shift change, as required. The LVN acknowledged the importance of reconciling controlled substances to ensure accountability and prevent diversion or accidental exposure to residents. Additionally, the facility did not include verifying signatures from the Director of Nursing (DON) or a Registered Nurse (RN) on the Medication Count Sheet accountability logs for controlled substances awaiting disposal. During an interview, the DON admitted that the logs lacked signatures, which are necessary to ensure each controlled substance dose is accounted for until disposal. The facility's policies and procedures require controlled substances to be counted at the end of each shift and for the medication disposition record to contain witness signatures, which were not adhered to in this case.
Failure to Monitor Antibiotic Prophylaxis for UTI
Penalty
Summary
The facility failed to ensure that a licensed pharmacist provided a recommendation on the use of methenamine hippurate as a prophylaxis for urinary tract infection (UTI) for a resident. The resident, who was admitted with diagnoses including thrombocytopenia, gastro-esophageal reflux disease, and cerebral infarction, had been on methenamine hippurate since September 2023 without an order for monitoring signs and symptoms of UTI to evaluate its effectiveness. The resident's Minimum Data Set indicated moderate cognitive impairment and the use of a high-risk drug class antibiotic. During interviews and record reviews, it was revealed that the Infection Preventionist (IP) and the Consultant Pharmacist (PHARM) had differing views on whether methenamine hippurate is an antibiotic or antibacterial. The PHARM stated that there should be renal function monitoring and monitoring for signs and symptoms of UTI to ensure the medication's effectiveness as a prophylaxis. However, the facility did not conduct such monitoring, nor did they follow up with the attending physician regarding the prolonged use of the medication. The facility's policy on Antibiotic Stewardship, last reviewed in June 2024, indicated that the consultant pharmacist should include medication safety criteria in the monthly medication regimen review. Despite this policy, the facility did not adhere to these guidelines, resulting in the risk of the resident receiving excessive dosages of methenamine hippurate, which could lead to adverse effects and potential hospitalization.
Failure to Monitor Methenamine Hippurate Use in Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the use of methenamine hippurate as a prophylaxis for urinary tract infections (UTIs). The resident, who was admitted with diagnoses including thrombocytopenia, gastro-esophageal reflux disease, and cerebral infarction, was prescribed methenamine hippurate without adequate monitoring for signs and symptoms of UTI. The medication was used for an excessive duration without an end date or proper monitoring, which could lead to adverse effects from its continued use. Interviews with the Infection Preventionist and the Consultant Pharmacist revealed discrepancies in the understanding of methenamine hippurate's classification and the necessary monitoring protocols. The Consultant Pharmacist emphasized the need for renal function monitoring and regular checks for UTI symptoms to ensure the medication's effectiveness and prevent adverse effects. The facility's policy on antibiotic stewardship was not adequately followed, as there was no monitoring for signs and symptoms of UTI, and the staff did not follow up with the physician regarding the prolonged use of the medication.
Inconsistent Hospice Care for Resident
Penalty
Summary
The facility failed to ensure consistent provision of necessary care for a resident receiving hospice services. The resident, who was admitted with diagnoses including malignant neoplasm of the colon, acute and chronic respiratory failure, and type 2 diabetes mellitus, was under hospice care with a plan that required hospice aide visits twice a week. However, during the week of January 19 to January 25, 2025, the hospice aide visited only once, on January 22, 2025, instead of the scheduled two visits. This inconsistency in care was confirmed during interviews with Registered Nurses 4 and 1, who noted the absence of documentation explaining the missed visit. The Director of Nursing acknowledged that the missed hospice aide visit could potentially affect the resident's choice for care and their mental and psychosocial well-being. The facility's policy on hospice care emphasizes the importance of coordinated care plans that reflect the resident's goals and wishes, including palliative goals and interventions. The failure to adhere to the hospice plan of care, as outlined in the facility's policy, highlights a deficiency in maintaining the resident's highest practicable physical, mental, and psychosocial well-being.
Infection Control Deficiencies in Labeling and Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two main deficiencies. Firstly, a resident's urinal bottle was not labeled with the resident's name and room number, which is a necessary measure to prevent cross-contamination. During an observation, the urinal was found hanging on the side rail without any identification, and both the treatment nurse and the Director of Nursing acknowledged that this oversight could lead to the switching of urinals between residents, potentially causing cross-contamination and infection spread. The facility's policy requires that single resident-use items be labeled to prevent such issues. Secondly, during a tour of the laundry area, it was observed that clean linens, clothing, and curtains were improperly placed on the floor in the Clean Linen Folding Area. This included clean donation clothing in a plastic bin, clean resident room curtains in plastic bags, and clean clothing in cardboard boxes, some of which were touching the floor. The Maintenance Supervisor and the Infection Preventionist both confirmed that clean linens should not be placed on the ground as it could lead to contamination from dirt and bacteria, which could then be transferred to residents, potentially causing illness. The facility's policy clearly states that clean linens should be stored and handled in a way that prevents cross-contamination. These deficiencies highlight lapses in the facility's adherence to its own infection control policies, which are designed to ensure a safe and sanitary environment for residents. The failure to label personal items and properly store clean linens poses a risk of spreading infections among residents, as acknowledged by the facility staff during interviews.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse reporting policy and procedure by not reporting an allegation of injury of unknown origin to the State Survey Agency within the required two-hour timeframe. This deficiency involved a resident who was originally admitted with a dislocation of an internal left hip prosthesis and a fracture of the left femur neck, among other diagnoses. The resident, who had severely impaired cognition and was dependent on staff for activities of daily living, experienced severe pain and possible hip displacement, leading to a discharge to a general acute care hospital for further evaluation and treatment. Despite the unusual occurrence of the resident's left hip dislocation, the facility did not report the incident to the State Survey Agency as required by their policy. Interviews with facility staff, including the MDS Nurse and the Director of Nursing, revealed that the incident was not reported, and an investigation was conducted internally. The facility's policy mandates immediate reporting of suspected abuse, neglect, or injury of unknown origin to the administrator and relevant authorities, but this protocol was not followed in this case.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to promote the residents' right to examine the results of the most recent survey by not posting the survey results in a prominent and accessible location. This deficiency was identified during an interview with four resident council attendees who stated they did not know where to examine the most recent survey results. The Activity Director confirmed that the survey results, which were previously placed in front of the business office, had been removed due to wall painting, and a sign was posted indicating the results were available upon request. Further interviews revealed that the survey results were not readily available, although the facility had them and would provide them upon request. The Director of Nursing emphasized the importance of making state inspection results available for residents, visitors, and the public to understand the expected care standards. A review of the facility's policy indicated that the most recent survey results should be maintained in a 3-ring binder in an area frequented by most residents, such as the main lobby or resident activity room.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to meet the required room size of 80 square feet per resident in multiple bedrooms for 35 out of 38 resident rooms. This deficiency was identified through observation, interview, and record review. The rooms in question were found to have less than the required space per resident, with measurements ranging from approximately 69.67 to 72.75 square feet per resident. Despite this, observations noted that there was sufficient space for residents to move freely and for the operation of wheelchairs, walkers, or canes. The facility had submitted a Room Waiver Request Letter, indicating that the rooms did not meet federal regulations but argued that the variance did not affect the care and services provided. Interviews with residents and staff supported the claim that the room sizes did not impede care. A resident in a room measuring 69.73 square feet per person stated there was enough space for care, and a CNA confirmed that the rooms allowed for adequate movement and care provision without needing to rearrange furniture. The Director of Nursing also stated that the room sizes provided enough space for residents' comfort and privacy. The facility's policy and procedure indicated compliance with federal and state requirements, yet the room sizes did not meet the specified standards.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to adhere to its policy and procedure for reporting allegations of abuse within the required timeframe. Specifically, the facility did not report an abuse allegation involving a resident within two hours of being made aware, as mandated by their policy. The resident, who was admitted with a nondisplaced fracture of the left femur and severe obesity, alleged that a woman attempted to assault him while under the facility's care. Despite the seriousness of the allegation, the facility did not notify the State Survey Agency (SSA) or conduct an investigation in a timely manner. During an interview, the Administrator acknowledged the failure to report the incident to the SSA and the inability to conduct an investigation or submit a written report. The facility's policy requires that any suspicion of abuse, neglect, exploitation, or misappropriation be reported immediately, defined as within two hours for incidents involving abuse or serious bodily injury. The delay in reporting and investigating the allegation may have placed the resident at risk for further abuse.
Failure to Investigate and Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident. The resident, who was admitted with a nondisplaced fracture of the left femur and severe obesity, was able to communicate needs but could not make medical decisions. The resident alleged that a woman attempted to assault him by shoving power up his bottom while under the facility's care. Despite this serious allegation, the facility did not report the incident to the State Survey Agency (SSA) as required by their policy. During an interview and record review, the facility's administrator acknowledged that the abuse allegation was not reported to the SSA and that an investigation was not conducted. The facility's policy mandates that any suspicion of abuse must be reported immediately, defined as within two hours of the allegation. Additionally, a written investigation report should be submitted within five working days. The administrator admitted the importance of reporting to ensure the resident's safety and protection, highlighting the facility's failure to adhere to its own policies and procedures.
Failure to Implement Care Plan for Change of Condition
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was admitted with a diagnosis of a severe pressure ulcer of the hips. The resident was capable of making their needs known but was unable to make medical decisions. Despite a change in the resident's condition, specifically the development of a productive cough as noted in a Change of Condition Assessment, the facility did not create a care plan to address this new condition. This omission was confirmed during an interview with an LVN, who acknowledged the absence of a care plan for the productive cough. The Director of Nursing also confirmed the importance of having a care plan to outline the interventions for the resident's change of condition. The facility's policy, last revised in 2016, mandates the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's needs. The lack of a care plan for the resident's productive cough represents a failure to adhere to this policy, potentially leading to inconsistent care delivery.
Failure to Monitor and Document Resident's Change of Condition
Penalty
Summary
The facility failed to adequately monitor a resident after a change in condition, specifically a productive cough, was noted. The resident, who was admitted with a severe pressure ulcer and was unable to make medical decisions, experienced a change in condition that required close monitoring. However, the facility did not document the resident's condition every shift for 72 hours as required by their policy. This lapse in documentation was confirmed during interviews with the nursing staff, where it was revealed that the responsible nurse became busy and forgot to document the monitoring process. The Director of Nursing acknowledged the importance of monitoring and documenting changes in a resident's condition to prevent missed changes that could delay care. The facility's policy, which mandates recording changes in a resident's medical or mental condition, was not followed in this instance. The lack of documentation and monitoring could lead to serious health issues for the resident, as changes in their condition might go undetected.
Failure to Notify Physician and Family of Pressure Ulcer
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident, leading to the development of a pressure ulcer (PU). The resident, admitted with conditions including a fracture, muscle weakness, and dementia, was identified as at risk for PU. On a specific date, a Certified Nursing Assistant reported an open area on the resident's coccyx to a Licensed Vocational Nurse, but there was no documented evidence that the physician was notified. This lack of notification delayed obtaining appropriate treatment instructions from the physician. Additionally, the facility did not inform the resident's family member about the pressure ulcer. The family member discovered the wound after the resident was discharged to a Board and Care facility, where a caregiver noted the wound during a change of the resident's incontinent brief. The family member was later informed by a Home Health Nurse that the resident had a stage 2 PU, but stated they were not notified by the facility about this condition. The facility's policies require notifying the physician and family of significant changes in a resident's condition, such as the development of a PU. However, the documentation reviewed showed that these notifications were not made, violating the facility's policy and the family member's right to be informed. The Director of Nursing confirmed that the physician and family should have been notified according to the facility's procedures.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident. The resident, admitted with a fracture, generalized muscle weakness, and dementia, was at risk for pressure ulcers as indicated in their care plan and Minimum Data Set. Despite this, the facility did not inform the physician of the resident's pressure ulcer on the coccyx, which was first noted on June 23, 2024. The lack of notification meant that no treatment was initiated, and the ulcer progressed to a stage 2 pressure ulcer by the time the resident was discharged on July 3, 2024. The facility also failed to inform the resident's family member about the pressure ulcer, violating the family member's rights. The facility's policy required notification of family members in the event of a significant change in the resident's condition, but this was not done. Additionally, the facility did not develop a care plan to address the pressure ulcer, which is a critical step in managing and treating such conditions. The absence of a care plan meant that there were no documented interventions to treat the ulcer. Furthermore, the facility inaccurately assessed the resident's risk for pressure ulcers using the Braden Scale. The assessment did not reflect the actual condition of the resident, as it documented a potential problem for friction and shear instead of an existing problem. This inaccurate documentation contributed to the lack of appropriate care and intervention for the resident's pressure ulcer, ultimately leading to the development of a stage 2 ulcer.
Failure to Remove IV Catheter Post-Hydration
Penalty
Summary
The facility failed to remove an intravenous catheter from a resident after the completion of IV fluid hydration, which was ordered due to the resident's poor oral intake. The resident, who was admitted with a fracture, generalized muscle weakness, and dementia, had an IV catheter inserted for hydration purposes. The physician's order specified the administration of Dextrose Normal Saline at 60 ml per hour for two days. However, after the completion of the IV fluids on the specified date, the catheter was not removed as required. This oversight was discovered when the resident was discharged to a Board and Care facility with the IV catheter still in place. Interviews with facility staff revealed that the responsibility for removing the IV catheter lay with the registered nurse who completed the IV fluids. The Director of Nursing confirmed that the catheter should have been removed to prevent potential complications such as redness, discomfort, and infection. The facility's policy on peripheral IV catheter removal outlined the conditions under which a catheter should be removed, including the discontinuation of infusion therapy. Despite these guidelines, the catheter remained in place until it was discovered by the caregiver at the Board and Care facility, prompting a call to the facility to address the issue.
Inaccurate Documentation of Resident Notifications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, which is a violation of accepted professional standards. Specifically, the Situation Background Assessment and Recommendation (SBAR) Communication Form for the resident was not accurately documented. On two occasions, the form did not correctly record the date and time when the physician and the family were notified about the resident's condition. On one occasion, the form indicated that the physician and family member were informed at midnight, but the form was actually created at 3:47 p.m., suggesting a discrepancy in the documentation. On another occasion, the form was left blank regarding whether the physician and family member were notified. The resident involved was admitted with a fracture of the neck of the left femur, generalized muscle weakness, and dementia, which severely impaired their cognitive skills for daily decisions. The resident was dependent on staff for various activities of daily living and had issues with incontinence. The Director of Staff Development acknowledged the inaccuracies in the documentation, emphasizing the importance of accurate record-keeping to ensure proper treatment orders. The Director of Nursing confirmed that it is the facility's policy to notify family and physicians of any change in condition and to document these notifications accurately.
Failure to Prevent Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate care to prevent the development of a Stage 3 pressure ulcer on a resident's right heel. The resident, who was admitted with a history of a right femur fracture, hemiplegia, hemiparesis, and vascular dementia, was at risk for pressure ulcers due to limited mobility and other health conditions. Despite this, the facility did not ensure that the resident's right heel was offloaded from the mattress, which contributed to the development of the pressure ulcer. The facility also failed to provide the resident with a Low Air Loss Mattress, which is designed to prevent skin breakdown by distributing body weight over a broad surface area. Additionally, the resident's care plan lacked specific interventions to prevent pressure ulcers, and there was no documented evidence of regular skin inspections as required by the facility's policies. The resident's skin condition was not monitored on several occasions, and the care plan did not include the use of pressure-relieving devices or repositioning strategies. Interviews with facility staff revealed that the resident's care plan was incomplete and not individualized, and there was no documentation of interventions to offload the resident's heels or use a Low Air Loss Mattress. The facility's policies on pressure injury prevention and comprehensive care planning were not followed, leading to the resident developing a Stage 3 pressure ulcer that required surgical intervention.
Failure to Secure Urinary Catheter
Penalty
Summary
The facility failed to provide proper care for a resident with a urinary indwelling catheter, which was not secured to the resident's thigh as required. This deficiency was identified during an observation where the catheter tubing was found hanging on the side of the bed without a securement device. The registered nurse acknowledged that the catheter should have been anchored to prevent potential complications such as bleeding and infection. The resident involved had a history of stage 4 pressure ulcer, type 2 diabetes mellitus, and dementia, and was dependent on staff for toileting hygiene. The facility's policy on urinary catheter care, reviewed with the Director of Nursing, emphasized the importance of securing the catheter to reduce friction and movement at the insertion site. However, this policy was not followed, leading to the identified deficiency.
Infection Control Lapses During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection control measures during a COVID-19 outbreak, as observed in the actions of five staff members. The Medical Records Assistant was seen walking in the hallway without a protective mask, despite being aware of the presence of COVID-19 positive residents. She admitted to not having an N95 mask available at the receptionist desk and acknowledged the importance of wearing one to protect against respiratory viruses. Licensed Vocational Nurses 1 and 2 were observed with their N95 masks hanging around their necks, leaving their noses and mouths exposed while standing outside residents' rooms. Both nurses were aware of the ongoing COVID-19 outbreak and the facility's masking policy but failed to comply. LVN 1 mentioned forgetting to reposition her mask after taking a sip of water, while LVN 2 had just removed his mask. LVN 3 was found without a mask at the nurse's station, later donning a surgical mask after being questioned by a surveyor. The Director of Staff Development Assistant was observed in the Director of Nursing's office with her mask hanging around her neck, engaging in close conversation with the Activity Director. Despite being aware of the facility's policy to wear N95 masks in resident care areas, she believed it was permissible to remove the mask inside the office. The Infection Preventionist confirmed the facility's policy required N95 masks in all resident care areas during the outbreak, emphasizing the risk of spreading COVID-19 due to noncompliance.
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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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