Santa Monica Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 1320 20th Street, Santa Monica, California 90404
- CMS Provider Number
- 055540
- Inspections on file
- 33
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Santa Monica Health Care Center during CMS and state inspections, most recent first.
The facility failed to follow its care plan conference policy by not holding IDT meetings with resident and/or representative participation for three cognitively intact residents who required moderate to total assistance with ADLs and had diagnoses such as afib, PVD, chronic respiratory failure, acute kidney failure, BPH, and muscle weakness. For each resident, record review showed no admission IDT care conference or documented discussion of the plan of care, despite the facility’s policy requiring the IDT, together with the resident or surrogate, to develop a plan of care based on the comprehensive assessment and to encourage their participation. Staff interviews, including with the MDS nurse, interim SSD, and DON, confirmed that these conferences were not conducted or documented as required.
A resident with a history of aggressive and unpredictable behavior did not receive necessary behavioral health care and services, as outlined in their care plan, leading to a physical altercation that caused harm to another resident. Despite staff awareness of the resident's behavioral issues and the implementation of a 1:1 sitter for safety within the facility, the resident was allowed to go out on pass without supervision, and repeatedly declined psychological services.
A resident with a history of diabetes, COPD, and hypertension, who was full code, became unresponsive and was not breathing. During CPR, an LVN used a non-rebreather mask instead of an Ambu bag, which is not appropriate for non-breathing individuals. Staff interviews and facility policy confirmed that a bag valve mask should have been used to provide positive pressure ventilation.
A resident with diabetes, receiving insulin and tube feeding, was admitted without a physician order for blood glucose monitoring. Despite a care plan identifying the risk for unstable blood glucose, nursing staff did not obtain necessary orders or check blood sugar during an acute change in condition, contrary to facility policy. The resident became unresponsive and died, with staff interviews confirming that required monitoring protocols were not followed.
A resident with diabetes and chronic kidney disease experienced erratic blood sugar levels that were not reported to the physician, despite facility policy requiring such notification. The resident was found unresponsive with hypoglycemia and required emergency intervention and hospitalization. Staff interviews revealed a lack of communication regarding blood sugar trends and meal intake, contributing to the incident.
Surveyors identified multiple failures in food storage and sanitation, including missing refrigerator temperature logs, absence of a thermometer, expired food in storage, lack of documentation for ice scoop cleaning, and staff food stored with resident food. These deficiencies were confirmed by the RD and were not in accordance with facility policy.
The facility did not submit MDS assessments to CMS within the required 14-day period after completion for three residents with complex medical needs, including cognitive impairment and chronic conditions. The MDSN confirmed the late submissions, and the DON acknowledged the regulatory requirement for timely reporting of assessment data.
A resident admitted with muscle wasting, difficulty walking, and hypertension was assessed as incontinent of bowel and bladder, but no care plan was initiated to address these needs. Staff interviews and record reviews confirmed the absence of a care plan, which was not in accordance with facility policy requiring comprehensive care planning for identified needs.
A resident with severe cognitive impairment and multiple diagnoses did not have an individualized care plan addressing dementia, despite requiring substantial assistance with ADLs. The DON confirmed that such care plans are necessary and acknowledged the omission, which was not in line with facility policy requiring the IDT to create resident-centered plans for those with dementia.
A resident with severe cognitive impairment and multiple medical conditions was found to have oxygen tubing in use beyond the facility's required seven-day change interval. The DON confirmed the tubing had not been changed as per infection control policy, which mandates weekly replacement of respiratory equipment.
The facility failed to inform three residents about the State Long-Term Care Ombudsman program, as confirmed by interviews and record reviews. Despite policies stating residents should be notified upon admission and during resident council meetings, the residents were unaware of the program and how to contact the Ombudsman.
The facility failed to follow standardized recipes and diet textures, resulting in residents on mechanical soft and finely chopped diets receiving incorrect portion sizes and food textures. This included serving 4 ounces of chicken instead of 5 ounces, regular parsley rice instead of pureed rice, and long strips of bell pepper garnish, which could pose a choking hazard.
The facility failed to ensure safe and sanitary food storage and preparation practices, including improper storage of cooked and raw foods, inadequate handwashing by kitchen staff, unsanitary ice machine maintenance, and improper labeling and monitoring of resident food brought from outside. These deficiencies could lead to harmful bacteria growth and cross-contamination.
A facility failed to maintain a resident's dignity during feeding when a CNA was observed standing over a resident while assisting with breakfast. The resident, who had multiple medical conditions and was capable of making decisions, was not treated in accordance with the facility's policy requiring staff to be at eye level during feeding.
The facility failed to promptly and thoroughly investigate the loss of personal belongings for a resident who reported missing clothes and shoes after being moved to another room. Despite informing staff, no follow-up communication was made, and documentation lacked proper details and timestamps.
The facility failed to document that Advance Directive information was discussed and provided to two residents, potentially violating their rights to be fully informed about their options for advance directives. The Social Worker admitted there was no documentation, and the Director of Nursing was unaware of the missing forms.
A resident was using a low air loss mattress (LALM) without a physician's order, set at an incorrect weight. The resident had multiple diagnoses, and the absence of a physician's order for the LALM was confirmed by the Treatment Nurse and Director of Nurses, highlighting a failure to follow facility policy.
A resident with a history of a left femur fracture and other conditions experienced severe pain that was not adequately managed by the facility. Despite frequent complaints and requests for stronger pain relief, the facility did not promptly notify the MD or adjust the pain management plan, resulting in the resident suffering from severe pain levels of 7 to 8 out of 10. The facility's pain management policy was not followed, leading to prolonged and severe pain for the resident.
Failure to Conduct IDT Care Plan Conferences With Resident Participation
Penalty
Summary
The deficiency involves the facility’s failure to implement its policy and procedure for conducting care plan conferences and involving residents and/or their representatives in the development of person-centered plans of care. For Resident 1, who was admitted with atrial fibrillation, peripheral vascular disease, and an anxiety disorder, the Minimum Data Set (MDS) showed intact cognitive skills for daily decision-making and a need for moderate assistance with ADLs. However, review of the medical record as of 1/23/2026 showed no documentation of an Interdisciplinary Team (IDT) meeting or care plan conference upon admission. Resident 1’s care coordinator reported visiting the facility to inquire about the resident’s plan of care and goals, but no staff could provide a care plan or related documentation, and attempts to obtain information from social services were unsuccessful. For Resident 3, admitted with chronic respiratory failure, acute kidney failure, and muscle weakness, the MDS indicated intact cognitive skills for daily decisions and total dependence on staff for ADLs. A review of this resident’s medical record as of 1/23/2026 similarly revealed no IDT meeting or care plan conference upon admission. During an interview and record review, the MDS nurse confirmed that there was no IDT care conference completed and no discussion documented regarding Resident 3’s plan of care. For Resident 4, admitted with benign prostatic hyperplasia, atrial fibrillation, and muscle weakness, the MDS showed intact cognitive skills for daily decisions and a need for maximal to total assistance with ADLs. As with the other residents, review of the medical record as of 1/23/2026 showed no IDT meeting or care plan conference upon admission. The MDS nurse confirmed that no IDT care conference or discussion of the plan of care had been completed for this resident. The DON and interim Social Services Director both stated that, per facility practice and policy, an IDT care conference including the resident and/or resident representative should be held upon admission to discuss the plan of care, services, and discharge planning. The facility’s written policy, “Care Plan Conference,” requires the IDT, in conjunction with the resident or representative, to develop the plan of care based on the comprehensive assessment and to hold care plan conferences within specified timeframes, encouraging resident and representative participation, which did not occur for these residents.
Failure to Provide Necessary Behavioral Health Services Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services as part of their comprehensive assessment, resulting in a physical altercation that caused harm to another resident. The resident in question was admitted with several medical diagnoses, including autoimmune thyroiditis, hyperlipidemia, gastroesophageal reflux disease, muscle weakness, and unsteadiness on feet. Despite being cognitively intact and not requiring mobility devices, the resident exhibited aggressive and unpredictable behavior, as documented in care plans and staff interviews. The care plan for verbal and physical aggression included referral to a psychologist or psychiatrist, but psychology notes indicated the resident repeatedly declined to be seen. Staff interviews revealed that the resident often became agitated, frustrated, and aggressive when things did not go their way, leading to concerns about potential harm to themselves and others. Nursing staff and supervisors described the resident as not getting along with roommates, yelling at staff, and requiring a 1:1 sitter for safety due to aggressive behavior. The need for a sitter was specifically to protect other residents and staff from potential physical altercations, as the resident was considered unpredictable and prone to anger. Despite these interventions, the facility allowed the resident to go out on pass without a sitter, with the DON stating that the facility's responsibility was limited to the resident's behavior inside the facility. The facility's policy on safety supervision emphasized individualized, resident-centered approaches based on assessed needs and identified hazards, but the implementation did not address the resident's behavioral health needs adequately, as evidenced by the incident and ongoing behavioral concerns.
Failure to Use Appropriate Oxygen Delivery Device During CPR
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to use the appropriate oxygen delivery device during cardiopulmonary resuscitation (CPR) for a resident who was unresponsive, had no pulse, and was not breathing. Instead of using a bag valve mask (Ambu bag) to provide positive pressure ventilation, the LVN placed the resident on a non-rebreather mask at 10 liters of oxygen. The non-rebreather mask is not designed for use on individuals who are not breathing, as it cannot deliver oxygen without the patient’s own respiratory effort and may obstruct the airway. The resident involved had a medical history including diabetes mellitus, chronic obstructive pulmonary disease, and hypertension, and was admitted to the facility with a full code status, as indicated by the Physician Orders for Life-Sustaining Treatment (POLST). On the day of the incident, the resident was observed having convulsions, became unresponsive, and was found to have no pulse and was not breathing. CPR was initiated, but the LVN used a non-rebreather mask rather than the Ambu bag, contrary to facility policy and standard emergency procedures. Emergency medical services (EMS) were called and arrived shortly after, but the resident was pronounced dead. Interviews with facility staff, including the LVN involved, the Director of Nursing (DON), and other nurses, confirmed that the correct procedure during CPR for a non-breathing resident is to use an Ambu bag to provide positive pressure ventilation. The facility’s policies and national guidelines also specify the use of a bag valve mask in such situations. The use of a non-rebreather mask on a non-breathing resident was acknowledged by staff as inappropriate and potentially obstructive to oxygen delivery.
Failure to Monitor Blood Glucose in Diabetic Resident on Insulin
Penalty
Summary
The facility failed to implement a system to ensure blood glucose monitoring for a resident with diabetes who was receiving insulin and tube feeding. Upon admission, the resident had a diagnosis of diabetes mellitus and was prescribed Lantus insulin twice daily, but there was no physician order for blood sugar monitoring, despite the resident's care plan identifying a risk for unstable blood glucose levels. The resident's hospital discharge records also did not include blood sugar monitoring orders, and this omission was not addressed by the facility's licensed nursing staff. On the morning of the incident, a licensed vocational nurse observed the resident experiencing convulsions, body shaking, and unresponsiveness, with no pulse or breathing. Despite the resident's diabetic status and the acute change in condition, the nurse did not check the resident's blood glucose level, stating uncertainty about the need to do so. Cardiopulmonary resuscitation was initiated, and emergency services were called, but the resident was pronounced dead shortly after. The facility's policy required blood glucose checks for diabetic residents on insulin, especially during changes in condition or when unresponsive, but this protocol was not followed. Interviews with facility staff, including the DON and the medical director, confirmed that blood glucose monitoring is standard practice for diabetic residents on insulin, particularly when there is a change in condition. The facility's own policies and procedures outlined the necessity of obtaining physician orders for blood glucose monitoring upon admission and during episodes of unresponsiveness. However, these procedures were not adhered to, resulting in the failure to monitor and respond appropriately to the resident's diabetic condition.
Failure to Notify Physician of Erratic Blood Sugar Levels Resulting in Hypoglycemic Event
Penalty
Summary
The facility failed to notify the physician of a resident's fluctuating blood sugar (BS) levels, which were not reported despite being erratic and outside the normal range. The resident, who had diagnoses including type 2 diabetes mellitus, chronic kidney disease, and dysphagia, was admitted with specific dietary and insulin orders. The resident's blood sugar levels ranged from 83 to 328 mg/dL, but these variations were not communicated to the medical doctor as required by facility policy. On the day of the incident, the resident was found unresponsive with a blood sugar reading of 43 mg/dL, indicating hypoglycemia with altered mental status. Emergency interventions were initiated, including administration of glucagon and transfer to a general acute care hospital. Interviews with staff revealed that the licensed nurse did not notify the physician about the erratic blood sugar levels, believing the levels were at baseline, and failed to consider trends across all shifts. The director of nursing acknowledged that the physician should have been informed to adjust insulin dosages and prevent such episodes. Further review showed that the registered dietician had not reviewed the resident's blood sugar levels or meal intake, despite the resident's reduced food consumption, which could contribute to hypoglycemia. The facility's policy required notification of the physician and resident representative when significant changes in condition occurred, but this procedure was not followed, resulting in the resident experiencing a hypoglycemic event requiring hospitalization.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as evidenced by several observations and interviews. There were no temperature logs for two refrigerators, and one refrigerator lacked a thermometer, making it impossible to verify that perishable foods were stored at safe temperatures. Additionally, a container of black beans was found in the refrigerator past its use-by date, and the ice machine scoop did not have a cleaning log to document when it was last sanitized. Staff food items were also found stored in a refrigerator designated for residents, contrary to facility policy. These deficiencies were confirmed through interviews with the Registered Dietician, who acknowledged the lack of documentation and the presence of expired food and staff items in resident storage areas. The facility's policies require proper food storage, temperature monitoring, and separation of staff and resident food to prevent contamination, but these procedures were not followed. All 56 residents who received food from the kitchen were potentially affected by these lapses.
Failure to Timely Submit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure timely electronic submission of Minimum Data Set (MDS) assessments to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day period after completion. Specifically, for three sampled residents with significant medical conditions such as cerebral infarction, hypertension, dementia, anxiety, atrial fibrillation, chronic kidney disease, and altered mental status, the MDS assessments were completed but not transmitted to the system within the regulatory timeframe. The MDS Nurse confirmed that the assessments for these residents were completed on specific dates but were not submitted until several weeks later, exceeding the 14-day requirement. Record reviews and staff interviews revealed that the MDS assessments for these residents, who required varying levels of staff assistance with activities of daily living and were cognitively impaired, were not submitted as per CMS regulations. The DON acknowledged the requirement for timely submission and the importance of notifying CMS of any changes in resident care. The deficiency was further supported by reference to the CMS Resident Assessment Instrument (RAI) Manual, which outlines the 14-day submission requirement for MDS data.
Failure to Initiate Care Plan for Incontinence Upon Admission
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with multiple diagnoses, including muscle wasting, difficulty walking, and hypertension. Upon admission, assessments documented that the resident was incontinent of both bowel and bladder, with inadequate control and frequent episodes of incontinence. Despite these findings, there was no care plan initiated to address the resident's incontinence, as confirmed by both record review and staff interviews. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the absence of a care plan meant that staff did not have documented goals or interventions to guide care for the resident's incontinence. The facility's policy required a comprehensive care plan to be developed for each resident, including measurable objectives and timetables to address identified needs. The lack of a care plan for incontinence was identified during the survey and was not in accordance with the facility's established procedures.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident diagnosed with dementia. Record review showed that the resident was admitted with multiple diagnoses, including dementia, hypertension, and acute kidney failure. The Minimum Data Set assessment indicated the resident had severe cognitive impairment and required substantial to maximal assistance with most activities of daily living, such as eating, hygiene, and dressing. Despite these needs, there was no care plan addressing the resident's dementia diagnosis. During an interview, the DON confirmed that care plans are required for all residents, especially for those with high-risk diagnoses like dementia, to guide staff in providing appropriate interventions. The DON acknowledged that the absence of a dementia-specific care plan could result in staff not knowing the necessary interventions for the resident. Review of the facility's policy indicated that the interdisciplinary team is responsible for creating a resident-centered care plan for individuals with confirmed dementia, but this was not done for the resident in question.
Failure to Change Oxygen Tubing per Policy
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures for one resident by not ensuring that oxygen tubing was changed every seven days as required. During a record review, it was found that a resident with severe cognitive impairment and dependence on activities of daily living was receiving oxygen via nasal cannula, and the tubing in use was dated beyond the seven-day change interval. The Director of Nursing confirmed that the tubing had not been changed according to policy and acknowledged the requirement for weekly changes. The resident's medical history included depression, hypertension, and atrial fibrillation, and a physician's order was in place for oxygen administration as needed to maintain oxygen saturation above 92%. Facility policy specified that respiratory equipment such as cannulas and humidifiers should be changed every seven days or when visibly contaminated. The failure to follow this schedule was observed during a concurrent observation and interview, and the facility's policy was confirmed through record review.
Failure to Inform Residents About Ombudsman Program
Penalty
Summary
The facility failed to provide information about the State Long-Term Care Ombudsman to three of four sampled residents. Resident 15, 45, and 53, who were alert and oriented, stated during a Resident Council Meeting that they were not aware of the Ombudsman program or how to contact the Ombudsman's office. This deficiency was identified through interviews and record reviews, which revealed that these residents had not been adequately informed about the Ombudsman program despite the facility's policy stating that residents should be notified upon admission and during resident council meetings. Interviews with the Social Service Director, Activities Assistant, and Director of Nursing confirmed that the responsibility for informing residents about the Ombudsman program was not consistently executed. The Social Service Director stated that residents were notified upon admission and during resident council meetings, while the Director of Nursing indicated that the Activities Director was responsible for informing residents about the Ombudsman. However, the residents' lack of awareness indicated a failure in the communication process, leading to the deficiency noted in the report.
Failure to Follow Standardized Recipes and Diet Textures
Penalty
Summary
The facility failed to ensure the standardized recipes for the lunch menu were followed on 3/26/2024. Specifically, the cook used a smaller scoop size to serve chicken Dijon, resulting in 16 residents on mechanical soft and finely chopped diets receiving 4 ounces of chicken instead of the prescribed 5 ounces. Additionally, 13 residents on finely chopped diets received regular parsley rice instead of pureed parsley rice as required by the menu. The cook admitted to making a mistake with the scoop sizes and not noticing the menu's requirement for pureed rice, which could lead to residents feeling hungry and potentially choking on improperly prepared food. Furthermore, the cook added long strips of sliced red bell pepper as a garnish for residents on mechanical soft diets, which was not in accordance with the mechanical soft diet policy. Nine out of 16 residents on mechanical soft and finely chopped diets received these long strips, which could pose a choking hazard. The kitchen supervisor and registered dietitian confirmed that the bell peppers should have been chopped into smaller pieces. The facility's policies and procedures, as well as the menu and diet spreadsheet, clearly indicated the correct portion sizes and food textures that were not adhered to during this meal service.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices. Cooked eggs were stored on the same shelf and on top of cartons of raw liquid eggs, and a large piece of raw pork loin was stored on top of imitation crab meat. The cook acknowledged that the refrigerator space was small, leading to improper storage and potential cross-contamination. Additionally, a kitchen staff member did not wash their hands properly before handling clean dishes, using a bucket of soapy water instead of the designated handwashing sink, which could lead to the transfer of germs from dirty to clean dishes. The ice machine in the kitchen was not maintained in a sanitary manner, with red color residue observed inside the ice storage bin. The kitchen supervisor and maintenance supervisor confirmed that the residue was likely from juice spills, as the ice storage bin was kept open while filling beverage containers. The facility's policy required the ice machine to be kept closed when not in use, but this was not followed, leading to potential contamination. Food brought in by residents or their families was not properly labeled or dated, and the resident food refrigerator was not monitored for temperature. Expired and moldy food was found in the refrigerator, and the maintenance staff admitted that they were not allowed to discard food per the facility's policy. The director of staff development and the maintenance supervisor acknowledged that the refrigerator had not been cleaned and that the food was not safe for residents due to the lack of proper labeling and monitoring.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced a resident's dignity, respect, and individuality for one of four sampled residents. On 3/26/2024 at 8 AM, a Certified Nursing Assistant (CNA) was observed standing over Resident 208 while assisting the resident during breakfast. This action did not align with the facility's policy, which requires staff to be at eye level with residents while feeding them to ensure dignity and respect. Resident 208, who was admitted with medical diagnoses including hyperlipidemia, hypertension, peripheral vascular disease, chronic obstructive pulmonary disease, acute pulmonary edema, and a left femur fracture, was capable of understanding and making decisions. During an interview, the CNA acknowledged the mistake and the Director of Nursing confirmed that staff must be at eye level with residents while feeding them. The facility's policy on assisting residents to eat also supports this requirement.
Failure to Investigate Lost Belongings Promptly
Penalty
Summary
The facility failed to promptly and thoroughly investigate the loss of personal belongings for Resident 27. Resident 27, who was cognitively intact and required maximal assistance with activities of daily living, reported missing two bags of clothes, including five pairs of pants, five shirts, and one pair of orthopedic shoes, after being moved to another room. Despite informing facility staff about the missing items, no follow-up communication was made with Resident 27 regarding the investigation or resolution of the issue. Interviews with the Social Worker and Administrator revealed that the information about the missing property was noted, and a decision was made to replace the lost items. However, the facility's documentation, including the Inventory of Personal Effects list and the Grievance/Complaint Report, lacked proper details and timestamps. The facility's policies on misappropriation of resident property and grievance resolution were not adhered to, resulting in a delay in addressing Resident 27's concerns and replacing the lost belongings.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to document that Advance Directive information was discussed and provided to two residents, Resident 8 and Resident 22. Resident 8, who was admitted with multiple diagnoses including bilateral knee osteoarthritis, anxiety disorder, and major depressive disorder, was found to be moderately cognitively impaired and required maximal assistance with personal hygiene. During an interview, the Social Worker (SW) admitted that there was no documentation in Resident 8's medical record regarding the acknowledgment of advance directives. Similarly, Resident 22, who was admitted with conditions such as orthostatic hypotension, anemia, and COPD, was cognitively intact but also lacked documentation of having received information about advance directives. The SW confirmed that although information was provided, there were no notes or documentation to support this claim for either resident. The Director of Nursing (DON) was unaware of the missing advance directive acknowledgment forms for Residents 8 and 22. The facility's policy, dated 8/16/2021, mandates that residents or their representatives be provided with written information regarding advance directives upon admission and that this be documented in the resident's clinical record. The failure to document these discussions and provide written information as required by the facility's policy potentially violated the residents' rights to be fully informed about their options for advance directives.
Failure to Obtain Physician's Order for Low Air Loss Mattress
Penalty
Summary
The facility failed to obtain a physician's order for a low air loss mattress (LALM) for a resident, which is designed to distribute body weight and help prevent skin breakdown. The resident, who was admitted with multiple diagnoses including cellulitis, tremor, depression, hypothyroidism, hyperlipidemia, manic episode, anxiety disorder, obstructive sleep apnea, and hypertension, was observed using the LALM set at 320 pounds, despite weighing only 187 pounds. The Treatment Nurse confirmed the absence of a physician's order for the LALM and stated the need to call the physician to obtain one. The Director of Nurses also acknowledged the importance of having a physician's order to ensure appropriate treatment for the resident. The facility's policy and procedures require physician orders to provide clear direction in the care of residents. This deficiency had the potential to result in inappropriate care and treatment for the resident, as the LALM was being used without proper authorization and at an incorrect setting for the resident's weight.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident, resulting in severe pain. The resident, who was cognitively intact and had a history of a left femur fracture, seizures, anxiety disorder, depression, and hypertension, reported that the pain medications administered did not relieve their pain for more than three hours. Despite the resident's continual complaints and requests for stronger pain relief, the facility did not notify the MD promptly or adjust the pain management plan accordingly. The resident's pain levels were consistently reported between 7 to 8 out of 10, indicating severe pain, yet the care plan only addressed mild pain interventions and did not include strategies for managing severe pain. Interviews with staff revealed that the resident frequently complained of pain and sometimes refused the offered medications, stating they were ineffective. The certified nursing assistant and licensed vocational nurse both reported the resident's ongoing pain to the RN supervisor, who then contacted the MD. Initially, the MD was reluctant to increase or change the pain medication without identifying the underlying cause of the pain but eventually ordered the pain medication to be administered every four hours instead of every six hours and requested further tests to determine the cause of the pain. The facility's policy on pain management emphasized the need for regular pain screening, evaluation, and care management, including notifying a physician and administering therapeutic interventions as ordered. However, the facility did not adhere to these procedures, resulting in the resident experiencing prolonged and severe pain without adequate intervention or timely communication with the MD to adjust the pain management plan.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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