Sherman Oaks Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Sherman Oaks, California.
- Location
- 14401 Huston St., Sherman Oaks, California 91423
- CMS Provider Number
- 056250
- Inspections on file
- 43
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sherman Oaks Health & Rehab during CMS and state inspections, most recent first.
A resident with diabetes and other comorbidities, who was oriented and knowledgeable about her medications, reported that an LVN brought an insulin pen labeled with another resident’s name to her bedside and placed it on her tray table. The resident noticed the incorrect name on the pen, informed the LVN, and photographed the pen, after which the LVN removed it and returned with insulin pens labeled for the correct resident and administered the insulin. The LVN later stated she had placed an expired insulin pen for another resident and the correct resident’s insulin pen on top of the medication cart and mistakenly picked up the wrong pen when bringing medications into the room, contrary to facility policy and standard practice requiring verification of the five rights and preparation of medications for only one resident at a time.
A resident with DM2, morbid obesity, and HTN had orders for basal and sliding-scale insulin. One evening, an LVN preparing medications placed multiple residents’ insulin pens on top of the med cart and inadvertently brought an insulin pen labeled for another resident into the room, placing it on the bedside tray. The alert resident recognized the wrong name on the pen, informed the LVN, and the LVN then retrieved and used the correct insulin pen. The LVN later acknowledged she had mistakenly grabbed the other resident’s pen and also acknowledged that she did not document this medication error in the medical record, despite facility policies and nursing staff statements that all medication errors and related incidents must be charted. Review of the record confirmed there was no nursing note about the incident, resulting in an incomplete clinical record for the resident.
A resident with intact cognitive skills reported that a visitor used inappropriate language towards her, which staff recognized as verbal abuse. Although the incident was reported to staff, a miscommunication prevented the administrator from being fully informed, resulting in a failure to notify the State Survey Agency, ombudsman, and law enforcement within the required two-hour timeframe. This delay led to a late investigation and potentially placed the resident at risk.
A resident's EHR containing sensitive medical information was left open and unattended at a nurses' station, with no staff present to monitor the workstation. The DON confirmed that staff are required to lock EHRs when not in use, and facility policy mandates that computer terminals be shielded and logged off when unattended. This failure resulted in a breach of privacy and confidentiality for the resident's protected health information.
A resident with hemiplegia and high fall risk, dependent on staff for transfers and requiring a mechanical lift with two-person assistance, was transferred by staff without the required lift. Following the transfer, the resident developed new leg pain, swelling, and bruising, and was later diagnosed at a hospital with a left knee fracture. Staff interviews confirmed the transfer was performed improperly and not in accordance with facility policy.
Two medication carts were found open and unattended in a nurses' station, as confirmed by the DON during an interview. Facility policy requires medication carts to be locked when out of staff view, but this was not followed, creating the potential for unauthorized access to medications.
CNAs failed to accurately and timely document the percentage of food consumed by three residents with severe cognitive impairments and complex medical conditions. Meal intake records were often incomplete, missing, or recorded at incorrect times, leading to inaccurate medical records. Facility leadership confirmed that documentation did not meet professional standards or facility policy.
A resident with moderate risk for pressure ulcers and impaired mobility was found to have a low air-loss mattress set incorrectly at 160 lbs, despite weighing 115 lbs. Staff interviews and record reviews confirmed the mattress should have been set to 120 lbs according to the resident's weight and manufacturer guidelines. This failure to follow professional standards and facility policy placed the resident at risk for pressure ulcer development.
The facility failed to obtain proper informed consent for psychotropic medications for several residents, including those with major depressive disorder and dementia. Incomplete consent forms lacked signatures from residents or their representatives and prescribing physicians, leading to the administration of medications without documented consent. This oversight was acknowledged by the facility's RN and DON, highlighting a failure to follow policy and potentially resulting in the use of unnecessary psychotropic drugs.
The facility did not make the most recent survey results accessible to residents and their representatives, as required by policy. Residents were unaware of where to find the survey results, and the binder was not visible or up-to-date. The Administrator confirmed the importance of making these results available, but the facility failed to comply with its own policy.
The facility failed to follow proper protocols for the use of restraints on two residents. A resident had a bed alarm applied without a restraint assessment, physician's order, informed consent, or care plan, while another resident had pillows tucked under the fitted sheet as a restraint without the necessary documentation and approvals. These actions did not comply with the facility's policy on restraint use, which requires thorough assessment and documentation.
Two residents in an LTC facility did not receive proper monitoring for medication side effects and effectiveness. One resident, on blood thinners for atrial fibrillation, was not monitored for bleeding, while another, on atorvastatin for hyperlipidemia, did not have lipid levels checked. The facility's policies required such monitoring, but it was not documented.
The facility's nursing staff failed to rotate insulin injection sites for three residents, leading to a deficiency in care. Despite physician's orders and guidelines, insulin was repeatedly administered in the same areas, risking adverse effects. The DON and RN acknowledged the oversight and the importance of site rotation to prevent skin complications.
The facility failed to maintain a safe environment for residents, leading to multiple deficiencies. A resident at high risk for falls had floor mats obstructed by equipment, compromising their effectiveness. Another resident's room had environmental hazards like protruding nails, and a third resident was left unattended in a high bed position during wound care, increasing fall risk. These actions violated facility policies aimed at ensuring resident safety.
The facility failed to properly administer and document oxygen therapy for residents requiring respiratory care. A resident with metabolic encephalopathy and dementia received oxygen therapy without consistent documentation on the MAR. Another resident with Alzheimer's Disease also received oxygen therapy without proper documentation and monitoring. Additionally, a resident's oxygen tubing was observed touching the floor, posing a risk of infection. These deficiencies could lead to respiratory distress and infections.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, as required by their care plan and facility policy. The resident, dependent on hemodialysis, had multiple instances where post-HD assessments were not documented, potentially delaying care and detection of complications. Interviews confirmed the importance of these assessments, yet documentation was incomplete despite regular staff training.
A facility failed to account for three doses of controlled medications for three residents, leading to a deficiency in pharmaceutical services. An LVN admitted to administering the medications but did not document the administration on the accountability logs, violating facility policy. This lack of documentation increased the risk of medication errors and potential harm to the residents, who required these medications for chronic pain, pressure ulcers, and neuropathy.
A CP failed to report irregularities in drug regimen reviews for two residents, leading to deficiencies in monitoring for adverse effects of medications. One resident on blood thinners was not monitored for bleeding, and another on atorvastatin was not monitored for lipid levels. The DON acknowledged the lack of documentation, and the CP admitted to missing these issues in reviews.
A facility failed to monitor drug regimens and side effects for three residents, leading to potential unnecessary drug use. One resident on Eliquis, clopidogrel, and gabapentin lacked monitoring for bleeding and drug toxicity. Another resident on atorvastatin had no lipid panel conducted since admission. A third resident on apixaban lacked monitoring for adverse effects. The facility's policies emphasized the need for such monitoring to prevent harm.
The facility failed to ensure appropriate use of psychotropic medications for several residents, including administering lorazepam without proper documentation, prescribing mirtazapine and divalproex without specific target behaviors, and administering sertraline and divalproex sodium without informed consent. Additionally, alprazolam was prescribed PRN without a stop date, leading to potential unnecessary medication use.
A facility failed to maintain a medication error rate below five percent, resulting in a 12.5% error rate. Two residents experienced errors: one received carvedilol at the wrong time, an incorrect multivitamin, and missed polyethylene glycol; another received carvedilol late. LVNs cited being busy as the cause. The facility's policy requires medications to be administered within a 60-minute window, which was not followed.
The facility failed to rotate insulin injection sites for three residents, leading to significant medication errors. Despite physician's orders and guidelines, insulin was repeatedly administered in the same areas, risking adverse effects. This deficiency was confirmed through record reviews and staff interviews.
The facility failed to update its staffing plan, resulting in medication administration delays for two residents. LVNs were assigned more residents than the assessed ratio of 1 LVN to 24 residents, leading to late administration of carvedilol. The facility's assessment had not been updated since 12/1/2024, despite changes in resident acuity.
The facility failed to maintain an effective infection prevention and control program by using permeable linen cart covers, which allowed contamination from dust and liquids. Observations and interviews revealed that all 17 linen carts were covered with unsuitable materials, and the cleaning methods used were not aligned with the manufacturer's guidelines or facility policies. This deficiency had the potential to spread infections among residents and staff.
A resident with a DNR order was mistakenly given CPR after being found unresponsive due to a failure in filing the correct documentation in their current chart. The oversight led to the assumption that the resident was full code status, resulting in a violation of their rights to dignity and respect.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating resident needs. One resident with dementia and a history of falls had the call light hanging on the wall, while another alert and oriented resident had the call light on the floor. Staff acknowledged the oversight and confirmed the importance of having call lights accessible to ensure timely responses to residents' needs.
The facility failed to assist two residents with formulating Advance Directives (ADs) upon admission, despite their severe cognitive impairments and need for assistance with daily activities. The facility's records lacked documentation of any inquiry or assistance offered to the residents' representatives regarding ADs, contrary to the facility's policy. Interviews confirmed that necessary steps were not taken, potentially impacting the residents' care in emergencies.
The facility failed to maintain a safe and homelike environment for two residents. One resident had a damaged floor mat that was not replaced, despite being at high risk for falls. Another resident's room had a broken baseboard and windowsill with exposed nails and debris, and unrelated red letters on the wall, creating an unsafe and institutional setting. These conditions were not in line with the facility's policy for a homelike environment.
A facility failed to provide a written notice of the bed-hold policy to a resident's representative during a hospital transfer. The resident, with diagnoses including metabolic encephalopathy and sepsis, was transferred due to medical issues, but the required notification was not given, as confirmed by staff interviews. This oversight could lead to the resident being moved to a non-preferred facility.
A resident with a documented DNR order was administered CPR after being found unresponsive, due to a failure in filing the resident's PIC Authorization/Decisions form in the current chart. The oversight led staff to consider the resident as full code status, resulting in a violation of the resident's rights and preferred treatment wishes.
A resident with significant medical conditions was transferred to a hospital due to elevated WBC and BUN levels, but the facility failed to perform a required change of condition assessment. This omission was confirmed by staff interviews and contradicted the facility's policy, potentially impacting the resident's care.
Two residents with urinary catheters were at risk of UTIs due to improper catheter care. One resident with obstructive uropathy had a suprapubic catheter with a loop in the tubing, preventing proper drainage. Another resident with benign prostatic hyperplasia had a foley catheter with coiled tubing, also hindering drainage. Staff confirmed the need for proper catheter alignment to prevent backflow and infection, as per facility policy.
A resident with chronic conditions and significant weight loss was not provided Ensure, a nutritional supplement, as ordered by the physician. The resident reported a weight drop from 195 to 144 pounds, and the LVN confirmed the oversight. The facility's policies required adherence to physician orders and documentation of nutritional support, which was not followed in this case.
The facility failed to properly administer IV fluids for two residents. One resident had a loose and soiled PICC line dressing that was not changed promptly, and another resident's PIV injection port lacked a sterile cap. These deficiencies were observed during a random inspection and confirmed by staff interviews and policy reviews, placing residents at risk for infection.
A facility failed to conduct a quarterly assessment for bed rail entrapment risk for a resident with dementia and a history of falls. Despite the resident's high fall risk and impaired cognition, the last assessment was over a year ago. The facility's policy required quarterly assessments to ensure safe use of bed rails, which were not followed, as confirmed by staff interviews.
A facility failed to label intravenous meropenem with a resident's name, as required for safe medication administration. The medication was taken from an emergency kit due to a pharmacy delay, and the oversight was acknowledged by the RN. The DON confirmed that the facility's policy, which mandates labeling to prevent errors, was not followed.
A facility failed to follow up with an endocrinologist after a resident's HbA1c test result indicated poor blood sugar control. Despite notifying the attending physician, there was no documentation of follow-up with the endocrinologist to adjust the resident's diabetes management. This oversight placed the resident at risk for complications related to uncontrolled blood sugar levels.
The facility failed to label a pitcher of cranberry juice with the date it was poured, as observed during a kitchen tour with the DM. The DM and DON acknowledged that the staff should have dated the pitcher to ensure freshness and prevent potential food-borne illnesses. The facility's policy requires all refrigerated foods to be labeled and dated, which was not adhered to in this instance.
A facility failed to accurately document a resident's elopement risk, despite the resident's condition indicating a risk. The resident, with cerebral infarction and dementia, required substantial assistance with daily activities. Elopement risk assessments inaccurately documented the resident as not at risk, despite a calculated score indicating otherwise. MDS Nurses acknowledged the documentation error, which contradicted the facility's policy requiring objective, complete, and accurate records.
A facility failed to ensure a fair arbitration process for a resident with cognitive impairments by using an outdated arbitration agreement that did not provide for a neutral arbitrator or a convenient venue. Despite having updated the agreement in 2019, the facility used a version from 2007, potentially disadvantaging the resident during arbitration. The Admission's Coordinator and Administrator acknowledged the oversight, noting the importance of the agreement in waiving the right to a jury trial.
A facility failed to ensure proper hospice care for a resident by not obtaining the hospice doctor's signature on the initial Certification of Terminal Illness and not receiving the updated hospice plan of care from the hospice provider. This lack of documentation and communication could negatively impact the resident's care.
A facility failed to complete a resident's MDS Quarterly Assessment within the required timeframe. The assessment, due by 1/10/2025, was completed late on 1/13/2025, as confirmed by the Final Validation Report. This delay could affect timely reporting of the resident's health status and quality measures, as noted by the MDS Nurse and DON.
The facility failed to ensure accurate MDS assessments for two residents, affecting their care plans. One resident's admission date was incorrectly coded, impacting billing and health status documentation. Another resident's discharge status was not accurately reflected, potentially causing confusion and delays in care. The facility's policy requires certification of MDS accuracy, which was not followed.
Insulin Pen Labeled for Another Resident Brought to Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an LVN brought an insulin pen labeled for a different resident to the bedside. The affected resident had type 2 diabetes mellitus, morbid obesity, and essential hypertension, and required varying levels of assistance with activities of daily living. The resident had physician orders for Insulin Glargine 60 units at bedtime, to be held if blood sugar was less than 100, and Insulin Lispro per sliding scale before meals and at bedtime. On the evening in question, the resident reported that an LVN entered the room around 11 p.m. with an insulin pen that had a male resident’s name on the label and placed it on the bedside tray table. The resident, who was oriented and knowledgeable about her medications, read the name on the pen, recognized it did not belong to her, and informed the LVN. The resident took a photo of the insulin pen, which showed a male first and last name corresponding to another resident. The resident stated that after pointing out the error, the LVN left the room with the incorrect pen and later returned with an insulin pen labeled with the correct name, after which the insulin injection was administered. The resident reported feeling stressed after discovering the medication error. In a subsequent interview, the LVN explained that while preparing medications at the cart outside the resident’s room, she removed an expired insulin pen that did not belong to the resident and placed it on top of the cart to address later. She then removed the correct resident’s insulin pen from the container and also placed it on the same side of the cart. While gathering the rest of the resident’s medications, she inadvertently picked up the other resident’s insulin pen from the top of the cart and brought it into the room, stating she had not yet read the name on the pen when the resident noticed the error. The DON and another LVN described the standard process for medication administration, including verifying the “five rights” and preparing medications for only one resident at a time, and facility policies required checking the medication label three times to ensure the right resident, medication, dose, time, and route. The incident occurred when these procedures were not followed, resulting in the wrong resident’s insulin pen being brought to the bedside and observed by the resident.
Failure to Document Insulin Medication Error Resulting in Incomplete Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure a complete and accurate medical record for one resident when a medication error was not documented in accordance with facility policy. The resident had a history of type 2 diabetes mellitus, morbid obesity, and essential hypertension, and required varying levels of assistance with activities of daily living. The resident had physician orders for Insulin Glargine 60 units at bedtime, to be held if blood sugar was less than 100, and Insulin Lispro per sliding scale before meals and at bedtime. On the evening in question, the resident reported that an LVN entered the room around 11:00 p.m. with an insulin pen labeled with another resident’s name and placed it on the bedside tray table. The resident recognized that the insulin pen did not belong to her, informed the LVN, and took a photo of the pen showing a male resident’s first and last name. The LVN then left the room with the incorrect insulin pen and returned with the correct insulin pen labeled with the resident’s name, after which the resident received her insulin injection. The resident stated she felt stressed after discovering the medication error. In a subsequent interview, the LVN acknowledged that she had separated an expired insulin pen belonging to another resident from the medication cart container and placed it on top of the cart, then also placed the resident’s insulin pen on the same side of the cart while preparing medications. The LVN stated she mistakenly grabbed the other resident’s insulin pen from the top of the cart and brought it into the resident’s room, and that the resident identified the wrong name on the pen before administration. The LVN admitted she did not document this medication error and only reported it verbally to her RN supervisor. Review of the resident’s electronic medical record showed no nursing progress notes documenting a medication error or incident on that date. The DON and nursing staff stated that standard practice and facility policies require documentation of medication errors or incidents in the resident’s clinical record, including a factual description of the error and events, incidents, or accidents involving the resident. The failure to document the medication error resulted in an incomplete medical record for the resident on that date. Interviews with other nursing staff confirmed that insulin pens are labeled by pharmacy with resident names, that nurses are expected to verify the “five rights” (right patient, drug, dose, route, and time) when preparing and administering medications, and that medication errors must be documented in the clinical record. The facility’s policies on Charting and Documentation and on Adverse Consequences and Medication Errors require that events, incidents, or accidents involving the resident, and any medication errors, be documented in the resident’s medical record, including a factual description of the error. Despite these requirements, no documentation of the incident involving the wrong insulin pen was found in the resident’s record.
Failure to Timely Report Allegation of Verbal Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of visitor-to-resident verbal abuse within the required two-hour timeframe to the State Survey Agency, the ombudsman, and local law enforcement, as outlined in its own policies. A resident, who was cognitively intact and able to make decisions, reported that a visitor used inappropriate language towards her due to a complaint about a loud television. The incident was reported by the resident to a Social Service Assistant (SSA) the following morning, who then notified the Administrator (ADM) and attempted to address the issue with the visitor. Multiple staff interviews confirmed that the allegation of verbal abuse was recognized and discussed among staff, including the SSA, a Licensed Vocational Nurse (LVN), and a Registered Nurse (RN). Each staff member acknowledged that the use of inappropriate language constituted verbal abuse and that such allegations should be reported immediately to the appropriate authorities. However, there was a breakdown in communication between the SSA and the ADM, resulting in the ADM not being fully informed of the abuse allegation and, therefore, not initiating the required reporting and investigation procedures. The facility's policies clearly state that all allegations of abuse must be reported to the administrator and relevant authorities within two hours if abuse is involved. Despite this, the miscommunication led to a delay in reporting the incident, and the required notifications and investigation were not initiated in a timely manner. This failure resulted in a delay in the investigation and had the potential to place the resident at risk for abuse.
EHR Left Unattended, Compromising Resident Privacy
Penalty
Summary
Staff failed to maintain the privacy and confidentiality of a resident's medical records when an electronic health record (EHR) was left open and unattended at a nurses' station. During an observation with the Director of Nursing (DON), it was noted that the EHR containing the resident's personal and medical information was accessible, with no staff present to monitor the workstation. The DON confirmed that staff are required to lock EHRs when not in use to prevent unauthorized access, as leaving them open poses a risk of exposing protected health information. The resident involved had been admitted with diagnoses including hypertension, type 2 diabetes mellitus, and a history of falls. Assessment records indicated the resident was dependent on staff for several activities of daily living and was able to understand and communicate. Facility policy required that computer terminals be shielded from public view and that users log off or clear screens when leaving workstations unattended, which was not followed in this instance.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all surface-to-surface transfers and required the use of a mechanical lift with two-person assistance, was transferred without the use of the required mechanical lift. The resident had significant medical conditions, including hemiplegia affecting the right side, cerebral infarction, and end stage renal disease, and was assessed as a high fall risk. Facility records, including the Minimum Data Set and a facility-provided record, indicated that the resident's transfer protocol required a Hoyer lift and two-person assistance. On the day of the incident, the resident complained of new left leg pain and swelling, which was assessed by nursing staff. The resident reported to staff that a male staff member had transferred her without the Hoyer lift, and this was confirmed by interviews with the CNA and LVN involved. The resident's leg was found to be swollen, warm, and later developed significant bruising. Medical evaluation and imaging at a general acute care hospital revealed a left knee fracture involving the anterior tibial tuberosity and patellar tendon, with severe swelling and moderate effusion. Interviews with facility staff, including the CNA, LVN, RN, and Administrator, confirmed that the resident was transferred improperly, without the required mechanical lift and two-person assistance, which was not in accordance with the facility's policies and procedures. The improper transfer was identified as the cause of the resident's fracture, and the event resulted in the resident's transfer to the hospital for further evaluation and treatment.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that two medication carts, identified as Medication Cart 1 and Medication Cart 2, were left open and unattended in Nurses' Station 2. This observation was made during a concurrent interview with the Director of Nursing (DON), who confirmed that both carts were open and acknowledged that all medication carts should be locked when staff are out of sight. The DON stated that locking the carts is necessary for resident safety, as unlocked carts could allow unauthorized access to medications. A review of the facility's Policy and Procedures (P&P) titled 'Security of Medication Carts,' last reviewed on 9/27/2024, indicated that medication carts must be securely locked at all times when out of the nurse's view. The failure to lock the medication carts when unattended was identified as a deficient practice, as it had the potential to allow residents or unauthorized personnel access to the medications stored within the carts.
Failure to Accurately Document Resident Meal Intake in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for three residents were maintained in accordance with accepted professional standards and practice. Certified Nursing Assistants (CNAs) did not consistently document the percentage of food consumed by the residents at the correct times, resulting in incomplete and inaccurate nutritional intake records. For example, there were multiple instances where meal intakes were either not documented at all or were recorded at times that did not correspond with actual meal times, such as breakfast and lunch intakes being documented in the afternoon or evening. Resident 1, who had diagnoses including pneumonia, osteoarthritis, and dementia with severely impaired cognitive skills, had several days where meal intakes were missing or documented inaccurately. CNA 1 confirmed that the documentation was incomplete and not reflective of when meals were actually consumed. The Director of Staff Development also acknowledged that the documentation was incomplete and inaccurate, which could affect the identification of causes for weight changes. Similar issues were found for two other residents, both with significant cognitive impairments and medical conditions such as chronic kidney disease, hemiplegia, encephalopathy, and osteoarthritis. Their records also showed missing or inaccurately timed meal intake documentation. The Director of Nursing confirmed that CNAs should document meal intake after consumption and that records should not be left blank. The facility's own policy required that all services and changes in condition be documented objectively, completely, and accurately, but this standard was not met in these cases.
Failure to Set Low Air-Loss Mattress Correctly for Pressure Ulcer Prevention
Penalty
Summary
A resident with diagnoses including pneumonia, osteoarthritis, and dementia was admitted to the facility and assessed as being at moderate risk for pressure ulcer development, as indicated by a Braden Scale score of 14. The resident had severely impaired cognitive skills and required maximal assistance for mobility. Physician orders specified the use of a low air-loss mattress (LALM) for skin management. However, observations and interviews revealed that the LALM was set to 160 lbs, while the resident's actual weight was 115 lbs, as confirmed by both a CNA and LVN. The LALM setting was not adjusted according to the resident's weight, contrary to the manufacturer's guidelines and facility policy. Staff interviews confirmed that the LALM should have been set to 120 lbs based on the resident's weight, and that charge and treatment nurses were responsible for ensuring correct settings. The DON acknowledged that the incorrect LALM setting rendered the device ineffective in preventing pressure ulcers. Review of facility policy and the LALM operation manual further supported that mattress settings should be based on the resident's weight. This failure to ensure the LALM was set appropriately placed the resident at risk for the development of pressure ulcers.
Deficiency in Informed Consent for Psychotropic Medications
Penalty
Summary
The report identifies a deficiency in the facility's process of obtaining informed consent for the use of psychotropic medications for several residents. Resident 48 was admitted with diagnoses including major depressive disorder and congestive heart failure. Despite having the capacity to understand and make decisions, the informed consent forms for trazodone hydrochloride and temazepam were incomplete, lacking signatures from both the resident or their representative and the prescribing physician. This oversight was acknowledged by the RN and DON, who confirmed that the consent process was not followed, potentially leaving the resident unaware of the risks and benefits of the medications. Similarly, Resident 8, who was diagnosed with unspecified mood disorder and dementia, did not have completed informed consent forms for divalproex sodium and sertraline. The resident's capacity to understand and make decisions was impaired, necessitating consent from a representative. However, the forms were blank, and the medications were administered without documented consent. The MDS Nurse and DON both recognized the failure to obtain informed consent, which could result in the administration of psychotropic medications without the family's knowledge or agreement. The report also highlights deficiencies in the informed consent process for Residents 96 and 89. Resident 96, with diagnoses of anxiety disorder and major depressive disorder, had incomplete informed consent forms for sertraline and alprazolam, lacking documentation of who consented to the medication use. Resident 89, diagnosed with major depressive disorder and dementia, did not have a new informed consent obtained when the dosage of quetiapine was increased. The DON confirmed that the facility's policy was not followed, denying residents their rights to informed care and potentially leading to the use of unnecessary psychotropic drugs.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to promote resident rights by not making the most recent survey results easily accessible to residents, family members, and legal representatives. During an interview with seven resident council group attendees, it was revealed that they were unaware of where to find the survey results. They pointed to a black metal rack outside the Activity Director's office, but upon inspection, no survey binder was found there. The Activity Director later indicated that the binder was placed on a table outside the social services and admissions office, but it was not visible as it was placed underneath the tabletop without a sign. Additionally, the binder did not contain the most recent recertification survey results from 2024. The Administrator acknowledged that the State inspection results should be available for all residents and their representatives to understand what the facility is working on. The facility's policy and procedure on Resident Rights, last reviewed in September 2024, stated that a copy of the most recent standard survey should be maintained in a three-ring binder in an area frequented by most residents, such as the main lobby or resident activity room. However, the facility did not adhere to this policy, resulting in residents and their representatives not having access to examine the most recent survey results.
Failure to Follow Restraint Protocols for Residents
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, as evidenced by the cases of two residents. Resident 49 had a bed alarm applied without a restraint assessment, physician's order, informed consent, or a care plan. The bed alarm was used because Resident 49 was at high risk for falls, but the necessary procedures to justify its use as a restraint were not followed. This oversight placed Resident 49 at risk for restriction of movement, which could lead to a decline in physical function. Resident 267 was found with pillows tucked under the fitted sheet on both sides of the bed, which restricted the resident's movement. This was done as a safety measure due to the resident's history of falls and attempts to dangle legs over the bed. However, there was no restraint assessment, physician's order, informed consent, or care plan in place for this intervention. The use of pillows in this manner was acknowledged by staff as a form of restraint, yet the proper protocols were not followed, potentially leading to a decline in the resident's functioning. The facility's policy on the use of restraints requires a thorough assessment, physician's order, informed consent, and a care plan before implementing any restraint. These steps were not taken for either resident, indicating a failure to adhere to the facility's own policies and procedures. The Director of Nursing confirmed that the use of pillows as a restraint was not acceptable and that the necessary steps were not taken to ensure the safety and well-being of the residents involved.
Failure to Monitor Medication Side Effects and Effectiveness
Penalty
Summary
The facility failed to implement the care plans for two residents, leading to deficiencies in monitoring for adverse effects of medications. Resident 42, who was prescribed Eliquis and clopidogrel for atrial fibrillation, did not receive monitoring for signs and symptoms of bleeding and bruising, as outlined in their care plan. Additionally, Resident 42 was prescribed gabapentin for epilepsy, but there was no documentation of monitoring for drug toxicity, which was also required by the care plan. Resident 79, diagnosed with hyperlipidemia and prescribed atorvastatin, did not have a lipid panel conducted to monitor the effectiveness of the medication. The care plan for Resident 79 required monitoring of lipid levels to assess the risk of cardiac distress and the effectiveness of atorvastatin, but no such monitoring was documented. The Director of Nursing acknowledged the lack of documentation and monitoring for both residents, which was considered a standard of practice. The Consultant Pharmacist also failed to identify these deficiencies in their monthly drug regimen reviews. The facility's policies and procedures emphasized the importance of monitoring for adverse drug reactions and maintaining the highest level of resident functionality, which were not adhered to in these cases.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards by not rotating subcutaneous insulin administration sites for three residents, leading to a deficiency in care. Resident 17, who was readmitted with diagnoses including type 2 diabetes mellitus and dementia, had physician's orders for insulin administration that required site rotation. However, the Medication Administration Record (MAR) indicated that the insulin was repeatedly administered in the same area, contrary to the physician's orders and the manufacturer's guidelines. This oversight was acknowledged by RN 1 and the Director of Nursing (DON), who both confirmed the necessity of site rotation to prevent adverse effects such as pain and skin complications. Similarly, Resident 48, who had intact cognition and required assistance with activities of daily living, also received insulin injections without proper site rotation. The MAR showed repeated administration in the same abdominal areas, despite clear physician's orders to rotate sites. RN 1 and the DON reiterated the importance of following the guidelines to prevent skin issues and other complications associated with improper insulin administration. Resident 107, admitted with type 2 diabetes mellitus and other health conditions, also experienced the same deficiency. The Location of Administration Report revealed multiple instances where insulin was administered in the same site, contrary to the facility's policy and the manufacturer's guidelines. The DON confirmed that the licensed nurses should have rotated the injection sites to prevent potential adverse effects. This consistent failure to rotate injection sites for insulin administration across multiple residents highlights a significant lapse in adhering to professional standards of care.
Failure to Maintain a Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to multiple deficiencies. Resident 4, who was at high risk for falls due to dementia and other conditions, had floor mats intended to prevent injury from falls. However, observations revealed that a wheelchair and an overbed table were placed on top of these mats, compromising their effectiveness. Staff interviews confirmed that placing items on the mats was against policy and could lead to injury if the resident fell. Similarly, Resident 272, also at high risk for falls, had floor mats improperly placed with equipment on top of them, and a bed alarm was not installed as ordered. Observations and staff interviews highlighted that these practices could affect the integrity of the mats and increase the risk of injury during falls. The facility's policies emphasized the importance of keeping the environment free from obstacles and ensuring interventions were properly implemented, which was not adhered to in these cases. Additionally, Resident 70's room had environmental hazards, including a broken baseboard with protruding nails and a damaged windowsill, which were not addressed promptly. The Maintenance Director admitted to leaving the hazards unattended for a week, and the DON acknowledged the potential for injury. Furthermore, Resident 13 was left unattended in a high bed position during wound care, contrary to safety protocols, increasing the risk of falls. These deficiencies demonstrate a failure to maintain a safe environment and adhere to established safety policies.
Deficiencies in Oxygen Therapy Administration and Documentation
Penalty
Summary
The facility failed to ensure proper administration and documentation of oxygen therapy for residents requiring respiratory care. Resident 70, who was readmitted with diagnoses including metabolic encephalopathy, sepsis, and dementia, was observed receiving oxygen therapy via nasal cannula. However, there was a lack of documentation on the Medication Administration Record (MAR) for the administration of PRN oxygen, despite the resident's oxygen saturation levels being recorded. Interviews with nursing staff revealed inconsistencies in the documentation process, with some staff acknowledging the importance of documenting oxygen administration but failing to do so consistently. Similarly, Resident 74, diagnosed with Alzheimer's Disease and other conditions, was observed receiving oxygen therapy without proper documentation in the MAR. The resident had a physician's order for PRN oxygen, but the administration was not consistently recorded, and there was no evidence of monitoring for the effectiveness of the oxygen therapy. Staff interviews indicated a lack of adherence to the facility's policy on documenting PRN oxygen use, which could lead to unnecessary administration and failure to address underlying causes of respiratory distress. Additionally, the facility failed to maintain proper infection control practices for Resident 96, whose oxygen tubing was observed touching the floor. This practice poses a risk of respiratory infections due to potential contamination. The facility's policy requires immediate replacement of contaminated tubing, but this was not adhered to, as confirmed by staff interviews. These deficiencies in respiratory care and infection control practices have the potential to place residents at risk for respiratory distress and infections.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis (HD) received treatment consistent with professional standards of practice. The deficiency involved a lack of documented assessments by licensed nurses after the resident's HD sessions. This failure was identified for one resident who was dependent on HD due to end-stage renal disease and hypertension. The resident was admitted to the facility with these diagnoses and had a care plan in place to document the condition post-HD. The facility's policy required licensed nurses to perform and document post-HD assessments immediately upon the resident's return from the dialysis center. These assessments were crucial to detect any changes in the resident's condition, such as changes in consciousness, bleeding from the arteriovenous shunt, or changes in vital signs. However, the review of the resident's Dialysis Communication Record forms revealed multiple instances where these assessments were not documented, indicating they may not have been performed. Interviews with the Minimum Data Set Nurse and the Director of Nursing confirmed the importance of these assessments and the facility's policy requirements. Despite monthly in-services on completing the Dialysis Communication Record, the documentation was incomplete, suggesting non-compliance with the facility's policy. The lack of documentation for post-HD assessments placed the resident at risk for delayed care and detection of potential complications from HD.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to account for three doses of controlled medications for three residents, leading to a deficiency in pharmaceutical services. During an observation and interview, it was found that there was a discrepancy between the controlled drug record accountability log and the actual medication count in the medication cart. Specifically, one dose of Belbuca for Resident 5, one dose of hydrocodone with acetaminophen for Resident 97, and one dose of pregabalin for Resident 272 were missing from the medication cart or bubble pack compared to the accountability log. Licensed Vocational Nurse (LVN) 3 admitted to administering the medications to the residents but failed to document the administration on the accountability logs as per the facility's policy and procedures. This failure to document immediately after administration led to a lack of control and accountability for the controlled medications, increasing the risk of medication errors and potential harm to the residents. The Director of Nursing confirmed that LVN 3 did not follow the facility's policy of documenting the preparation and administration of controlled medications immediately. The residents involved had specific medical conditions requiring these medications. Resident 5 was prescribed Belbuca for chronic pain, Resident 97 was prescribed hydrocodone with acetaminophen for pain management related to pressure ulcers and disc degeneration, and Resident 272 was prescribed pregabalin for neuropathy. The failure to document the administration of these medications accurately could lead to medication errors and potential harm to the residents, as noted by LVN 3 and the Director of Nursing.
Failure to Monitor Medication Side Effects and Effectiveness
Penalty
Summary
The Consultant Pharmacist (CP) failed to report irregularities in the monthly drug regimen review for two residents, leading to deficiencies in monitoring for potential adverse effects of medications. Resident 42, who was prescribed Eliquis and clopidogrel for atrial fibrillation, was not monitored for signs and symptoms of bleeding and bruising, which are critical due to the blood-thinning nature of these medications. Additionally, Resident 42 was prescribed gabapentin for epilepsy but was not monitored for signs of drug toxicity, such as nausea, dizziness, or chest pain, as outlined in the resident's care plan. Resident 79, diagnosed with hyperlipidemia and prescribed atorvastatin, was not monitored for lipid levels through a lipid panel, which is essential to assess the effectiveness of the medication and adjust the treatment plan if necessary. The facility's policies and procedures require such monitoring to prevent adverse consequences and ensure the medications are providing the intended benefits without causing harm. The Director of Nursing (DON) acknowledged the lack of documentation and monitoring for both residents, which was supposed to be recorded in the Medication Administration Record (MAR). The CP admitted to failing to identify these monitoring deficiencies in the drug regimen reviews conducted over several months. The facility's policies emphasize the importance of monitoring for adverse drug reactions and maintaining the highest practicable level of functioning for residents, which was not adhered to in these cases.
Failure to Monitor Drug Regimens and Side Effects
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary drugs by not adequately monitoring for side effects and adverse consequences. Resident 42 was prescribed Eliquis and clopidogrel for atrial fibrillation and gabapentin for epilepsy. However, there was no documentation of monitoring for signs and symptoms of bleeding and bruising associated with the use of Eliquis and clopidogrel, nor was there monitoring for signs of drug toxicity related to gabapentin. This lack of monitoring was noted in the resident's Medication Administration Record (MAR) for March 2025, despite the care plan indicating the need for such monitoring. Resident 79, who was prescribed atorvastatin for hyperlipidemia, did not have a lipid panel ordered or conducted since admission to the facility. The care plan for Resident 79 indicated the need to monitor the effect of the medication and perform laboratory work, but the clinical chart lacked any lipid laboratory results. This oversight was confirmed during an interview with a Licensed Vocational Nurse and the Director of Nursing, who acknowledged the importance of monitoring lipid levels to ensure the effectiveness of atorvastatin. Resident 40, who was on apixaban for deep vein thrombosis prophylaxis, did not have an order for monitoring adverse effects of the medication. The care plan highlighted the risk of adverse effects from this high-risk drug class, yet there was no monitoring for potential bleeding. The Director of Nursing confirmed that staff should have obtained an order for monitoring adverse effects and emphasized the importance of such monitoring to prevent complications. The facility's policies and procedures also underscored the need for monitoring adverse drug reactions and ensuring residents maintain the highest practicable level of functioning.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for five residents were free from unnecessary psychotropic medications. Resident 95 was admitted with diagnoses including dementia, generalized anxiety disorder, and major depressive disorder. The resident was prescribed lorazepam PRN for restlessness or shortness of breath, but the order was not transcribed correctly, lacked an end date, and was administered beyond the 30-day limit without proper evaluation or documentation. This oversight placed the resident at risk of receiving unnecessary medication without a documented rationale for its continued use. Resident 79 was prescribed mirtazapine and divalproex for mood disorders, but there was no specific, measurable target behavior documented for their use. Despite the absence of depressive symptoms or poor appetite, there was no attempt for a Gradual Dose Reduction (GDR) or documented clinical rationale for continuing the medications. Similarly, Resident 89 was prescribed fluoxetine for depression without a specific behavior to monitor, leading to potential unnecessary use of the medication. The lack of specific behavior monitoring could result in inaccurate assessments of the medication's effectiveness. Resident 8 was administered sertraline and divalproex sodium without documented informed consent from the resident's representative. The orders lacked specific behaviors to monitor, which could lead to inaccurate monitoring and unnecessary medication administration. Resident 63 was prescribed alprazolam PRN for anxiety before dental procedures without a stop date, increasing the risk of unnecessary medication use. The facility's failure to adhere to its policies on psychotropic medication use and informed consent contributed to these deficiencies.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12.5% error rate during a survey. This deficiency affected two residents, who experienced medication administration errors. Resident 21 received carvedilol at a different time than prescribed, was given an incorrect form of multivitamin, and did not receive polyethylene glycol as ordered. Resident 77 also received carvedilol at a time different from the physician's order. The errors were observed during medication administration rounds. LVN 1 administered carvedilol to Resident 77 at 9:15 a.m., outside the prescribed time frame of 7:15 a.m. with breakfast. LVN 3 administered carvedilol and an incorrect multivitamin to Resident 21 at 9:27 a.m., instead of the scheduled 7:15 a.m. with breakfast, and failed to administer polyethylene glycol. Both LVNs cited being busy with other residents as the reason for the delays and errors. Interviews with the LVNs and the Director of Nursing confirmed these errors and acknowledged the potential for adverse effects due to the deviations from prescribed medication schedules. The facility's policies require medications to be administered within a 60-minute window of the prescribed time, which was not adhered to in these instances. The facility's policy also emphasizes the importance of following physician orders to prevent medication errors and adverse consequences.
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. Three residents, identified as Residents 107, 17, and 48, were affected by this deficiency. The primary issue was the failure to rotate subcutaneous insulin administration sites as per physician's orders, manufacturer's guidelines, and accepted professional standards. This oversight was identified during a review of the residents' medication administration records and confirmed through interviews with nursing staff and the Director of Nursing (DON). Resident 17, who was readmitted to the facility with diagnoses including type 2 diabetes mellitus and dementia, had physician's orders for insulin lispro that required site rotation. However, the medication administration records indicated that the insulin was repeatedly administered in the same area, contrary to the physician's orders and facility policy. Similarly, Resident 48, with diagnoses of type 2 diabetes mellitus and congestive heart failure, also had orders for insulin administration that were not followed correctly, as the injection sites were not rotated as required. Resident 107, admitted with type 2 diabetes mellitus and chronic kidney disease, also experienced the same issue with insulin administration. The records showed multiple instances where the insulin was administered in the same site without rotation. Interviews with the nursing staff and the DON confirmed that the failure to rotate injection sites was a medication error, as it did not comply with the physician's orders, manufacturer's guidelines, or professional standards. This deficiency had the potential to cause adverse effects such as bruising, lipodystrophy, and cutaneous amyloidosis.
Failure to Update Staffing Plan Leads to Medication Delays
Penalty
Summary
The facility failed to revise and provide a current staffing plan in the Facility's Assessment, which evaluates the resident population and determines the necessary resources to care for residents competently during both day-to-day operations and emergencies. This deficiency resulted in residents receiving medications later than scheduled, specifically affecting Residents 21 and 77, who received their carvedilol doses after the prescribed time. The delay in medication administration was acknowledged as a medication error by the Licensed Vocational Nurses (LVNs) involved. Interviews with LVNs revealed that the delay in administering medications was due to the high number of residents assigned to each nurse, which exceeded the facility's assessed staffing ratio of 1 LVN to 24 residents. LVNs reported being unable to administer medications within the required timeframe due to being occupied with other tasks such as handoffs, resident rounds, and medication cart checks. The facility's policy allowed a 60-minute window for medication administration, but the LVNs were unable to meet this requirement due to their workload. The facility's assessment, dated 12/1/2024, indicated a staffing need of 1 LVN per 24 residents during the day shift. However, the actual staffing ratios between 3/11/2025 and 3/13/2025 were significantly higher, with LVNs being assigned to 36 to 45 residents each. The Administrator acknowledged that a new assessment was needed when the facility's acuity changed, but no new assessment had been conducted since 12/1/2024. The failure to maintain the assessed staffing ratio contributed to the delay in medication administration and the resulting medication errors.
Inadequate Linen Cart Covers Compromise Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring that clean linens were adequately protected from environmental contaminants. During observations and interviews, it was found that all 17 clean linen carts were covered with a permeable, loosely woven material, which allowed air and water to pass through. This material was not suitable for preventing contamination from dust and liquids, as confirmed by the Infection Preventionist and the Housekeeping Supervisor. The Director of Nursing acknowledged that the linen cart covers had not been changed since the last recertification survey and recognized the importance of using non-porous covers to maintain linen cleanliness. The facility's current practice involved using bleach wipes for cleaning the linen carts, which were only recommended for hard, non-porous surfaces, according to the Safety Data Sheet. The Manufacturer's Guidelines for the linen cart covers also indicated that the material was not suitable for the facility's cleaning methods. The facility's policy on cleaning and disinfection required adherence to CDC and OSHA standards, which were not met due to the use of porous linen cart covers. This deficiency had the potential to spread infections and illnesses among residents and staff.
Failure to Honor DNR Order for a Resident
Penalty
Summary
The facility failed to honor the Do Not Resuscitate (DNR) order for Resident 115, which resulted in a violation of the resident's rights to dignity and respect. Resident 115, who had been diagnosed with metabolic encephalopathy, sepsis, and dementia, was found unresponsive with no vital signs. Despite having a DNR order in place, facility staff initiated cardiopulmonary resuscitation (CPR) and called emergency services, who continued resuscitation efforts until the resident was pronounced deceased. The deficiency occurred because the Preferred Intensity of Care (PIC) Authorization/Decisions form, which indicated the resident's DNR status, was not properly filed in the resident's current chart upon readmission. The MDS Nurse and Social Services Director acknowledged that the form was mistakenly filed in the resident's old chart, leading to the assumption that the resident was full code status. This oversight meant that the resident's wishes were not followed, and CPR was administered contrary to the DNR order. Interviews with facility staff, including the MDS Nurse, Social Services Director, and Director of Nursing, revealed a lack of adherence to the facility's policies and procedures regarding DNR orders. The staff admitted that the resident's preferred intensity of care should have been verified and documented in the current chart upon readmission. The facility's policies clearly state that DNR orders must be followed unless a signed request to end the order is provided, which was not the case for Resident 115.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure the call light was within reach for two residents, leading to a deficiency in accommodating resident needs and preferences. Resident 46, who was admitted with multiple diagnoses including dementia and a history of falls, was observed with the call light hanging on the wall, out of reach. The resident's care plan specifically indicated that the call light should be within easy reach to encourage its use for assistance. During an observation, the Infection Preventionist acknowledged the oversight and confirmed that the call light should have been placed within reach for dignity reasons and to allow the resident to call for help if needed. Similarly, Resident 107, who was alert and oriented, was found with the call light resting on the floor beside the bed. The Assistant Director of Staff Development and a Registered Nurse both confirmed that the call light should always be within reach to allow the resident to call for help when necessary. The Registered Nurse also noted that if the call light frequently falls, it should be clipped to the bed sheet to prevent it from becoming a trip hazard and to ensure it remains accessible. The Director of Nursing reviewed the facility's policies and procedures, which emphasized the importance of having the call light accessible to residents to ensure timely responses to their needs. The failure to adhere to these policies resulted in a deficiency, as the call lights were not within reach for the residents, potentially delaying care and services.
Failure to Assist with Advance Directives for Two Residents
Penalty
Summary
The facility failed to offer assistance with formulating an Advance Directive (AD) to two residents, Residents 79 and 97, upon their admission. Resident 79 was originally admitted on January 29, 2024, and readmitted on September 17, 2024, with diagnoses including dementia and hemiplegia following a stroke. The resident's records indicated severely impaired cognition and a need for substantial assistance with daily activities. Despite these conditions, the facility did not document any inquiry or assistance offered to the resident's representative regarding the presence or formulation of an AD. Similarly, Resident 97, admitted on June 26, 2024, with Alzheimer's Disease and other mental health conditions, also had severely impaired cognition and required maximal assistance with daily activities. The facility's records for Resident 97 also lacked documentation of any inquiry or assistance offered to the resident's representative about an AD. Interviews with the Social Services Director and a Registered Nurse confirmed that the necessary steps to inquire about or assist with ADs were not taken for either resident. The facility's policy on Advance Directives, last reviewed on September 27, 2024, mandates that the social services director or designee inquire about the existence of any written ADs upon admission. The policy also requires that information about ADs be prominently displayed in the medical record. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation and inquiry regarding ADs for both residents, potentially impacting their care in emergencies.
Deficiencies in Providing a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, leading to deficiencies in their living conditions. Resident 79, who has severe cognitive impairment and is at high risk for falls, was found to have a floor mat with tears covered by black tape and one tear that was not covered. Despite the presence of a physician's order for bilateral floor mats to prevent injury, the staff did not notify the maintenance department to replace the damaged mat, compromising the resident's safety and the homelike environment. Resident 70, who is dependent on staff for daily activities and has limited cognitive abilities, was found in a room with a broken baseboard and windowsill, exposing nails and broken concrete. The Maintenance Director had left the room in this condition for about a week, believing it was not unsafe. Additionally, red stenciled letters were observed on the wall, which were unrelated to the resident and contributed to an institutional rather than homelike setting. The Director of Nursing acknowledged that these conditions were hazardous and not in line with the facility's policy for a homelike environment. The facility's policy on providing a homelike environment emphasizes safety, cleanliness, and personalization, which were not upheld in these cases. The deficiencies observed in the residents' rooms had the potential to negatively impact their psychosocial well-being and comfort, as the facility failed to maintain a clean and orderly environment as required by their policy.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy and return form to a resident's representative when the resident was transferred to a general acute care hospital. This deficiency was identified during a review of the records for a resident who was admitted to the facility with diagnoses including metabolic encephalopathy, sepsis, and pneumonitis. The resident was transferred to the hospital due to coffee ground emesis, hypotension, and tachycardia, with a seven-day bed hold indicated in the order summary report. However, the facility did not provide the required written notification of the bed-hold policy to the resident or their representative at the time of transfer. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the notification was not provided. The facility's policy requires that residents and their representatives be informed in writing of the bed-hold policy both in advance of any transfer and at the time of transfer, or within 24 hours in the case of an emergency. The failure to provide this notification could result in the resident's responsible party being unaware of the bed-hold policy, potentially leading to the resident being transferred to another skilled nursing facility not of their preference.
Failure to Adhere to DNR Order for Resident
Penalty
Summary
The facility failed to adhere to a Do Not Resuscitate (DNR) order for a resident, identified as Resident 115, who was administered cardiopulmonary resuscitation (CPR) despite having a documented DNR order. The resident had been admitted with conditions including metabolic encephalopathy, sepsis, and dementia, and was not capable of making decisions regarding their care. The resident's representative had authorized no CPR, consistent with the resident's wishes, as documented in the Preferred Intensity of Care (PIC) Authorization/Decisions form. The deficiency occurred when Resident 115 was found unresponsive with no vital signs, and CPR was initiated by facility staff. The PIC Authorization/Decisions form, which indicated the resident's DNR status, was not filed in the current chart upon the resident's readmission, leading staff to consider the resident as full code status. The Social Services Director acknowledged the oversight in not verifying the resident's previous PIC Authorization/Decisions form, which resulted in the administration of CPR contrary to the resident's documented wishes. Interviews with facility staff, including the MDS Nurse and the Director of Nursing, revealed that the facility's policy and procedure for handling DNR orders were not followed. The facility's policy required that DNR orders be respected unless a signed request to end the DNR order was provided by the resident or their legal surrogate. The failure to properly document and communicate the resident's DNR status led to the violation of the resident's rights and preferred treatment wishes.
Failure to Conduct Change of Condition Assessment
Penalty
Summary
The facility failed to ensure a comprehensive assessment for a resident who experienced a significant change of status. The resident, who had been admitted with diagnoses including metabolic encephalopathy, acute and chronic respiratory failure, and the presence of vascular implants and grafts, was discharged to a General Acute Care Hospital due to abnormal laboratory results indicating elevated white blood cells and blood urea nitrogen levels. Despite these significant changes, no change of condition assessment was performed on the day of the transfer, as confirmed by the review of records and interviews with facility staff. The lack of a change of condition report was acknowledged by both a Registered Nurse and the Director of Nursing during interviews. The facility's policy requires that such assessments be conducted to document and communicate the resident's condition and the interventions provided prior to transfer. This omission in documentation and communication had the potential to negatively affect the provision of necessary care and services to the resident.
Failure in Catheter Care Leading to UTI Risk
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, leading to a potential risk of urinary tract infections (UTIs) for two residents. Resident 272, who was admitted with obstructive and reflux uropathy, had a suprapubic catheter that was observed with a loop in the tubing, preventing proper urine drainage. Despite having a care plan that required maintaining proper alignment of the catheter to promote drainage, the tubing was found coiled with urine inside, which could lead to backflow and infection. Interviews with staff confirmed that the catheter should be positioned to allow free urine flow, and the facility's policy emphasized keeping the catheter and tubing free of kinks. Similarly, Resident 371, admitted with benign prostatic hyperplasia and obstructive uropathy, also had issues with catheter care. The resident's foley catheter tubing was observed coiled, not promoting proper drainage, contrary to the care plan's intervention to maintain proper alignment. Staff interviews reiterated the importance of preventing loops in the tubing to avoid urine backflow and potential UTIs. The facility's policy on catheter care, reviewed in 2024, highlighted the need to check the catheter frequently to ensure it is not kinked and is draining properly. The observations and interviews indicate a failure in adhering to the facility's catheter care policy, which aims to prevent catheter-associated complications, including UTIs. Both residents had catheter tubing that was not properly aligned, posing a risk of urine backflow and infection. The staff acknowledged the importance of maintaining catheter tubing without loops or kinks, yet the deficiency persisted, highlighting a lapse in the implementation of care protocols.
Failure to Administer Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to provide nutritional support as ordered for a resident, identified as Resident 42, who was at risk of weight loss. The resident, who had been readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, chronic pain syndrome, and Parkinson's disease, had a physician's order for Ensure, a nutritional supplement, to be given twice daily. However, during an observation and interview, it was noted that the Ensure was not present in the resident's room, and the resident reported a significant weight loss from 195 pounds to 144 pounds since admission. The resident stated that the Ensure was usually brought to him after breakfast but before lunch, yet it was not provided on the day of the observation. Licensed Vocational Nurse (LVN) 1 confirmed that the Ensure had not been given to the resident as scheduled and acknowledged the oversight. The Director of Nursing (DON) stated that the Ensure required a doctor's order and should be administered as prescribed. The facility's policy and procedure for physician orders and snack service emphasized the importance of following specific orders and documenting the provision of snacks, including nutritional supplements like Ensure. The failure to provide the Ensure as ordered had the potential to contribute to further weight loss for the resident.
Deficient IV Fluid Administration Practices
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids consistent with professional standards of practice for two residents. For Resident 269, the facility did not change a loose and soiled dressing on a peripherally inserted central line catheter (PICC line) in a timely manner. The resident, who was admitted with conditions including osteomyelitis and anxiety disorder, had a care plan indicating that dressings should be changed every seven days or as needed if they became wet, loose, or soiled. Despite this, the dressing was observed to be loose and soiled after the resident had a shower, and it was not changed promptly, which was confirmed by both a registered nurse (RN) and the Director of Nursing (DON). For Resident 15, the facility failed to place a sterile injection cap over the injection port of a peripheral intravenous line (PIV). The resident, who had been readmitted with pneumonia, Alzheimer's Disease, and major depressive disorder, had a physician's order to flush the PIV with normal saline and to change the dressing as needed. During an observation, it was noted that the needleless injection port did not have a sterile injection cap, which was acknowledged by an RN and the DON. The lack of a sterile injection cap after use was against the manufacturer's guidelines, which state that a new cap should be placed on the needleless connector after each use. These deficiencies were observed during a random inspection and were confirmed through interviews with facility staff and a review of the facility's policies and procedures. The facility's failure to adhere to established protocols for IV care placed both residents at risk for complications such as infection, as noted in the report.
Failure to Conduct Quarterly Bed Rail Safety Assessment
Penalty
Summary
The facility failed to conduct a quarterly assessment for the risk of entrapment from bed rails for Resident 88, who was admitted with diagnoses including dementia, age-related physical debility, and a history of falling. The resident was on fall precaution and did not have the capacity to make medical decisions. Despite the resident's impaired cognition and high risk for falls, the last Side Rail Safety/Entrapment Assessment was conducted over a year ago, on 2/21/2023. The facility's policy required quarterly assessments to ensure the appropriateness and safe use of bed rails, which were being used as a restraint for Resident 88. The resident's care plan indicated the need for quarterly assessments by the interdisciplinary team to evaluate the appropriateness of the restraint. However, this was not adhered to, as confirmed by RN 1 during an observation and interview, who acknowledged the lapse in conducting the necessary assessments. The Director of Nursing confirmed that the facility's protocol required a physician's order, a safety/entrapment assessment, informed consent, and a care plan before using side rails as a restraint. The facility's policy on bed safety and bed rails outlined the need for comprehensive assessments, including factors such as medical diagnosis, cognition, and mobility, to determine the risk of entrapment. The failure to perform these assessments predisposed Resident 88 to potential risks associated with bed rail use.
Failure to Properly Label Intravenous Medication
Penalty
Summary
The facility failed to ensure that intravenous meropenem, a medication used to treat bacterial infections, was labeled with the resident's name, which is a requirement for safe medication administration. This deficiency was identified during the review of a resident who had been admitted and readmitted to the facility with diagnoses including malignant neoplasm of the prostate and a urinary tract infection. The resident was observed receiving meropenem intravenously, and the medication bag was labeled with the medication name, dose, and nurse's initials, but not the resident's name. The Registered Nurse (RN) acknowledged the oversight, stating that the pharmacy had not delivered the medication, so it was taken from the emergency medication kit and should have been labeled with the resident's name. The Director of Nursing (DON) confirmed that the facility's policy and procedures for medication labeling were not followed, which require the resident's name to be included on the label to ensure the correct administration of medication. The facility's policies emphasize the importance of labeling to prevent medication errors, but in this instance, the policy was not adhered to, leading to the potential for medication administration errors.
Failure to Follow Up on Abnormal Lab Results
Penalty
Summary
The facility failed to follow up with the endocrinologist regarding a resident's hemoglobin A1C test result, which was reported to the facility. The resident, who was admitted with diagnoses including diabetes mellitus with diabetic neuropathy, congestive heart failure, and chronic kidney disease, had an HbA1c test result of nine percent, indicating poor blood sugar control. Despite the test result being documented and the attending physician being notified, there was no follow-up with the endocrinologist to determine if medication adjustments were necessary for the resident's diabetes management. The facility's policy and procedures require that the attending physician be promptly notified of diagnostic test results, and the director of nursing services or charge nurse is responsible for this notification. However, the MDS Nurse noted that there was no documentation of follow-up with the endocrinologist the day after the test result was received. This lack of follow-up placed the resident at risk for complications associated with uncontrolled blood sugar levels.
Failure to Label Cranberry Juice in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices by not labeling a pitcher of cranberry juice with the date it was poured. During a kitchen observation tour, a surveyor, along with the Dietary Manager (DM), found the pitcher stored in the kitchen refrigerator without a date label. The DM acknowledged that the staff should have dated the pitcher to ensure the juice was fresh and not past its best use-by date, which could prevent food-borne illnesses. The Director of Nursing (DON) also confirmed that the dietary staff should have labeled the pitcher to track the age of the juice, as consuming old juice could lead to stomach problems such as nausea, vomiting, and diarrhea for residents. A review of the facility's policy and procedure titled 'Food Receiving and Storage' indicated that all foods stored in the refrigerator or freezer should be covered, labeled, and dated with a use-by date. This policy was not followed, leading to the deficiency observed by the surveyors.
Inaccurate Elopement Risk Assessment Documentation
Penalty
Summary
The facility failed to maintain medical records within accepted professional standards for a resident reviewed for accidents by inaccurately completing the elopement risk assessment. The resident, who was originally admitted in 2021 and readmitted in 2024, had diagnoses including cerebral infarction and dementia, which impaired their cognitive abilities and required substantial assistance with daily activities. Despite the resident's condition indicating a risk for elopement, the elopement risk assessments conducted in October 2024 and January 2025 inaccurately documented the resident as not being at risk, despite a calculated score indicating otherwise. During interviews, MDS Nurses acknowledged the documentation error, noting that the electronic health record system automatically calculated the risk score based on the resident's condition. The facility's policy required documentation to be objective, complete, and accurate, which was not adhered to in this case. The inaccurate documentation had the potential to lead to confusion regarding the resident's current status, as the summary of the review did not reflect the resident's true risk for elopement.
Failure to Ensure Fair Arbitration Process
Penalty
Summary
The facility failed to ensure the fairness and integrity of the binding arbitration process for a resident, identified as Resident 3, who was admitted on 3/24/2007 and readmitted on 9/4/2024. The resident had diagnoses including metabolic encephalopathy, acute on chronic respiratory failure, and COPD. Despite having expressive aphasia and moderately impaired cognition, the resident was assessed to have the capacity to understand and make decisions. The arbitration agreement signed by the resident's representative on 11/14/2023 did not provide for the selection of a neutral arbitrator agreed upon by both parties or a venue convenient to both parties. During interviews and record reviews, it was revealed that the Admission's Coordinator and the Administrator acknowledged the importance of the arbitration agreement, which involves giving up the constitutional right to a jury or court trial. The facility had updated its arbitration agreement in 2019 to include provisions for a neutral arbitrator and a convenient venue, but Resident 3's agreement, signed in 2023, used an outdated version from 2007 that lacked these provisions. The Admission's Coordinator, who was not employed at the facility in 2023, could not explain why the outdated version was used. The Administrator confirmed that the facility's process was not followed, as the arbitration agreement signed by Resident 3's representative did not include the necessary elements of a neutral arbitrator and a convenient venue. The facility did not have a specific policy regarding arbitration agreements but relied on the revised 2019 agreement and an information form to guide the process. The failure to use the updated agreement potentially placed the resident in a less favorable position during arbitration.
Failure to Ensure Proper Hospice Documentation and Communication
Penalty
Summary
The facility failed to ensure consistent and necessary care for a resident receiving hospice services. Specifically, the hospice doctor did not sign the initial Certification of Terminal Illness (CTI) for the resident, which is required to certify that the patient is terminally ill with a prognosis of six months or less. Additionally, the hospice provider did not provide the updated hospice plan of care to the facility upon completion of the resident's CTI recertification. This lack of documentation and communication had the potential to negatively impact the resident's physical comfort and psychosocial well-being. The resident, who was admitted to the facility with diagnoses including dementia, generalized anxiety disorder, and major depressive disorder, was under the care of a hospice provider. The facility's policy requires that the hospice provider manage the resident's care related to the terminal illness, including providing an appropriate hospice plan of care. However, the absence of the hospice doctor's signature on the CTI and the failure to provide the updated plan of care created a communication barrier between the hospice and the facility, potentially resulting in a delay or lack of necessary care and services for the resident.
Failure to Timely Complete MDS Assessment
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) Assessment for a resident in a timely manner, as required by regulations. Specifically, the MDS Quarterly Assessment for a resident admitted on 9/20/2024 with diagnoses including type II diabetes mellitus, major depressive disorder, and hypertension, was not completed within the required timeframe. The assessment, which should have been completed by 1/10/2025, was instead completed on 1/13/2025, as indicated by the registered nurse assessment coordinator's signature. This delay was confirmed during a review of the Final Validation Report, which showed the assessment was completed more than 14 days after the assessment reference date of 12/27/2024. Interviews with the MDS Nurse and the Director of Nursing revealed that the delay in completing the MDS Assessment could lead to a delay in reporting the resident's health status and quality measures. The facility's policy and procedure, as well as the CMS Long-Term Care Facility Resident Assessment Instrument Manual, require that MDS assessments be completed and submitted within specific timeframes to ensure accurate and timely reporting of residents' health status. The failure to adhere to these timeframes constitutes a deficiency in the facility's compliance with regulatory requirements.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential impacts on their care plans and services. For one resident, the MDS Entry assessment was incorrectly coded with the wrong admission date, despite the resident being admitted for rehabilitation and skilled nursing services under Medicare A. The MDS Nurse acknowledged the error during a review and interview, noting that the incorrect entry could affect billing and the resident's health status documentation. The Director of Nursing emphasized the importance of accurate MDS assessments to prevent duplication and ensure the correct resident information is recorded. For another resident, the MDS assessment was not accurately coded to reflect the resident's discharge status. The resident left the facility against medical advice, but the MDS assessment did not indicate the discharge date or the discharge return not anticipated status. This oversight was identified during a review with the MDS Nurse, who admitted the error could cause confusion regarding the resident's status and potentially delay necessary care and services. The facility's policy requires all individuals completing portions of the MDS to certify the accuracy of their entries, which was not adhered to in these cases.
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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