Shoreline Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 4029 East Anaheim Street, Long Beach, California 90804
- CMS Provider Number
- 055353
- Inspections on file
- 26
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Shoreline Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that a bed was positioned so that it partially blocked a door marked as an emergency exit in a room shared by four residents, all with impaired cognition and needing assistance with ADLs. One resident with a right patella fracture reported that during heavy rain, water entered from under this exit door, flooding the floor and soaking her clothing, which she then hung to dry. The facility’s Disaster and Evacuation Plan identified this door as an exit to a back patio, and the Fire and Disaster policy required exits to remain clear at all times. The Maintenance Supervisor confirmed the door was unlocked, operable via a push bar, and that flooding occurred from rainwater entering under the door, with no modifications made to prevent recurrence. The DON and Administrator stated that, although the door was marked as an exit on the floor map, it was not included in the emergency exit plan and staff were not trained to use it during emergencies.
A resident with a right patella fracture and moderately impaired cognition, requiring supervision or touch assistance for ADLs, was placed in a bed positioned so that the head of the bed partially blocked an emergency exit door. During heavy rain, water entered under this exit door, flooding the floor near the bed and soaking the resident’s clothing, which had been kept on the floor and was later observed hanging to dry on a chair. The exit door was found unlocked and operable via a push bar to a back patio, and the Maintenance Supervisor reported that while housekeeping had mopped and used towels after the incident, no changes were made to the door to prevent future flooding. The DON acknowledged that having an exit door by the bed could affect resident safety, and the ADM stated the belongings would not have been wet if the bed had not been placed by the exit door.
A resident with a history of pressure ulcer, neuromuscular bladder dysfunction, and moderate cognitive impairment did not receive documented toileting hygiene after a bowel movement. Staff interviews and record reviews revealed unclear and inconsistent documentation practices, with no specific record of hygiene care being provided after the resident's last bowel movement, despite the resident's total dependence on staff for such care.
A resident admitted with a left heel blister and right heel SDTI did not receive timely or adequate wound assessments, consistent offloading interventions, or prompt referrals to a wound care practitioner. The care plan was not updated when the wound status changed, and the physician was not notified of significant changes, including infection and wound deterioration. As a result, both heel wounds progressed to unstageable pressure injuries, causing pain and requiring hospital transfer for advanced treatment.
Three residents with ROM and mobility concerns did not receive required therapy evaluations, interventions, or restorative nursing services as ordered, including sit-to-stand transfers, AAROM, PROM, and splinting. One resident lost the ability to stand, and others were at risk for further ROM decline due to the facility's failure to follow physician orders, accurately assess joint mobility, and implement care plan reviews.
A resident with a history of physical and emotional abuse was not protected from further mental abuse when a family member, against whom there was an open APS case, was able to enter the facility twice, including once during personal care, causing the resident significant emotional distress and requiring medication for anxiety. The facility did not follow its abuse prevention policy, failed to offer a room change, and did not thoroughly investigate or report the incident as required.
A resident with significant physical and cognitive impairments was left with his genital area exposed during personal care, while the privacy curtain between him and his awake roommate remained open. Two CNAs acknowledged that they should have covered the resident and closed the curtain to maintain privacy, in accordance with facility policy and expectations stated by the DON.
Two residents did not have required Interdisciplinary Team (IDT) meetings to discuss their care plans and discharge goals. One resident's IDT meeting was not documented in the medical record, while the other did not have an IDT meeting at all, despite facility policy requiring these meetings within 72 hours of admission. Both the Social Service Director and DON confirmed the deficiency.
Two residents did not have required Interdisciplinary Team (IDT) meetings to discuss their person-centered care plans and discharge goals. One resident's IDT meeting was not documented in the medical record, while another did not have an IDT meeting at all, despite facility policy requiring these meetings within 72 hours of admission. Both residents had significant medical needs and required assistance with daily activities.
A resident with moderate cognitive impairment and significant medical conditions was admitted without the facility obtaining a copy of their Advance Directive, despite documentation indicating one existed and facility policy requiring it. Staff interviews confirmed the omission, resulting in a deficiency related to resident rights and documentation.
Two residents experienced significant changes in skin integrity, including the development and worsening of pressure injuries, but the facility failed to promptly notify the physician and responsible family members as required. One resident's left heel wound deteriorated to an unstageable pressure injury with pain and odor before the physician was informed, while another resident's right buttock wound progressed to a stage four pressure injury without timely family notification. Facility staff did not follow established protocols for communication and documentation of changes in condition.
Three residents did not receive timely, individualized care planning: one with a heel wound did not have updated interventions after the wound worsened; another was not weighed for months due to unaddressed equipment-related pain, resulting in unmonitored significant weight loss; and a third developed a severe pressure injury without timely care plan updates or risk reassessment. Staff interviews confirmed delays and omissions in care plan development and implementation.
Two residents did not receive required care as ordered: one was not seen by neurology despite physician orders, and another did not have decision-making capacity determined or documented, even though assessments indicated severe cognitive impairment. Facility staff interviews and record reviews confirmed missed appointments and lack of follow-up, with policies requiring these actions not being followed.
Nursing staff failed to demonstrate competency in wound care and documentation for two residents with pressure injuries. One resident's left heel wound progressed from a suspected deep tissue injury to an unstageable pressure injury without proper assessment, documentation, or physician notification. Another resident developed a right buttock pressure injury that advanced to stage four without timely clinical oversight or escalation to the DON. These deficiencies resulted in a lack of accurate wound documentation and delayed care.
Two residents did not receive required psychosocial and trauma assessments upon admission, despite having significant medical and trauma histories. Staff interviews revealed that assessments were either not completed or delayed, and facility policy requiring timely social services and behavioral health evaluations was not followed.
The facility did not keep required records for emergency drug usage from the Cubex system, failed to obtain proper witness signatures for non-controlled drug destruction, and did not ensure nurses verified medications against orders upon receipt, resulting in two residents receiving incorrect medications. Additionally, a nurse crushed medications for a resident without a physician order, and the facility lacked a policy on medication administration guidance.
Surveyors observed that the facility's medication error rate exceeded 5%, with three errors out of 31 opportunities. In two cases, residents received incorrect medications or dosages, including administration of the wrong strength of benazepril, giving vitamin C instead of calcium, and providing morphine IR instead of the prescribed ER formulation. These errors were confirmed through direct observation, interviews with nursing staff, and review of physician orders and medication packaging.
Two residents experienced significant medication errors when one was given immediate release morphine instead of the prescribed extended release formulation, leading to inadequate pain control and increased use of Norco, while another received double the ordered dose of benazepril due to a pharmacy dispensing error and failure to verify the correct dose during administration.
Staff did not follow standardized recipes and portion sizes for residents on ground, mechanical soft, and pureed diets during a lunch meal. A cook used the wrong scoop, resulting in under-portioning BBQ chicken for residents on ground diets, and served mechanical soft chicken in inconsistent, unground pieces. For pureed diets, chicken was not blended with BBQ sauce as required. Dietary supervisors, RDs, and a speech therapist confirmed that menus and recipes were not followed, leading to improper food texture and portioning.
Staff failed to consistently use required PPE for a resident on contact isolation for C. diff and did not ensure a family member wore PPE, while another resident with an indwelling catheter under EBP had their catheter bag on the floor and was handled without PPE. Additionally, an outbreak of C. diff was not reported to public health authorities as required by facility policy.
The facility did not consistently monitor or document the immunization status for influenza and pneumococcal vaccines for two residents, resulting in incomplete medical records. For both residents, there were discrepancies and lack of verification regarding whether the vaccines were received or refused, and the required documentation was not maintained as per facility policy.
The facility did not maintain documentation of COVID-19 vaccination status for all required staff, including on-call, part-time employees, and licensed professionals entering the facility. Interviews with the IPN and DON confirmed gaps in tracking and documentation, despite facility policy requiring comprehensive vaccination records for all staff categories.
A resident with severe cognitive impairment and a history of multiple falls was not identified as a fall risk due to the absence of a falling star sticker on their door, as required by facility policy. Staff were unaware of the resident's fall risk status, resulting in inadequate supervision and failure to implement necessary fall prevention measures.
A resident with respiratory failure and COPD, requiring continuous oxygen, was found to have a nasal cannula in use beyond the facility's seven-day replacement policy. Staff and nursing leadership confirmed the equipment had not been changed as ordered, resulting in a failure to follow infection control procedures.
A resident with multiple chronic conditions and severe cognitive impairment did not receive a required face-to-face physician visit within the mandated 60-day interval. Review of records and staff interviews confirmed the absence of physician documentation and visits, contrary to facility policy.
A resident with a documented strawberry allergy and dislike was served strawberry flavored gelatin, despite this information being clearly listed on their meal ticket and care records. Dietary staff and the supervisor were aware of the allergy, but the resident still received the inappropriate dessert and did not consume it.
A resident with mobility and ROM concerns did not have accurate medical record documentation for restorative nursing services, as staff were found to have initialed records for dates they did not work and for services they did not provide. Facility records and payroll data confirmed these discrepancies, and interviews revealed that staff sometimes signed for each other, resulting in incomplete and inaccurate documentation of care.
The QAA committee did not provide effective oversight or timely implementation of the QAPI plan, as evidenced by delayed action on skin and pressure injury issues. Although a pressure injury was identified in a resident, the administrator did not consider it widespread and did not initiate a QAPI project until later, contrary to facility policy requiring proactive and data-driven quality improvement.
A resident with a history of physical and emotional abuse was subjected to repeated, unwanted visits by a family member who was the subject of an open APS case. Despite staff and police intervention during incidents where the family member was verbally and emotionally abusive, the facility's abuse coordinator did not report the incidents to the state agency or conduct a thorough investigation, as required by policy. The resident experienced significant distress and required anti-anxiety medication following the events.
A resident with a history of physical and emotional abuse was subjected to two unauthorized visits by a family member, during which the individual forced entry into the resident's room, shouted at the resident, and caused significant emotional distress. Despite staff awareness of the resident's wishes and visible signs of trauma, the facility did not conduct a thorough investigation or report the incident as required by its abuse prevention policy.
Two multi-bed rooms and two single-bed rooms were found to be below the required minimum square footage per resident, as confirmed by facility records and direct measurement. The MS was unaware of the regulatory requirements, and the DON stated that inadequate space could impact residents' ability to store belongings and receive care.
An LVN failed to administer 9 a.m. medications on time for five residents, as observed during a survey. The residents had various medical conditions requiring timely medication, such as hypertension and depression. The facility's policy mandates that medications be administered as prescribed and documented on the MAR. The DON acknowledged the potential risks of missing routine medications.
A facility failed to label a multi-dose vial of Humulin N insulin with an open date, risking the administration of potentially expired medication. An LVN found the vial in a medication cart without the necessary labeling, and the DON confirmed the requirement for labeling to ensure medication safety.
An LVN failed to follow infection control protocols by leaving a resident's room with used gloves and not performing hand hygiene after a blood sugar check. This was observed by a surveyor and the DON, and the LVN admitted the oversight. The facility's infection control policy emphasizes hand hygiene to prevent infection spread.
The facility failed to implement and revise comprehensive care plans for three residents, leading to discomfort during care activities, lack of emergency preparedness for a dialysis patient, and inadequate monitoring of medication side effects.
The facility staff failed to properly store lentils and black beans and improperly placed thawing meat in the refrigerator, risking cross-contamination. Observations revealed open bags of lentils and black beans closed with plastic ties, and thawing chicken and fish placed inappropriately in the refrigerator. Interviews with staff confirmed these practices were against facility policies.
The facility failed to ensure proper infection control practices for two residents. One resident's oxygen tubing was found on the floor, and another resident's foley catheter was unsecured and touching the floor. Staff confirmed that these practices could lead to infection, and the facility's policies were not followed.
The facility failed to implement its antibiotic stewardship program policy for three residents by not completing the McGeer's Criteria to determine appropriate antibiotic use. The Infection Prevention Nurse did not complete the necessary surveillance forms on time, and the Director of Nursing emphasized the importance of the program in combating antibiotic-resistant bacteria.
The facility failed to ensure the call lights of two residents were fixed in a timely manner, resulting in delays in care. Both residents required substantial assistance with ADLs and reported nonfunctional call lights, which were confirmed through observations. Staff acknowledged the issue but did not address it promptly, posing safety risks to the residents.
The facility failed to monitor and assess two residents' conditions as per care plans and physician orders. One resident experienced a delay in wound care, leading to discomfort and infection risk, while another was not monitored for Aspirin side effects, risking delayed treatment.
The facility failed to follow the physician's order for the RNA program, providing RNA four times a week instead of the prescribed five times a week for a resident with a history of falling and difficulty walking. Interviews revealed a lack of documentation for RNA refusals, and the facility's policy emphasized the importance of maintaining residents' range of motion and mobility.
The facility failed to act on a pharmacist's recommendation to clarify an Ibuprofen order for a resident, potentially leading to side effects from taking the medication on an empty stomach. The resident had diagnoses of orthostatic hypotension and syncope and required partial assistance with daily activities. The facility's policy requires such recommendations to be communicated to the physician within seven working days, but this was not done.
The facility staff failed to maintain accurate documentation of the RNA weekly progress report for a resident. The report was found to be incomplete, and both the DON and DSD confirmed that the medical record should be complete and accurate. The facility's policy also indicated that appropriate documentation should be completed to address goals.
Blocked Exit Door and Water Intrusion Create Unsafe Egress Route
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and unobstructed exit and to prevent water intrusion that created an unsafe exit route in a shared resident room. Surveyors observed that one resident’s bed was positioned so that the head of the bed partially blocked a door marked with signage as an emergency exit, stating “Exit WARNING!! ALARM WILL SOUND EMERGENCY EXIT ONLY!” This door was identified in the facility’s Disaster and Evacuation Plan as an exit leading to a back patio. The facility’s Fire and Disaster Policy/Procedure required that exit ways be kept clear at all times and that exit doors never be blocked, but this requirement was not followed in the room occupied by four residents. Resident 1, who had a displaced transverse fracture of the right patella, moderately impaired cognition, and required supervision or touch assistance with ADLs, had been assigned to the current bed for several days. During observation, her bed was found positioned halfway blocking the exit door. Resident 1 reported that on a recent day of heavy rain, water flooded the floor near her bed, and her clothing became wet. She believed the water came in from under the exit door and stated that she hung her wet clothes on a chair to dry because she was concerned they could develop mildew and odors. Residents 3, 6, and 7 also occupied the same room and all had severely impaired cognition and required substantial to total assistance with ADLs. The Maintenance Supervisor confirmed that the exit door was unlocked, operable via the push bar, and led to a back patio, and acknowledged that Resident 1’s bed was partially blocking the exit and would need to be moved for full access in an emergency. He stated that flooding had been reported to him after it occurred, that housekeeping had already mopped and placed towels, and that the flooding was caused by heavy rain entering under the exit door, wetting some of Resident 1’s clothing that was kept on the floor. He also stated that no changes were made to the door to prevent future flooding. The DON and Administrator both stated that, despite the door being marked as an exit on the floor map, it was not considered part of the emergency exit plan and staff were not trained to use it during emergencies, while also acknowledging that having an exit door by the bed could impact resident safety.
Resident Bed Placement by Flood-Prone Exit Door Compromises Living Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when a resident’s bed was positioned so that the head of the bed partially blocked an exit door that was marked as an emergency exit. The resident, who had been admitted with a displaced transverse fracture of the right patella and had moderately impaired cognition, required supervision or touch assistance for ADLs. During observation, the resident was seen hanging a pair of pants and two shirts over a towel on a chair next to the bed. The resident reported that she had been in that bed for about six to seven days and that on the previous day water had flooded the floor near her bed during rain, causing her clothing to become wet, which led her to hang the clothes on the chair to dry. The Maintenance Supervisor stated that the flooding incident was reported to him after it had already occurred and that when he arrived, housekeeping had already mopped and towels had been placed to absorb remaining water. He attributed the flooding to heavy rainwater entering under the exit door and acknowledged that some of the resident’s clothing became wet because she kept belongings on the floor. The exit door in the resident’s room was observed to be unlocked and operable via a push bar leading to a back patio area. The Maintenance Supervisor confirmed that no changes were made to the door to prevent future water intrusion. The DON stated that the flooding near the resident’s bed was reported to her later and acknowledged that having an exit door by the bed could impact the resident’s safety. The Administrator stated that the resident’s belongings would not have been wet if the bed had not been positioned by the exit door.
Failure to Provide Toileting Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide toileting hygiene care after a bowel movement for a resident who was dependent on staff for all activities of daily living, including toileting hygiene. The resident had a history of acute respiratory failure, a Stage 3 pressure ulcer on the right buttock, and neuromuscular dysfunction of the bladder, and was assessed as having moderate cognitive impairment and requiring maximal to total assistance for personal care. Emergency personnel reported that the resident was found with soiled incontinence briefs and had not been changed or showered in some time when transported from the facility. Interviews with staff and review of documentation revealed inconsistencies and lack of clarity in how toileting hygiene was recorded. The CNA task flowsheet did not have a specific section to document whether toileting hygiene was provided after a bowel movement, and staff relied on assumptions that care was given if a bowel movement was recorded. Documentation showed a gap between the last recorded bowel movement and the last documented toileting hygiene, with no clear evidence that hygiene care was provided after the resident's last bowel movement. The facility's policy required assistance with activities of daily living for residents unable to perform them, but this was not consistently documented or verified in practice.
Failure to Prevent and Manage Pressure Ulcers Resulting in Wound Deterioration
Penalty
Summary
A resident with a history of left femur fracture, joint replacement surgery, and type 2 diabetes was admitted to the facility with existing wounds, including a left heel blister and a right heel suspected deep tissue injury (SDTI). Upon admission, the facility failed to document comprehensive wound assessments, including descriptions and measurements of the wounds. The initial skin integrity check did not provide adequate baseline information, and subsequent weekly wound assessments were not documented as required by facility policy. The left heel blister was reclassified as an SDTI three days after admission, but this change was not communicated to the physician, and the care plan was not updated in a timely manner to reflect the new wound status or necessary interventions. The facility did not implement or consistently provide essential interventions to prevent the progression of the resident's wounds. The resident did not consistently receive offloading measures such as heel protector boots or a low air loss mattress, and nutritional supplements to promote wound healing were not initiated until much later. The interdisciplinary team, including the DON, treatment nurse, and registered dietician, did not meet to discuss or coordinate care for the resident's wounds. The resident was not referred to a wound care practitioner despite the presence of worsening wounds, and the physician was not notified when the left heel blister was reclassified as an SDTI or when the wound developed signs of infection, including foul odor, eschar, and slough. As a result of these failures, the resident's left heel blister and right heel SDTI progressed to unstageable pressure injuries, causing significant pain and requiring transfer to an acute care hospital for further management. The resident received intravenous antibiotics, pain management, and hydration in the emergency department. Interviews with staff and family members confirmed lapses in wound care, documentation, communication, and timely intervention, all of which contributed to the decline in the resident's condition.
Failure to Maintain or Improve Range of Motion and Mobility
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) and mobility for three residents with identified ROM and mobility concerns. For one resident with a history of muscle weakness, diabetes, peripheral vascular disease, and difficulty walking, the facility did not provide a physical therapy screening or evaluation after a decline in the ability to perform sit-to-stand transfers was identified. The resident's restorative nursing aide (RNA) program for sit-to-stand transfers was discontinued without a therapy evaluation, and no interventions were implemented to address the decline, despite facility policy requiring such actions. The resident did not receive a right-hand splint to prevent further ROM decline, even though significant limitations and contractures were observed and confirmed by occupational therapy. Additionally, the facility did not provide active assistive range of motion (AAROM) exercises to both arms and legs as ordered by the physician on a specified date. The report also documents that the facility did not accurately assess another resident's right hand during a joint mobility evaluation and failed to provide passive range of motion (PROM) exercises to both wrists during an RNA session, as ordered by the physician. For a third resident, the facility did not provide ROM exercises to both wrists, hands, and ankles during an RNA session, again failing to follow physician orders. These failures were identified through record reviews, staff and resident interviews, and direct observations of care sessions, which revealed inconsistencies between ordered care and care provided. As a result of these failures, one resident lost the ability to stand and experienced frustration and feelings of debilitation. The lack of appropriate interventions and assessments also created the potential for further ROM decline in the affected residents. The facility did not complete required interdisciplinary team (IDT) care plan reviews or document discussions regarding the residents' declines in mobility, and there was no evidence that therapy evaluations were requested or conducted when declines were identified.
Failure to Protect Resident from Mental Abuse by Family Member
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with a history of physical and emotional abuse from further mental abuse by a family member. The resident, who had diagnoses including confirmed physical abuse, major depressive disorder, and anxiety disorder, had an open Adult Protective Services (APS) case against a specific family member. The resident had clearly expressed to the facility's interdisciplinary team and case manager that she did not want any contact, calls, or visits from this family member, citing a long history of various forms of abuse. The care plan and medical record documented these wishes, and staff were notified accordingly. Despite these documented restrictions, the family member was able to enter the facility on two separate occasions. On the second occasion, the family member bypassed safety checks, pushed past staff, and attempted to enter the resident's room while she was receiving perineal care, trying to pull back the privacy curtain and shouting at the resident. The resident was visibly distressed, shaking her head no, tearful, and later required medication for anxiety. Staff intervened and called the police to remove the family member from the premises. The resident's emotional distress was documented, and a new order for Ativan was issued to manage her anxiety following the incident. The facility failed to implement its own abuse prevention policy, which required protecting residents from all forms of abuse, including mental abuse, and ensuring the health and safety of residents regarding visitors. The policy also indicated that room changes should be considered for resident safety, but there was no evidence that a room change was offered after either incident. Additionally, the administrator did not conduct a thorough investigation or report the incident to the state agency, as required by policy, due to incomplete information from staff. The resident's name remained posted outside her room, which may have facilitated the family member's access.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
Facility staff failed to protect and promote the rights of a resident by not maintaining privacy and dignity during personal care. During an observation, a resident with hemiplegia, hemiparesis, and a cognitive communication deficit was found lying in bed with his genital area exposed. While two CNAs assisted the resident in turning and repositioning, his back and buttocks were also exposed. The genital area remained uncovered even after repositioning, and the privacy curtain between the resident and his roommate was left open throughout the care. The roommate was awake and positioned to potentially observe the care being provided. Both CNAs acknowledged that the resident should have been covered and the curtain closed to protect privacy. The resident's medical records indicated significant physical and cognitive impairments, requiring maximal to total assistance for personal hygiene and showering. The facility's policy required that residents be treated in a manner that maintains privacy, including the use of closed doors or drawn curtains during personal care. The Director of Nursing confirmed that residents should be covered when not actively receiving care and that privacy curtains should be closed if a resident's genital area is exposed during care.
Failure to Conduct and Document Required IDT Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two of four sampled residents had Interdisciplinary Team (IDT) meetings to discuss their plan of care and discharge goals. For one resident, the admission record indicated diagnoses of dementia, bipolar disorder, and Type II Diabetes Mellitus, with mild cognitive impairment and significant assistance required for daily activities. Although an IDT meeting was reportedly conducted with the resident's representative over the phone, the Social Service Director stated that the meeting documentation was not included in the medical record, as it was kept exclusively by her and not entered into the chart. For another resident, admitted with dementia, a fracture, and traumatic subarachnoid hemorrhage, the record review and staff interviews confirmed that no IDT meeting was conducted, despite the resident being able to make her own medical decisions and having intact cognitive skills. The facility's policy requires that IDT meetings be held within 72 hours of admission to address the plan of care, concerns, medications, dietary preferences, and discharge plans. Both the Social Service Director and Director of Nursing acknowledged that the required IDT meetings were not completed or documented as per policy.
Failure to Conduct and Document Required IDT Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two of four sampled residents were provided with Interdisciplinary Team (IDT) meetings to discuss their person-centered plan of care and discharge goals. For one resident, the admission record indicated diagnoses including dementia, bipolar disorder, and Type II Diabetes Mellitus, with mild cognitive impairment and significant assistance required for daily activities. Although an IDT meeting was reportedly conducted with the resident's representative over the phone, the Social Service Director (SSD) stated that the documentation of this meeting was not included in the medical record, as it was kept exclusively by her and not entered into the chart. For another resident, who had diagnoses including dementia, a fracture, and traumatic subarachnoid hemorrhage, and was cognitively intact, the SSD confirmed that an IDT meeting was not conducted, despite facility policy requiring such meetings within 72 hours of admission. The Director of Nursing (DON) also confirmed that IDT meetings are necessary to address the resident's plan of care and that failure to conduct these meetings could result in residents' problems not being addressed. The facility's policy specifies that the IDT should include various professionals and, to the extent practicable, the resident or their representative.
Failure to Obtain Advance Directive Upon Admission
Penalty
Summary
The facility failed to obtain a copy of a resident's Advance Directive (AD) upon admission, as required by facility policy. The resident was admitted with diagnoses including cerebral infarction and metabolic encephalopathy, and their cognitive skills were noted to be moderately impaired. Documentation indicated that the resident had an AD and needed to bring a copy, but the facility did not secure this document at the time of admission. Both the Social Service Director and the Director of Nursing confirmed during interviews that the AD was not obtained, despite acknowledging the importance of having this information available in the resident's health record. A review of the facility's policy revealed that staff are required to provide written information about advance directives to residents or their representatives and to obtain and file a copy of the AD in the resident's health record when available. In this case, the required documentation was not collected or placed in the record, resulting in a deficiency related to honoring the resident's right to have their healthcare wishes known and respected.
Failure to Notify Physician and Family of Change in Condition for Two Residents
Penalty
Summary
The facility failed to notify responsible parties and physicians of significant changes in condition for two residents, resulting in delayed care and treatment. For one resident with a history of left femur fracture, diabetes, and recent hip surgery, a left heel wound initially identified as a blister progressed to a suspected deep tissue injury (SDTI) and later to an unstageable pressure injury with eschar, slough, and foul odor. Despite clear changes in the wound's appearance and the resident's increasing pain, the physician was not notified of the deterioration on the day it was observed. Documentation did not reflect timely communication or comprehensive wound assessments, and the resident was ultimately transferred to an acute care hospital for further evaluation and treatment after the wound worsened. Another resident, who lacked decision-making capacity and had a family member as the responsible party, developed right buttock redness that progressed to moisture-associated dermatitis (MASD), then to an unstageable pressure injury requiring debridement, and eventually to a stage four pressure injury. The family member was not informed of the initial skin changes or subsequent wound progression until the injury had reached stage four. Facility staff acknowledged that the family should have been notified at each stage of the wound's development, and the DON confirmed that both herself and the family member were not informed in a timely manner as required. Facility policies required prompt notification of physicians and responsible parties for changes in resident condition, as well as thorough documentation and escalation of wound care concerns. However, interviews and record reviews revealed that these protocols were not followed for either resident, resulting in a lack of timely intervention and communication regarding significant changes in their health status.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in unmet needs and inadequate care. For one resident with a left heel blister, the care plan was not updated in a timely manner to reflect the progression to a suspected deep tissue injury (SDTI). Although clinical documentation and wound care consults identified the need for specific interventions such as offloading the heel and using specialized mattresses, these interventions were not incorporated into the care plan until several days after the wound was reclassified. Interviews with nursing staff and the DON confirmed that the care plan update and implementation of person-centered interventions were delayed, despite the recognized importance of immediate action for wound healing and prevention of further decline. Another resident experienced a prolonged period of not being weighed, with no weight recorded for five months. The care plan only generically noted the resident's preference not to be weighed, without documenting the underlying reason or providing interventions to address the refusal. Interviews and observations revealed that the resident's refusal was due to pain caused by the lift equipment used for weighing, not a lack of willingness. The facility did not assess or accommodate this need, nor did they document efforts to resolve the issue. When the resident was finally weighed with proper support, a significant weight loss was discovered, which had gone unmonitored due to the lack of a comprehensive and individualized care plan. A third resident's care plan was not adequately personalized upon admission or when new skin issues developed. The resident, who had multiple risk factors including cognitive impairment and immobility, developed a right buttock pressure injury that progressed from redness to an unstageable wound and eventually to a stage four pressure injury. The care plan did not reflect timely updates or specific interventions in response to changes in the resident's condition. Staff interviews indicated that risk assessments were not reassessed when the resident's condition changed, and necessary interventions such as increased repositioning and nutritional support were not promptly implemented or documented in the care plan.
Failure to Complete Neurology Consults and Determine Decision-Making Capacity
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs for two of three sampled residents. For one resident with diagnoses including metabolic encephalopathy, cerebral infarction, and a lower spinal cord compression fracture, there were physician orders for a neurology consult within 2-4 weeks and a subsequent neuro consult for dementia. However, the resident was not seen by a neurologist as ordered. The resident's family member confirmed that the neurology appointment was missed, and facility staff interviews revealed that there was no documentation of appointment confirmation or follow-up in the resident's chart. The case manager was responsible for arranging and documenting such appointments, but this process was not completed, resulting in the missed consult. For another resident admitted with encephalopathy and a cognitive communication deficit, the medical record and assessments indicated severe cognitive impairment. The resident's history and physical noted that decision-making capacity should be deferred to psychiatry or neurology, but there was no clear documentation in the record regarding the resident's capacity to make decisions. Although the resident was seen by psychiatry, the visit summary did not address decision-making capacity, and the resident was not seen by neurology. Facility staff acknowledged that the determination of capacity was not completed or documented as required. Facility policies reviewed indicated that social services are responsible for ensuring medically related social services, including scheduling and transportation for appointments, and that informed consent procedures require documentation of a resident's capacity or surrogate decision maker. In both cases, the facility did not follow through with required consults and documentation, resulting in failures to meet physician orders and to determine and document decision-making capacity.
Failure to Ensure Competency in Wound Care and Documentation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in caring for residents with pressure injuries, as evidenced by the care provided to two residents. For one resident with a history of left femur fracture, diabetes, and recent hip surgery, the treatment nurse did not perform or document weekly wound assessments as required by the facility's Wound Management and Prevention Policy. The nurse also failed to complete a change of condition assessment or notify the physician when the resident's left heel wound changed from a suspected deep tissue injury to an unstageable pressure injury. The medical record lacked accurate and timely documentation of the wound's progress, and the physician was not informed of the wound's decline, despite the presence of eschar, slough, and signs of infection. The resident's wound worsened, requiring further medical intervention and wound care consultation. Another resident, admitted with multiple diagnoses including metabolic encephalopathy and a history of stroke, developed a right buttock pressure injury that progressed from redness to moisture-associated skin damage, then to an unstageable injury, and ultimately to a stage four pressure injury. The Director of Nursing was not aware of this resident's pressure injury until it had reached stage four, and there was no evidence of clinical oversight or timely escalation of the wound's status. The care plan and treatment administration records indicated ongoing changes in the wound's condition, but the DON was not informed of these changes, and interventions such as increased repositioning and offloading were not implemented in a timely manner. Interviews with staff, including the treatment nurse and DON, confirmed that required wound assessments, documentation, and physician notifications were not completed according to facility policy. The DON acknowledged that wounds should be assessed upon admission, for any changes, and weekly, with all findings recorded in the resident's chart. The treatment nurse admitted to not documenting wound progress or notifying the physician of significant changes, and the DON confirmed a lack of oversight and monitoring for residents with pressure injuries. These failures resulted in a lack of accurate documentation and delayed care for both residents.
Failure to Complete Psychosocial and Trauma Assessments on Admission
Penalty
Summary
The facility failed to provide medically-related social services to two out of four sampled residents by not completing required psychosocial and trauma assessments upon admission. For one resident with diagnoses including influenza, PTSD, and anxiety disorders, there was no trauma assessment or social services assessment completed at the time of admission. The Social Services Director confirmed that all residents should be screened for trauma on admission to ensure appropriate treatment and resources, but this was not done for the resident in question. Another resident, admitted with dementia, a fracture, a history of assault, and traumatic subarachnoid hemorrhage, also did not receive a trauma assessment or social services assessment upon admission. The Social Services staff indicated that trauma assessments were only performed if a resident had a diagnosis of PTSD, despite the resident's history of assault. The staff also stated that the social services assessment, which includes trauma-related questions, was not completed at the time of admission, as they believed they had up to a week to do so. Interviews with the Director of Nursing confirmed that trauma and psychosocial assessments should be initiated upon admission for all residents, regardless of diagnosis, to identify any needs or triggers that may require additional support. Facility policies reviewed indicated that social services and behavioral health assessments are to be completed for all new admissions to ensure the highest practicable well-being, but these were not followed in the cases identified.
Failure to Maintain Pharmaceutical Services and Medication Administration Standards
Penalty
Summary
The facility failed to maintain proper pharmaceutical services in several key areas. There was no separate record kept for emergency drug usage from the Cubex automated dispensing system, as required by state regulations. The discrepancy summary reports provided by the pharmacy did not include resident names or other necessary details, and the facility did not maintain records for emergency drug usage retrieved from the Cubex. The emergency kit logbook was only used for intravenous kits, and the oral emergency kits had been replaced by Cubex without an appropriate record-keeping system in place. Additionally, the facility did not ensure that two licensed nurses signed off on the disposition of non-controlled drugs, as evidenced by a missing witness signature on the Medication Disposition Log for a drug destruction event. The facility's policy required signatures of both the nurse performing the destruction and a witness, but this was not followed. This lapse was confirmed during interviews and a review of the facility's policy and procedure documents. There were also failures in medication administration and verification processes. Nurses did not consistently check medications received from the pharmacy against physician orders and medication administration records. This resulted in one resident receiving the wrong dose of benazepril and another receiving the wrong formulation of morphine. Furthermore, a nurse crushed medications for a resident without a physician order to do so, despite the resident being on a puree diet for non-medical reasons. The facility lacked a policy on medication administration guidance, and nurses were expected to follow standard nursing practice.
Medication Error Rate Exceeds 5% Due to Incorrect Drug Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 31 observed opportunities, resulting in a 9.68% error rate. In one instance, a resident with hypertension and heart failure was administered benazepril 40 mg instead of the ordered 20 mg, and was also given vitamin C 500 mg, which was not prescribed, instead of the ordered calcium 500 mg. The nurse involved acknowledged the errors after reviewing the resident's physician orders and medication packaging, confirming that the medications administered did not match the orders. In another case, a resident with a history of surgical aftercare and chronic lymphocytic leukemia was prescribed morphine sulfate ER 15 mg every 12 hours for pain management. During medication administration, the nurse gave the resident morphine IR 15 mg instead of the prescribed extended-release formulation. The nurse confirmed the discrepancy after reviewing the medication packaging and physician orders. These errors were directly observed during medication passes and confirmed through interviews and record reviews.
Significant Medication Errors Due to Incorrect Drug and Dose Administration
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. In the first instance, a resident with a history of surgical aftercare and chronic lymphocytic leukemia was ordered to receive morphine sulfate extended release (ER) 15 mg every 12 hours for pain management. Instead, the resident was administered morphine sulfate immediate release (IR) 15 mg, which did not match the physician's order. The error was identified when the nurse reviewed the medication bubble pack and the order, noting the discrepancy. The resident reported inadequate pain relief and required additional doses of Norco for breakthrough pain, as documented in the electronic medication administration record (eMAR) and confirmed by the resident and nursing staff interviews. In the second instance, another resident with hypertension and heart failure was ordered benazepril 20 mg once daily. However, the resident was administered benazepril 40 mg, which was dispensed by the pharmacy in error. The nurse failed to identify the incorrect dose during medication administration, despite facility policy requiring verification of the correct drug and dose against the order and eMAR. The director of nursing confirmed that the pharmacy sent the wrong medication and acknowledged the risk associated with the higher dose. Both incidents were observed during medication pass observations and were corroborated by interviews with nursing staff and review of medical records. The facility's policy on the six rights of medication administration was not followed, resulting in significant medication errors for both residents.
Failure to Follow Standardized Recipes and Portion Sizes for Modified Diets
Penalty
Summary
The facility failed to ensure that standardized recipes and portion sizes were followed for residents on modified diets during a lunch service. Specifically, the cook used a smaller scoop than required, resulting in residents on ground texture diets receiving 2 2/3 ounces of BBQ chicken instead of the 3 ounces specified in the menu. The cook admitted to not consulting the food portion and serving guide, leading to the incorrect portion being served. The dietary supervisor confirmed that the wrong scoop was used and that residents on ground diets received less food than those on regular diets. Additionally, residents on mechanical soft diets received BBQ chicken that was cut into inconsistent sizes rather than being ground as required by the menu and recipe. The mechanical soft and regular chicken were served from the same tray, and the mechanical soft chicken was not prepared to the correct texture. Both the cook and the dietary supervisor acknowledged that the menu and spreadsheet were not followed, and the registered dietitian verified that the recipe called for ground chicken, not cut pieces. The speech therapist emphasized the importance of following the correct texture for residents with chewing or swallowing difficulties. For residents on pureed diets, the facility did not follow the recipe for pureed BBQ chicken. Instead of blending the BBQ sauce with the chicken, the cook served plain pureed chicken with BBQ sauce poured on top. The dietary supervisor stated that this did not meet the recipe requirements and could lead to meal dissatisfaction. Review of facility policies and job descriptions confirmed that staff are required to follow standardized recipes and portion control procedures for all therapeutic diets.
Failure to Follow Infection Control Protocols and Report Outbreaks
Penalty
Summary
The facility failed to follow proper infection prevention and control protocols in several instances involving residents with infectious conditions and indwelling medical devices. For one resident on contact isolation for Clostridium difficile (C. diff), staff were observed delivering a lunch tray without wearing required personal protective equipment (PPE) such as gown and gloves, despite signage indicating transmission-based precautions. Additionally, a family member was present in the room without PPE and reported never being instructed to use it. Interviews with staff confirmed that all individuals entering a transmission-based precautions room should wear PPE, and that visitors should be educated and reminded to comply, but this was not consistently enforced. Another resident with an indwelling urinary catheter and under enhanced barrier precautions (EBP) was observed with their catheter bag resting on the floor, and a certified nurse assistant handled the bag without wearing gown or gloves. The CNA acknowledged the bag should not be on the floor and that it was missing a hook, but still failed to use appropriate PPE. The infection preventionist confirmed that EBP requires staff to wear gown and gloves during high-contact care activities, such as handling a catheter bag, to reduce infection risk. The facility also failed to report an outbreak of C. diff to local and state health departments, as required by policy. Infection surveillance data showed multiple positive cases over several months, meeting the facility's definition of an outbreak. The infection preventionist and director of nursing both acknowledged that the outbreak should have been reported to ensure proper guidance and resources for infection control, but this was not done. Facility policies reviewed confirmed the requirements for PPE use, catheter care, and outbreak reporting, which were not followed in these instances.
Failure to Monitor and Document Immunization Status for Flu and Pneumococcal Vaccines
Penalty
Summary
The facility failed to adequately monitor and document the immunization status for influenza and pneumococcal vaccinations for two residents. For one resident with chronic obstructive pulmonary disease, atrial fibrillation, and hypertension, there were inconsistencies in the records regarding vaccination status. The admission record and a spreadsheet indicated refusal or unknown status for the vaccines, while a consent form stated the resident had already received them. The Infection Preventionist Nurse (IPN) was unable to verify vaccination status through the California Immunization Registry and relied on resident or family reports, but no definitive documentation was available in the medical record. For another resident with Type II diabetes mellitus, heart failure, and hypertension, the records also showed refusal or unknown status for the vaccines. The consent form indicated a verbal refusal, but the IPN could not confirm vaccination history through the registry or other documentation. The facility's policy required screening and documentation of immunization status upon admission, but this was not consistently followed, resulting in incomplete medical records for both residents.
Failure to Document and Track COVID-19 Vaccination Status for All Staff
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination screening, education, offering, and current vaccination status for all employees, including on-call and part-time staff, as well as medical doctors and other licensed professionals who enter the facility. During interviews, the Infection Prevention Nurse (IPN) acknowledged not having the COVID-19 vaccination status for these groups and stated that such information is important to prevent staff from being exposed to and acquiring the infection. The Director of Nursing (DON) confirmed that all employees, including the Director of Staff Development, nurses, CNAs, MDs, and NPs, are considered staff and that vaccination status is important to prevent outbreaks. A review of the facility's policy and procedure on staff immunizations indicated that staff includes anyone providing care, treatment, or services for the facility or its residents, including those under contract or other arrangements, and that documentation of vaccination should be maintained. The policy also requires the Infection Preventionist to maintain surveillance data on vaccine coverage and reported rates among residents and staff. The lack of documentation and tracking for all required staff groups led to the deficiency.
Failure to Implement Fall Risk Communication Protocol
Penalty
Summary
The facility failed to follow its own Falling Star Program policy, which requires a star sticker to be placed on the door tag of any resident who has fallen within the last 30 days. Despite having fallen four times in the past four months and being assessed as high risk for falls, a resident did not have the required falling star sticker on their door post. Multiple observations confirmed the absence of the sticker, and staff interviews revealed that the lack of this indicator led to staff being unaware of the resident's fall risk status. As a result, staff did not provide the level of supervision or precautions that would have been indicated for a high fall risk resident. The resident involved had significant cognitive impairment, a history of dementia, and was dependent on staff for most activities of daily living. Documentation showed that the resident had experienced multiple falls and was consistently assessed as high risk for falls. However, the communication tool intended to alert staff to this risk—the falling star sticker—was not utilized as required by facility policy, leading to a lack of appropriate supervision and interventions.
Failure to Replace Oxygen Cannula as Required by Policy
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the timely replacement of oxygen delivery equipment for a resident with significant respiratory needs. Specifically, the policy required that the oxygen cannula or mask and the disposable humidifier be changed at least every seven days. However, for one resident with diagnoses including acute respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD), the nasal cannula in use was observed to be dated more than seven days prior, indicating it had not been replaced as required. This was confirmed during observations and interviews with facility staff, including the Director of Staff Development and the Director of Nursing, who both acknowledged the cannula should have been changed weekly to prevent infection. The resident in question had moderate cognitive impairment and required varying levels of assistance with daily activities, including being dependent for personal hygiene and toileting. The resident had a continuous oxygen order via nasal cannula, with specific orders to change the cannula and humidifier every Sunday. Despite these orders and the facility's policy, the cannula remained in use beyond the prescribed timeframe, as verified by the date marked on the equipment and staff interviews. The failure to replace the nasal cannula as scheduled constituted a breach of the facility's infection control practices.
Failure to Ensure Timely Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that a physician conducted a face-to-face visit with a resident at least once every 60 days, as required by facility policy. Review of the resident's records showed that the last physician note was dated 1/28/2025, and there were no subsequent notes or documentation of a physician visit in the electronic medical record or the resident's chart. The Assistant Director of Nursing (ADON) confirmed that the resident, who was classified as custodial, had not been seen by a physician since that date, despite the expectation that such residents are to be seen every two months. The resident involved had a history of Type II Diabetes Mellitus, heart failure, and hypertension, and was assessed as having severely impaired cognitive skills and being dependent on all activities of daily living. The facility's policy required physician visits at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. The deficiency was identified through interviews and record reviews, which confirmed the absence of required physician visits and documentation.
Failure to Honor Resident Food Allergy and Preference
Penalty
Summary
A deficiency occurred when a resident with a documented allergy and dislike to strawberries was served strawberry flavored gelatin during lunch. The resident's Nutrition-Quarterly Evaluation listed a strawberry allergy, and the meal ticket on the lunch tray also indicated this allergy. Despite this, dietary staff placed strawberry gelatin on the resident's tray, and the resident reported receiving and not consuming the dessert due to the allergy. The dietary supervisor confirmed awareness of the resident's allergy and acknowledged that an alternative dessert should have been provided, regardless of the gelatin containing only artificial flavorings. Observations during meal service and interviews with both the resident and dietary staff confirmed that the resident's food preferences and allergies were not honored as required by facility policy. The policy states that food preferences are to be adhered to and updated as resident needs change. The failure to provide an appropriate dessert option resulted in the resident not receiving a meal that accommodated their documented allergy and preference.
Inaccurate Documentation of Restorative Nursing Services
Penalty
Summary
The facility failed to ensure accurate and complete medical record documentation for a resident with range of motion (ROM) and mobility concerns. Specifically, the Restorative Nursing Aide (RNA) services provided to the resident were not properly documented, as the records did not accurately indicate which RNA performed active assistive range of motion (AAROM) exercises and sit-to-stand transfers on multiple dates. Review of the facility's sign-in sheets and payroll records revealed that the RNAs who initialed the records for providing services were not present or did not work on those dates. Additionally, there were inconsistencies between different versions of the resident's restorative nursing records, including future discontinue dates and discrepancies in which staff were documented as providing care. The resident in question had a medical history including muscle weakness, diabetes mellitus, peripheral vascular disease, and difficulty walking. Physician orders required the RNA to provide AAROM to both arms and legs and to assist with sit-to-stand transfers using a front wheeled walker, with changes to the orders over time as the resident's condition evolved. Observations and interviews confirmed that the resident received ROM exercises and that the resident was aware of some changes in their care, but was not always informed about discontinuation of certain services. During direct observation, the resident demonstrated limited ROM in the right hand and more active movement in the left, and described a history of using assistive devices for mobility. Interviews with RNAs and facility leadership confirmed that staff sometimes initialed records for each other or for dates they did not work, and that there was no policy or procedure in place for accurate medical record documentation. The Director of Nursing acknowledged that the medical record is a legal document and that only the staff providing the treatment should sign the record. The lack of accurate documentation resulted in incomplete and inaccurate medical records for the resident's restorative nursing services.
Failure to Ensure Effective QAPI Oversight and Timely Implementation
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to provide effective oversight and implementation of the Quality Assurance and Performance Improvement (QAPI) plan. The administrator indicated that QAPI projects are initiated for areas of concern that require improvement, such as negative trends, but stated that skin issues were not considered a main focus because they had not previously been widespread. Despite a pressure injury occurring in a resident in February or March, the administrator did not believe the issue was widespread enough to warrant a QAPI project at that time. The QAA minutes from March indicated that weights and pressure ulcers were discussed, but the QAPI plan for skin was not initiated until April. The facility's policy requires the QAA committee to establish and implement a QAPI plan, identify and prioritize performance improvement projects, and monitor corrective actions. However, the delay in addressing skin issues and the lack of timely implementation of a QAPI project for pressure injuries demonstrated a failure to follow these procedures. This deficiency had the potential to allow recurring issues that could impact the quality of care for residents.
Failure to Timely Report Alleged Abuse and Protect Resident from Family Member
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the state agency as required by its own policy and federal regulations. A resident with a history of confirmed physical abuse, major depressive disorder, and anxiety disorder was admitted to the facility after being abused by a family member. Despite clear documentation that the resident did not want contact with the alleged abuser and that the abuser was the subject of an open Adult Protective Services (APS) case, the facility did not report subsequent incidents of potential mental and verbal abuse by the same family member to the state agency within the required timeframe. On two separate occasions, the family member entered the facility and attempted to visit the resident against her wishes. During the second incident, the family member became hostile, pushed past staff, and attempted to enter the resident's room while she was receiving personal care, causing the resident visible distress, fear, and anxiety. Staff and police intervention were required to remove the family member from the premises. Documentation from staff, including the case manager and LVN, described the family member's actions as verbally and emotionally abusive, and noted the resident's significant emotional response, including the need for anti-anxiety medication. Despite these events, the facility's abuse coordinator (administrator) did not conduct a thorough investigation or report the incident to the state agency, citing a lack of complete information from staff and a belief that the incident was a family dynamic rather than abuse. The administrator acknowledged that, according to facility policy, such incidents should be reported and investigated as potential abuse, but this was not done. The resident was not offered a room change for her safety after either incident, and the administrator did not speak directly with the resident about the events.
Failure to Investigate and Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to investigate an allegation of abuse in accordance with its own policy and procedure for one resident. The resident, who had a documented history of physical abuse, major depressive disorder, and anxiety disorder, was admitted following an incident of confirmed physical abuse by a family member. Upon admission, the care plan and interdisciplinary team notes clearly indicated that the resident did not want any contact with the alleged abuser, and staff were made aware of these wishes. Despite this, the family member was able to enter the facility on two separate occasions, with the second incident involving the family member forcing entry into the resident's room, shouting at the resident, and causing visible emotional distress. During the second incident, staff attempted to prevent the family member from entering the resident's room, but he pushed past them and tried to pull open the privacy curtain while the resident was receiving personal care. The resident was observed to be visibly upset, tearful, and shaking her head in refusal, and required administration of anti-anxiety medication following the event. Staff interviews confirmed that the resident was traumatized by the encounter and that the family member's behavior was verbally and emotionally abusive. The incident was not thoroughly investigated or reported to the state agency as required by the facility's abuse prevention policy. The administrator, who served as the abuse coordinator, acknowledged that she was not fully informed of the details of the incident and did not conduct an interview with the resident regarding the situation. The facility's policy required prompt and thorough investigation of abuse allegations, including interviews with the resident and witnesses, documentation of findings, and protection of the resident from further abuse, such as offering a room change. However, there was no evidence that these steps were taken following either incident involving the family member.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that two of its resident rooms met the required minimum square footage per resident, as specified by regulations. Specifically, two multi-bed rooms were found to provide less than 80 square feet per resident, and two single-bed rooms provided less than 100 square feet per resident, based on measurements from the Client Accommodations Analysis form and direct observation. During interviews, the Maintenance Supervisor was unaware of the required square footage standards and believed the rooms were adequate, while the DON acknowledged that insufficient space could hinder residents' ability to store belongings and receive care. These findings were based on direct measurement, staff interviews, and review of facility records.
Medication Administration Delay
Penalty
Summary
Licensed Vocational Nurse (LVN) 1 failed to administer medications on time for five residents, as observed during a survey on March 3, 2025. The medications were scheduled for 9 a.m., but LVN 1 did not administer them as per the physician's orders. This was confirmed through observation, interviews, and a review of the Medication Administration Record (MAR), which was not signed to indicate that the medications had been given. LVN 1 acknowledged the oversight and stated that she would notify the residents' physicians about the missed doses. The residents involved had various medical conditions requiring timely medication administration. Resident 1 had essential hypertension, chronic pain syndrome, and major depressive disorder, with orders for medications such as Amitriptyline and Furosemide. Resident 2 had essential hypertension, hyperlipidemia, and type 2 diabetes mellitus, with orders for medications like Aspirin and Bisoprolol Fumarate. Resident 3 had essential hypertension and cardiomegaly, with an order for Metoprolol ER. Resident 5 had essential hypertension, major depressive disorder, and seizures, with multiple medication orders including Amlodipine Besylate and Keppra. Resident 6 had essential hypertension, muscle weakness, and cardiomegaly, with orders for medications such as Valsartan-Hydrochlorothiazide and Metoprolol ER. The facility's policy and procedures require that medications be administered as prescribed by the attending physician and documented on the MAR before administering the next resident's medication. The Director of Nursing (DON) acknowledged the potential risks of missing daily routine medications, which could lead to adverse reactions and complications. The failure to administer medications as ordered increased the risk of adverse outcomes for the residents involved.
Failure to Label Insulin Vial with Open Date
Penalty
Summary
The facility failed to label a multi-dose vial of Humulin N insulin with an open date, which is necessary to ensure the medication's efficacy and safety. During an observation and interview, a Licensed Vocational Nurse (LVN) found an opened vial of Humulin R insulin in medication cart #2 without an open date label. The LVN acknowledged that whoever opened the vial should have labeled it with the open date but was unaware of when it was opened. The Director of Nurses (DON) confirmed that the insulin should have been labeled with both an open and expiration date to prevent the administration of potentially expired medication.
Infection Control Breach by LVN
Penalty
Summary
Licensed Vocational Nurse (LVN 2) failed to adhere to proper infection control protocols after performing a blood sugar check on a resident. Specifically, LVN 2 was observed leaving the resident's room with used gloves and did not wash her hands or use an alcohol-based hand sanitizer before exiting. This action was witnessed by a surveyor and the Director of Nursing (DON). LVN 2 acknowledged the mistake, stating that she should have removed the gloves and performed hand hygiene before leaving the room. She also mentioned that she should have brought her medication cart closer to the room door to dispose of the lancets properly in the sharps container available on the cart. The Infection Preventionist Nurse (IPN) and the DON both confirmed that staff should not leave a resident's room with used gloves and emphasized the importance of hand hygiene before and after resident care. The facility's policy on infection control, dated October 2022, highlights hand hygiene as a critical measure to prevent the spread of infection, specifying the use of an alcohol-based hand rub or soap and water after contact with blood or bodily fluids. The failure to follow these protocols had the potential to result in cross-contamination and increased the risk of infection spread among residents.
Deficiencies in Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure a comprehensive care plan was implemented for a resident with a fracture of the fourth thoracic vertebrae and a rib fracture. The resident expressed discomfort during turning and repositioning in bed, and the assigned CNA was not informed of the fractures. The care plan for this resident included goals and interventions to manage pain and prevent injuries, but the nursing staff was not adequately informed, leading to the resident experiencing pain during care activities. Another resident, who was undergoing dialysis, did not have a care plan that included an emergency kit at the bedside to address possible bleeding emergencies. The RN confirmed that the resident should have an emergency kit available and that the care plan should reflect this intervention. The DON acknowledged that the care plan did not include the necessary emergency kit, which could delay care in case of a bleeding emergency. A third resident, who was prescribed Plavix, did not have a care plan that identified the risks, side effects, and interventions related to the medication. The resident was unaware of the side effects of Plavix, and the LVN confirmed that there was no specific care plan for monitoring the medication's effects. The DON stated that the care plan is essential for administering, monitoring, and evaluating the effectiveness of interventions and identifying any side effects or adverse reactions to medications.
Improper Food Storage and Thawing Practices
Penalty
Summary
The facility staff failed to properly store lentils and black beans according to the facility's policy and procedure. During an observation, an open bag of lentils and an open bag of black beans were found closed with plastic ties in the dry food storage area. Additionally, the facility's #1 refrigerator had chicken defrosting at the bottom in a metal tray with red liquid next to a plastic bin of raw vegetables containing cabbage and zucchini. Raw fish was also observed defrosting on ice in a metal tray placed on top of a box of hard-boiled eggs on the third shelf of the refrigerator. Interviews with the Cook and the Dietary Supervisor confirmed that the raw chicken and fish should be stored on the bottom of the refrigerator to avoid cross-contamination with other foods. The Dietary Supervisor also stated that dry goods such as beans and lentils should be stored in containers with tight lids to prevent pest contamination. A review of the facility's policies on thawing meat and storage of food and supplies indicated that thawing meat should be stored on the bottom shelf below prepared and ready-to-eat food to avoid cross-contamination, and dry bulk food should be stored in seamless metal or plastic containers with tight covers.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure that two residents were free from the risk of contracting infections due to improper handling and storage of medical devices. In the case of Resident 164, the oxygen tubing was found on the floor next to the bed during an observation. Both the Licensed Vocational Nurse (LVN 1) and the Director of Nursing (DON) confirmed that the oxygen tubing should be stored in a plastic bag to prevent exposure to infectious bacteria. The facility's policy, revised in May 2021, also indicated that the tubing should be kept off the floor and stored in labeled and dated bags when not in use. Similarly, Resident 2's foley catheter was found unsecured and touching the floor. Certified Nursing Assistant (CNA 1), LVN 1, Registered Nurse (RN 1), and the Infection Control Nurse (IPN) all acknowledged that the foley catheter should be secured and not touch the floor to prevent infection. The facility's policy on Indwelling Urinary Catheter Care, revised in December 2023, stated that the catheter should be secured and covered with a privacy bag to ensure hygiene and reduce the risk of infection. These observations and interviews highlight the facility's failure to adhere to its own infection control policies, thereby putting residents at risk of infection.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy for three residents by not completing the McGeer's Criteria, which is used to determine the appropriate use of antibiotics. Resident 27 was admitted with a diagnosis of a urinary tract infection and was prescribed Ceftriaxone for sepsis and UTI. However, the Infection Surveillance report for Resident 27 did not indicate whether the infection met the criteria for antibiotic use. Similarly, Resident 59, who was admitted with pneumonia, was prescribed Piperacillin and Vancomycin, but the Infection Surveillance report was not completed in a timely manner. Resident 164, admitted with a UTI and prescribed Cefepime for septic shock, also had an incomplete Infection Surveillance report, with neither box indicating whether the infection met the criteria for antibiotic use being marked. The Infection Prevention Nurse (IP) admitted to not completing the surveillance forms on time and was unsure who was responsible for follow-up when she was not working. During interviews, the IP stated that she only works Monday to Wednesday and was not present when the antibiotics were ordered for Resident 164. She also mentioned that she was still trying to finish the surveillance forms for Residents 27 and 59. The Director of Nursing (DON) emphasized the importance of the antibiotic stewardship program in identifying the right medication for the correct indication to combat antibiotic-resistant bacteria. The facility's policy on Antibiotic Stewardship, dated December 2023, indicated that the team would assess residents for any infection using McGeer's criteria, and the Infection Preventionist or designee would be responsible for infection surveillance. However, this policy was not followed, leading to the deficiency in monitoring antibiotic use for the three residents.
Failure to Fix Call Lights in a Timely Manner
Penalty
Summary
The facility failed to ensure the call lights of two residents, Resident 53 and Resident 42, were fixed in a timely manner. Resident 53, who was admitted with a diagnosis of cerebral infarction and required substantial assistance with activities of daily living (ADLs), reported that her call light had been nonfunctional for a while and that she had informed the head nurse. Observations confirmed that pressing the call light button did not activate the indicator light, the call light panel at the nursing station, or produce any sound in the hallway, resulting in no staff assistance for Resident 53. Similarly, Resident 42, who was admitted with diagnoses including sepsis, difficulty walking, and diabetes mellitus, also required substantial assistance with ADLs. Resident 42 reported waiting for two hours for assistance with toileting and feeling uncomfortable due to sitting in her feces. Observations confirmed that pressing the call light button did not activate the indicator light, the call light panel at the nursing station, or produce any sound in the hallway, resulting in no staff assistance for Resident 42. The Director of Staff Development confirmed the malfunctioning call lights for both residents and stated that staff should not miss addressing such issues. The Registered Nurse and Maintenance Supervisor both acknowledged that the malfunctioning call lights should have been reported and fixed immediately. The Director of Nursing and the Administrator both recognized the safety risks posed by nonfunctional call lights and emphasized the importance of addressing such issues promptly. The facility's policy indicated that defective call lights must be reported immediately to the unit supervisor to ensure residents' needs are met in a timely manner.
Failure to Monitor and Assess Residents' Conditions
Penalty
Summary
The facility failed to ensure that two residents received care consistent with standards of practice. For Resident 116, the facility did not monitor the left upper extremity for skin breakdown as per the care plan and physician orders. This resulted in a delay of approximately six hours in assessing and treating a wound, leading to discomfort and a risk of skin infection. The resident had informed the nurses about the injury, but no action was taken until much later in the day. The Licensed Vocational Nurse (LVN) and the Treatment Nurse (TN) both acknowledged the delay in care, and the Director of Nursing (DON) confirmed that the resident's skin should have been assessed during medication passes and that the delay put the resident at risk for infection. For Resident 27, the facility failed to monitor for the side effects of Aspirin, a medication prescribed to thin the blood. The resident was not assessed for signs of bleeding, such as bruising or cuts, despite the facility's policy requiring such monitoring. The LVN admitted to not checking the resident's skin for changes, and the DON confirmed that there was no physician order or care plan addressing the need to monitor for Aspirin's side effects. This lack of monitoring could lead to a delay in needed services. Both deficiencies highlight a failure to follow care plans and physician orders, resulting in delays in care and potential risks to the residents' health. The facility's policies and procedures were not adhered to, leading to these lapses in care. The DON acknowledged the failures and the risks they posed to the residents involved.
Failure to Follow Physician's Order for RNA Program
Penalty
Summary
The facility failed to follow the physician's order for the Restorative Nursing Assistant (RNA) program for a resident, resulting in RNA being provided four times a week instead of the prescribed five times a week. This deficiency was identified for a resident who had a history of falling and difficulty walking, and whose cognition was moderately impaired. The resident was dependent on facility staff for activities of daily living. The physician's order specified that the resident was to receive RNA five times a week for active assisted range of motion (AAROM) to bilateral lower extremities as tolerated. However, the review of the resident's restorative nursing flowsheet for April 2024 showed that RNA was provided on only eight specific dates, falling short of the required frequency. Interviews with the Restorative Nursing Assistant (RNA 1) and the Director of Nursing (DON) revealed that there was no documentation of the resident refusing RNA, and the RNA's should document their initials in the box if the resident refuses. The Director of Staff Development (DSD) confirmed that blank squares on the flowsheet indicated RNA was not provided and that refusals should be documented along with the interventions offered. The facility's policy on ROM and Contracture Prevention emphasized the importance of ensuring residents receive services to maintain or improve their range of motion and mobility. The failure to adhere to the physician's order had the potential to place the resident at risk for a decline in range of motion.
Failure to Act on Pharmacist's Medication Regimen Review Recommendation
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's recommendation for a medication regimen review (MRR) was acted upon for one resident. Specifically, the pharmacist recommended clarifying the order for Ibuprofen to include administration with food, but this recommendation was not followed up with the physician. This oversight was identified during an interview with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who acknowledged that the pharmacist's MRR order clarification was not acted upon. The facility's policy requires that such recommendations be communicated to the responsible physician within seven working days, but this was not done in this case. Resident 47, who was admitted with diagnoses of orthostatic hypotension and syncope, had an intact cognition and required partial assistance with activities of daily living. The resident had a physician's order for Ibuprofen to be taken as needed for mild to moderate pain. The pharmacist's MRR on 3/1/2024 indicated the need to clarify that Ibuprofen should be given with food, but this recommendation was not implemented. This failure had the potential to result in the resident experiencing side effects from taking Ibuprofen on an empty stomach.
Incomplete RNA Weekly Progress Report
Penalty
Summary
The facility staff failed to maintain accurate documentation of the Restorative Nursing Assistant (RNA) weekly progress report for Resident 48. The report dated 4/10/2024 was found to be incomplete. Resident 48, who was admitted with diagnoses including difficulty walking and muscle weakness, had an intact cognition as per the Minimum Data Set (MDS) dated 1/31/2024. During interviews, both the Director of Nursing (DON) and the Director of Staff Development (DSD) confirmed that the medical record should be complete and accurate, and that the absence of documentation implies that the activity did not occur. The facility's policy on Range of Motion (ROM) and Contracture Prevention dated 5/2019 also indicated that appropriate documentation should be completed to address goals.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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