Simi Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Simi Valley, California.
- Location
- 5270 East Los Angeles Avenue, Simi Valley, California 93063
- CMS Provider Number
- 555701
- Inspections on file
- 32
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Simi Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple cardiopulmonary and renal conditions had two POLST forms on file, one older form that was properly signed by a physician and a newer form reflecting updated DNR and treatment preferences that lacked a physician signature. Facility records, including the order summary, reflected the directives from the unsigned, newer POLST. During a sudden change in condition, staff found the resident unresponsive and called 911; EMS arrived to find the resident pulseless and apneic and encountered conflicting information and two DNR forms, with the most recent one unsigned, causing confusion about which to follow. The DON later confirmed that responsibility for ensuring POLST completion rested with the admission nurse, DON, and social services, and acknowledged that the updated POLST on readmission had been overlooked for physician signature despite facility policy requiring verification and signatures.
The facility did not have a full-time, qualified Director of Food and Nutrition Services, as the individual in the role had not completed required certification and resigned. Additionally, the part-time contracted RD did not provide regular oversight or follow-up on identified issues in the foodservice department. No other staff met the necessary qualifications, and required policies for consultation and oversight were not followed.
The facility did not procure food from approved sources or ensure that food was stored, prepared, distributed, and served according to professional standards, as observed by surveyors.
Surveyors found multiple expired medications in storage areas and medication carts, including normal saline, supplements, and prescription drugs, which had not been removed as required by facility policy. Additionally, E-Kits containing emergency medications were not replaced within 72 hours after being opened, as confirmed by staff and documentation.
The facility did not ensure that a licensed pharmacist completed monthly drug regimen reviews for four residents over a three-month period, despite facility policy requiring these reviews. This included residents with complex medical needs and those prescribed psychotropic medications, with no documentation found in their medical records.
Surveyors found that medications, including suppositories and inhalant drugs, were stored above manufacturer-recommended temperatures and that opened medication packaging was not dated as required. Additionally, temperature monitoring logs for medication storage areas were incomplete or missing, and staff could not provide the required documentation, in violation of facility policy.
Multiple residents had undated respiratory and urinary equipment, and a resident requiring enhanced barrier precautions did not have appropriate signage or PPE available, contrary to facility policy and physician orders.
A resident who preferred to sleep late and requested breakfast delivery between 9-9:30 a.m. consistently received cold, unpalatable food because staff delivered breakfast trays early and left them at the bedside. Despite repeated requests and documentation of the resident's nutritional risk and preferences, the facility did not adjust meal delivery times or update the care plan to reflect the resident's wishes.
A resident with anxiety and traumatic brain injury was prescribed Seroquel for psychosis, but the facility did not document any gradual dose reduction attempts or provide required monthly pharmacy reviews for several months. The resident was observed sleeping during the day, and a family member expressed concerns about the medication regimen. Facility policy required gradual dose reductions and documentation, which were not followed.
A resident receiving Cephalexin for pneumonia was incorrectly documented by nursing staff as not being on antibiotics in multiple progress notes, despite physician orders indicating ongoing antibiotic therapy. The ADON confirmed the documentation was inaccurate, contrary to facility policy requiring objective and accurate records.
A resident with a new order for Seroquel to treat psychosis was not reassessed for PASARR following this change in condition. The most recent PASARR on file was outdated, and the DON confirmed that no updated assessment was completed as required by facility policy.
A resident who pulled out a G-tube and required 72-hour CIC monitoring did not have all required monitoring entries documented in the medical record, with several entries missing across multiple shifts, contrary to facility policy.
A resident experienced a decline in vision and reported difficulty watching TV after requesting, but not receiving, an eye appointment. Although ophthalmology consults were ordered on two occasions, there was no evidence in the medical record that these consults were completed or documented, contrary to facility policy.
A resident with a tracheostomy and ventilator support was found to have only one spare tracheostomy tube at bedside instead of the required two, as per facility policy. The respiratory therapist confirmed that the missing tube had been used and not replaced, resulting in a deficiency in emergency respiratory care preparedness.
Dietary staff failed to properly prepare and test sanitizing solutions, with one worker unable to state the correct immersion time for test strips and another using unmeasured amounts of concentrated sanitizer and water, not following manufacturer guidelines. The resulting solution's concentration could not be accurately determined, and the process was confirmed by the dietary supervisor as not compliant with required procedures, creating a risk of toxic exposure.
Two residents requiring vegetarian diets did not receive meals planned in advance or evaluated for nutritional adequacy. Kitchen staff prepared cheese sandwiches without standardized recipes, and the amount of protein provided did not meet facility guidelines. Both residents reported limited variety and inconsistent meal quality, with one supplementing her diet with outside snacks. The RD confirmed the absence of a planned vegetarian menu and could not verify if nutritional needs were met.
A resident on a vegetarian diet was served a cheese sandwich with significantly less protein than the main entrée, due to the facility's lack of standardized vegetarian recipes and failure to follow its own dietary guidelines. Staff were unaware of available vegetarian alternatives, and the meal provided did not meet the required nutritional standards.
A resident with a history of traumatic brain injury and multiple fractures did not receive ordered PT and OT services due to errors in the insurance authorization process and lack of timely follow-up by facility staff. Despite medical orders and therapy evaluations indicating the need for skilled therapy, the resident was not provided these services as required.
The facility did not ensure that physician orders for Do Not Resuscitate (DNR) status were entered into the electronic health records for two residents, despite their POLST forms indicating DNR. The DON confirmed the absence of these orders in the system, resulting in incomplete and inaccurate medical records.
Two residents were found with call lights out of reach—one clipped near an electrical outlet and another on the floor behind the bed—preventing them from calling for assistance. The DON confirmed during observation that call lights should be accessible to residents at all times.
A resident with type 1 DM, Parkinson's disease, and heart failure did not receive ordered morning insulin or blood glucose monitoring due to the absence of a licensed nurse on the unit. Staff failed to document medication administration, blood sugar checks, or physician notification. The resident was later found unresponsive with critically high blood glucose, required emergency transfer, and died after ICU admission.
A five-hour lapse in licensed nurse coverage occurred when two scheduled nurses called in and no replacement was secured, leaving 73 residents without required nursing oversight. Attempts by staff to contact the DON and Administrator were unsuccessful, and a staffing error falsely indicated coverage on the assignment sheet.
Multiple residents with diabetes did not receive prescribed insulin doses or blood glucose monitoring as ordered, with no documentation or physician notification of the omissions. The MARs and progress notes were left blank for the scheduled dose, and staff confirmed that no licensed nurse was present during the medication administration window.
A licensed nurse was not provided with formal training or competency evaluation on the use of the electronic Point Click Care (PCC) system for documentation and care coordination. Facility policy required such training and documentation, but interviews and record review confirmed that no records of PCC training were available for staff.
A resident admitted with anemia, dementia, and two bruises to the left lateral ribs did not have a care plan developed to address the skin bruising, as required by facility policy. This omission was confirmed by both MR and the DON during interviews and record reviews.
Several newly admitted residents with treatment orders did not have comprehensive care plans developed upon admission, resulting in a failure to formally address their identified needs as required by regulation.
A resident with a history of falls and conditions affecting coordination and balance was not re-evaluated for fall risk upon readmission to the facility after an ER visit. Despite policies requiring re-evaluation and monitoring, the facility did not document a fall risk assessment, as confirmed by the DON.
A resident with multiple health conditions fell and sustained injuries, but the facility did not revise the care plan to address the incident. The existing interventions were not reassessed or modified, placing the resident at higher risk for future falls.
A resident experienced multiple lapses in care, including unsecured medications, improper medication administration through a gastrostomy tube, and unlabeled oxygen tubing. Medications were left unattended, and a nurse administered them without verifying orders. The gastrostomy tube placement was not checked before medication administration, and oxygen tubing lacked proper labeling, contrary to facility policies.
The facility did not report an allegation of abuse involving two residents to local law enforcement, as required by federal regulations. Despite the facility's policy mandating timely reporting, the incident was not communicated to the police. The Administrator explained that the decision was based on the facility's conclusion that the allegation was unsubstantiated.
A resident was found unable to reach the call light, as it was placed on the far side of the bed. A CNA admitted to forgetting to move it due to being in a hurry. The DON confirmed the call light should have been within reach, as per facility policy.
The facility failed to maintain kitchen sanitation and hygiene, with used gloves found on a food prep counter, an improperly maintained ice machine, and a kitchen staff member handling food and cleaning without gloves or hand hygiene. These actions increased the risk of food-borne illness for residents.
A resident was found with their bed pushed against a wall and a locked transfer chair on the other side, effectively restraining them. This setup was requested by the resident's family for safety after a previous fall, but there was no physician order, assessment, or care plan in place. The DON confirmed this arrangement was a form of physical restraint, violating the facility's policy on restraint use.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately indicated they were not on anticoagulant medication, despite an active order for Warfarin. Another resident was incorrectly documented as comatose, although they were alert and communicative. These inaccuracies were confirmed by a licensed nurse.
The facility failed to follow a care plan for a resident with shortness of breath by administering oxygen at an incorrect rate, and did not develop a care plan for another resident's hearing needs. These deficiencies were identified during a review of the residents' records and confirmed by facility staff.
A resident experienced significant weight loss due to the facility's failure to implement the Registered Dietitian's recommendations for increasing gastrostomy tube feedings. Despite recommendations to increase the feeding rate to address weight loss and nutrient needs for wound healing, the necessary changes were not ordered or implemented. The RD assumed the nurses would notify the physician, but this did not occur, leading to the deficiency.
A facility failed to ensure a POLST form for a resident was signed by a physician. During a review, it was found that the form, dated May 9, 2024, lacked a physician's signature. An LN acknowledged the missing signature and noted it was flagged for signing. This oversight could impact the resident's healthcare wishes during emergencies.
The facility failed to maintain the correct temperature in the medication storage refrigerator at Nurse Station One. A licensed nurse confirmed the refrigerator was at 50°F, exceeding the recommended range of 36-46°F as per facility policy. This could potentially affect the efficacy of refrigerated medications.
The facility failed to employ a qualified dietary supervisor in the absence of a full-time registered dietitian, potentially risking incorrect diets and food-borne illnesses for residents. The dietary supervisor was not certified, and the facility's administrator could not provide documentation of required training. The job description required a graduate of an accredited dietetic course and state registration, which was not met.
The facility failed to maintain infection control measures for storing oxygen therapy equipment for two residents. A nasal cannula was found on the floor, and another was on a bedside table, along with a nebulizer mask. Both had plastic bags for storage, but were not stored in them, contrary to facility policy.
The facility failed to document offering or explaining the risks and benefits of a COVID-19 vaccination to a resident, identified as Resident 443, who was later diagnosed with COVID-19. The Infection Preventionist confirmed there was no documentation of the resident being offered the vaccine, refusing it, or having received it prior to admission. This lack of documentation is contrary to the facility's policy, which requires offering vaccines and documenting education and vaccination status.
A resident's call light was found on the floor and out of reach, potentially delaying care. A CNA confirmed the call light should have been within reach, as per facility policy.
The facility failed to maintain a homelike environment for three residents, as observed during a tour with the maintenance supervisor. Peeling paint and missing plaster were found in two residents' rooms, and a cracked ceiling was noted in another. These issues were not reported by staff or logged in the maintenance log, despite the facility's policy to maintain a safe and comfortable environment.
A facility failed to develop a baseline care plan for a resident assessed as high risk for falls within 48 hours of admission. The resident, with conditions such as polyneuropathy and hypertension, had a high fall risk score, but the facility did not implement its fall prevention program, including the use of a yellow star sticker. The Director of Nursing acknowledged the oversight.
A resident with moderate cognitive impairment was forced to shower against their will and without privacy, as a CNA disregarded their request to delay the shower and exposed them naked in front of their roommate. This violated the resident's rights to self-determination and privacy.
A facility failed to monitor a resident's behavior after an allegation of mistreatment by a CNA during shower time. The resident expressed dissatisfaction, and the family and DON were informed. However, no monitoring for psychosocial changes was conducted, and the DON confirmed that a COC monitoring should have been implemented.
A facility failed to document a Shower Day Skin Inspection for a resident after a shower, as required by their policy. The Director of Nursing confirmed the shower occurred, but the necessary documentation was missing from the resident's file, which should have included details such as the date, time, assisting staff, and any skin assessment data.
A facility failed to maintain accurate medical records when a controlled medication for seizures was documented as administered despite being unavailable. The MAR inaccurately reflected the administration, and interviews with LNs confirmed the medication was not given.
Failure to Maintain Valid POLST Resulting in Conflicting Code Status Information
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records by not obtaining a physician’s signature on a resident’s updated Physician Orders for Life-Sustaining Treatment (POLST) form. The resident, an older female with multiple serious diagnoses including fracture of the left humerus, acute and chronic respiratory failure with hypoxia, interstitial pulmonary disease, pneumonia, and chronic kidney disease with hypertensive heart disease and heart failure, had two POLST forms on file. One POLST dated 10/05/2023 indicated DNR, selective treatment, and a trial period of artificial nutrition and was signed by a physician on 10/06/2023. A subsequent POLST dated 10/25/2024 indicated DNR, selective treatment, and no artificial means of nutrition, but this form lacked a physician’s signature. The facility’s Order Summary Report still reflected an active order for DNR, selective treatment, and no artificial means of nutrition, consistent with the unsigned 2024 POLST. On the day of the incident, progress notes documented that the resident was eating breakfast with assistance and tolerating a few bites and sips of juice before being found unresponsive around 8:15–8:20 a.m., prompting a 911 call. When EMS arrived, they found the resident pulseless and apneic, and staff provided conflicting information about the resident’s status. EMS noted there were two DNR forms, both marked DNR, but the most recent form was not signed, creating uncertainty about which POLST to follow. Basic Life Support was initiated due to this uncertainty, and the facility contacted the resident’s daughter, who requested full resuscitation measures. During interview, the DON acknowledged that there were two POLST forms, that EMS expressed confusion regarding which to follow, and that the updated POLST on readmission had been overlooked for physician signature, despite facility policy requiring POLST documents to be reviewed for validity and signed by the physician and the resident or legal decision-maker.
Failure to Employ Qualified Food and Nutrition Services Director and Provide Sufficient Dietitian Oversight
Penalty
Summary
The facility failed to employ a full-time Director of Food and Nutrition Services (DFN) who met both federal and state educational qualification requirements. The individual who had been serving as the Dietary Manager (DM) for the past year had not taken the Certified Dietary Manager (CDM) exam and was therefore unqualified for the position. This was confirmed by multiple staff interviews, including the per diem Dietary Services Supervisor (PD-DSS) and the Administrator, who both acknowledged that the DM did not meet the necessary qualifications. The DM resigned on the day of the survey, leaving the facility without a qualified DFN. Additionally, the facility relied on a part-time contracted Registered Dietitian (RD) who did not provide sufficient, regularly scheduled consultation to the DFN. The RD last completed oversight of the foodservice operations in February, several months prior to the survey, and did not follow up to ensure that identified deficits were addressed. Documentation showed that issues such as missing menu printouts, expired food handler certifications, and lack of a substitution log were not resolved. The RD confirmed that she had not provided adequate oversight or consultation to the DM during this period. Interviews with dietary aides and review of facility policies further revealed that no other staff members met the qualifications to serve as DFN or had completed the necessary training programs. The facility's own policies and job descriptions require a qualified DFN and regular consultation from an RD if the DFN is not a dietitian. The lack of qualified leadership and insufficient RD oversight had the potential to affect all residents receiving meals from the kitchen.
Failure to Follow Professional Standards for Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or incidents were provided in the report.
Expired Medications and Delayed E-Kit Replacement Identified
Penalty
Summary
The facility failed to ensure that all medications stored in its drug storage areas were available for use and had not expired, as well as to replace pharmaceutical emergency kits (E-Kits) within the required timeframe after opening. During observations and interviews, multiple expired medications were found in storage cabinets, countertop baskets, and medication carts, including normal saline unit doses, phosphorus supplements, valproic acid, lactulose, sucralfate, mineral oil, bisacodyl, ondansetron, and hyoscyamine. The Infection Preventionist confirmed that these medications should have been disposed of according to the facility's policy and procedure, which requires immediate removal of outdated, contaminated, or deteriorated medications. Additionally, the facility did not replace E-Kits within 72 hours of being opened, as required by its policy. Observations revealed that at least two E-Kits had been opened and not replaced within the specified timeframe, with billing slips and staff interviews confirming the delay. The Infection Preventionist acknowledged that the replacement of the E-Kits was not completed within the policy's required 72-hour window.
Failure to Complete Required Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed the required monthly drug regimen reviews (MRR) for four of nineteen sampled residents during the months of May, June, and July 2025. Specifically, there was no documentation of MRRs for these months in the medical records of residents with complex medical conditions, including colostomy status, gastrostomy status, and neuromuscular dysfunction of the bladder. During interviews and record reviews with the Director of Nursing (DON), it was confirmed that the required MRR documentation was missing for these residents. Additionally, a review of one resident's order summary revealed the use of Seroquel for psychosis and behavioral symptoms, yet there was no evidence of a pharmacist's monthly review for the same period. The facility's policy, dated January 2025, clearly states that the consultant pharmacist must review each resident's medication regimen at least monthly, but this was not followed for the identified residents.
Medication Storage and Temperature Monitoring Deficiencies
Penalty
Summary
Surveyors identified that medications and biologicals were not stored according to manufacturer specifications and facility policies. Specifically, Bisacodyl and Acetaminophen suppositories were observed stored at 80°F, exceeding the manufacturers' recommended maximum of 77°F. Additionally, inhalant medications such as Levalbuterol, Budesonide, and Ipratropium Bromide/Albuterol were found in opened foil packaging without being dated, contrary to both manufacturer instructions and facility policy, which require these medications to be used or discarded within specific timeframes after opening. Further review revealed that the facility failed to consistently monitor and document medication room temperatures. Temperature logs were incomplete, with only a few days recorded for April and May, and no logs available for June, July, or the beginning of August. The Infection Preventionist and DON confirmed the missing documentation and were unable to provide the required records, despite facility policy mandating daily temperature monitoring within a specified range.
Failure to Maintain Infection Control Practices and Precaution Signage
Penalty
Summary
The facility failed to observe proper infection control practices for multiple residents, as evidenced by undated nebulizer tubing, plastic storage bags, urinary catheter bags, and suction canisters for both sampled and unsampled residents. During observations, several residents were found with respiratory and urinary equipment that lacked required labeling to indicate the date of change, contrary to the facility’s own policy and procedure, which mandates labeling disposable circuits and supplies with the date of change. Interviews with staff, including a respiratory therapist, confirmed that all such equipment should be labeled with the date it was changed. Additionally, a resident with a gastrostomy tube, urinary catheter, and colostomy had a physician order for enhanced barrier precautions (EBP), but there was no EBP signage posted outside the room and no personal protective equipment (PPE) available inside or outside the room. The infection preventionist was unaware of the need for EBP for this resident until it was brought to his attention, despite the facility’s policies requiring PPE to be maintained and signage to be posted for residents on transmission-based precautions. These lapses were confirmed through interviews and review of facility policies.
Failure to Honor Resident Mealtime Preference Results in Cold, Unpalatable Food
Penalty
Summary
The facility failed to honor a resident's request for a later breakfast time, resulting in the resident consistently receiving cold and unpalatable food. The resident, who preferred to sleep late and wake around 9-9:30 a.m., repeatedly communicated her preference for breakfast to be delivered at that time. Despite this, staff continued to deliver breakfast trays early in the morning, leaving them at the bedside while the resident was still asleep. Observations confirmed that the food remained untouched and cold by the time the resident awoke. The resident's private caregiver and a CNA both confirmed that the issue had been raised with the facility multiple times, but no changes were made to accommodate the resident's preference. The resident's care plan documented a risk for altered nutrition and a goal to respect her right to choose and honor food preferences, yet there was no documentation of her preferred breakfast time in the care plan or nutritional notes. The Registered Dietician stated that resident mealtime requests should be honored within a reasonable window for food safety, and the facility's policy also indicated that resident mealtime preferences should be honored and food should be served at appropriate temperatures. Despite these policies and the resident's mental capacity to make decisions, the facility did not adjust its practices or documentation to meet the resident's request.
Failure to Conduct Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to conduct a gradual dose reduction (GDR) for psychotropic medication for one resident. Observation showed the resident sleeping in bed during the day, and interview with a family member revealed concerns about the resident's medication regimen, specifically noting that the resident was sleeping during the day and awake at night. The family member was aware the resident was taking a sleeping pill but was unsure of the administration time. Record review indicated the resident had diagnoses including anxiety and traumatic brain injury and had an active order for Seroquel (Quetiapine Fumarate) 12.5 mg twice daily for psychosis manifested by agitation and aggression. Further review found that the facility was unable to provide monthly pharmacy medication reviews for three consecutive months, and there was no documentation of any gradual dose reduction attempts during that period. The facility's policies required GDRs for residents on psychotropic medications unless clinically contraindicated, and required documentation and action on pharmacy drug regimen review recommendations. The lack of GDR and missing documentation led to the resident potentially receiving unnecessary medication.
Inaccurate Documentation of Antibiotic Use
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for one resident who was prescribed Cephalexin, an oral antibiotic, for community-acquired pneumonia. A review of the resident's physician's orders confirmed the ongoing antibiotic therapy, while progress notes over a period of several weeks contained ten entries by nursing staff incorrectly indicating that the resident was not currently on antibiotics. During an interview, the Assistant Director of Nursing confirmed that the resident was indeed on antibiotics and acknowledged the inaccuracy in the charting. The facility's policy requires that documentation in the medical record be objective and accurate.
Failure to Complete PASARR Assessment After Change in Mental Health Condition
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for a PASARR (Pre-admission Screening and Resident Review) following a change of condition related to mental illness. Specifically, the resident had a new order for Seroquel, an antipsychotic medication, administered via G-tube every eight hours for psychosis. Despite this significant change in the resident's mental health status and treatment, the facility did not complete a new PASARR assessment to reflect the updated condition and medication order. Record review showed that the most recent PASARR on file for the resident was dated nearly a year prior to the new Seroquel order. During an interview, the DON confirmed that no updated PASARR had been completed after the change in the resident's mental health status. The facility's policy indicated that the MDS Coordinator is responsible for ensuring PASARR updates per guidelines, but this process was not followed in this instance.
Failure to Document 72-Hour Monitoring After Change in Condition
Penalty
Summary
The facility failed to implement and document a complete care plan for a resident who experienced a change in condition after pulling out a gastrostomy tube (G-tube). The resident's G-tube was reinserted at bedside and the resident was placed on 72-hour change in condition (CIC) monitoring. However, review of the resident's progress notes revealed missing documentation of monitoring: one entry was missing on one day and three entries were missing on another day during the 72-hour period. The Assistant Director of Nursing confirmed that monitoring should have been documented on all three nursing shifts as per facility policy. The facility's policy requires nurses to record information related to changes in a resident's condition in the medical record.
Failure to Arrange and Document Ophthalmology Consult for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain their vision. The resident was observed squinting and having difficulty watching TV, and reported having requested an eye appointment that was not arranged by the facility. Review of the resident's Minimum Data Set (MDS) showed a decline in vision from adequate to moderately impaired over time. Medical records indicated that ophthalmology consults were ordered on two separate occasions, but there was no evidence that these consults were ever completed. The social services director confirmed there was no documentation explaining why the consult ordered in January was not done. Facility policy required social services to coordinate and document referrals, but this was not followed in this case.
Failure to Maintain Required Emergency Tracheostomy Tubes at Bedside
Penalty
Summary
The facility failed to ensure the availability of a reserve emergency tracheostomy tube at the bedside for a resident with a tracheostomy connected to a ventilator. During an observation, it was noted that only one spare tracheostomy tube was present in the resident's room, instead of the required two (one of the same size and one smaller). The respiratory therapist confirmed that two emergency tracheostomy tubes should be kept at the bedside for emergencies, and explained that the missing tube of the same size had been used previously and not replaced. A review of the facility's policy indicated that a tracheostomy tube of appropriate size must be maintained at the bedside for all intubated residents in case of accidental extubation, decannulation, or other emergencies, and that the reserve tube should be replaced immediately after use. The failure to replace the used emergency tracheostomy tube resulted in non-compliance with the facility's policy and created a deficiency in providing safe and appropriate respiratory care for the resident.
Improper Preparation and Testing of Sanitizing Solution by Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary support staff were competent and followed proper procedures for preparing and testing sanitizing solutions in the kitchen. During observations and interviews, a dietary worker demonstrated testing a sanitizing solution but was unable to state the correct immersion time for the test strip, instead guessing various timeframes. Another dietary assistant prepared a sanitizing solution by pouring an unmeasured amount of concentrated sanitizer into a bucket of water without measuring the water temperature or the quantity of sanitizer, and then immediately tested the solution without following the manufacturer's required immersion time for the test strip. The color of the test strip indicated a concentration that could not be accurately determined, as it exceeded the maximum reading on the test strip's color chart. The dietary assistant's method of preparing the sanitizing solution did not follow the manufacturer's guidelines, which specify a precise dilution ratio and temperature range. The product instructions required adding 1-2 fluid ounces of sanitizer per gallon of water to achieve a concentration of 200-400 ppm, and the test strip instructions required a 10-second immersion in solution at a specific temperature range. The dietary staff's failure to follow these instructions was confirmed by the person in charge of dietary services, who acknowledged that the solution was likely too concentrated, creating the potential for toxic exposure. The FDA Food Code was also reviewed, which emphasizes the importance of using chemical sanitizers according to EPA-registered label requirements to prevent harmful residues.
Failure to Provide Planned, Nutritionally Adequate Vegetarian Menu
Penalty
Summary
The facility failed to implement a vegetarian menu that was planned in advance and evaluated for nutritional adequacy for two residents who required vegetarian diets. Observations revealed that kitchen staff prepared cheese sandwiches for these residents without following a standardized recipe, and there was no evidence of a planned vegetarian menu or evaluation of its nutritional content. The dietary aide confirmed there was no recipe for cheese sandwiches, and the dietary supervisor indicated that only two slices of cheese, providing 5-6 grams of protein, were used per sandwich, which did not meet the facility's own diet manual guidance for protein content in vegetarian meals. Both residents involved had documented orders for vegetarian diets and the mental capacity to make dietary decisions. One resident reported being a lifelong lacto-ovo vegetarian and stated that her meals often consisted of grilled cheese sandwiches, with the quality and variety of meals varying depending on the kitchen staff. She was unaware of alternative vegetarian options available to her. The other resident, also a long-term vegetarian, reported receiving meals that were high in carbohydrates and lacking in variety and balance, sometimes leading her to supplement her diet with snacks purchased from outside the facility. She also expressed uncertainty about whether certain meals were vegetarian and felt limited in her choices. The registered dietitian confirmed that the facility did not have a vegetarian menu planned a week in advance and could not verify if the meals provided met recommended dietary allowances. Review of facility policies indicated that menus should be planned in advance, provide variety, and meet nutritional needs according to national guidelines, but these requirements were not met for the vegetarian residents. The lack of standardized vegetarian recipes, menu planning, and evaluation for nutritional adequacy led to inconsistent meal quality and potential nutritional deficits for the affected residents.
Failure to Provide Nutritive Vegetarian Meal Alternative
Penalty
Summary
The facility failed to provide a vegetarian alternate meal of similar nutritive value for a resident who required a vegetarian diet. During meal service, the resident received a cheese sandwich containing two slices of processed cheese, which provided only 5 grams of protein, compared to the main entrée of Hawaiian chicken that provided approximately 21 grams of protein. The dietary aide preparing the sandwich stated there was no recipe to follow, and the facility did not have standardized vegetarian recipes or planned vegetarian alternatives to ensure nutritional adequacy. The resident’s meal tray card indicated a vegetarian diet with no meats and a preference for veggie patties and cheese, but the meal provided did not meet the facility’s own diet manual guidance, which required 2 to 3 ounces of protein equivalent at lunch. Further review with the registered dietitian and dietary services supervisor confirmed that the cheese sandwich did not meet the protein requirements outlined in the facility’s diet manual. The facility also lacked vegetarian menus and standardized recipes that were analyzed for nutritional adequacy, and staff were unaware of vegetarian alternatives noted in the recipe for the main entrée. The facility’s policies required the use of approved, standardized recipes and the provision of suitable nourishing alternate meals, but these procedures were not followed in this instance.
Failure to Provide Required Physical and Occupational Therapy Services
Penalty
Summary
The facility failed to provide required physical and occupational therapy services to a resident who had a history of traumatic brain injury, multiple fractures, and acute respiratory failure following a motor vehicle accident. The resident, who was previously ventilator-dependent and required a gastrointestinal tube for nutrition, had shown improvement and was no longer dependent on these supports. Despite medical orders and therapy evaluations indicating the need for skilled PT and OT to maximize mobility and reduce caregiver burden, the resident did not receive these services as prescribed. Interviews and record reviews revealed that a referral for PT was made, but the insurance company did not receive the request due to errors in the authorization process, including the use of an incorrect CPT code and lack of timely follow-up by the business office. The resident was instead placed on a restorative nursing program, but did not receive the skilled therapy ordered. Staff confirmed that without PT authorization, therapy could not be provided, and the business office acknowledged that the lack of follow-up contributed to the ongoing absence of therapy services.
Failure to Maintain Accurate Code Status Orders in Medical Records
Penalty
Summary
The facility failed to ensure that resident medical records were accurate and complete by not having physician orders for code status in place for two residents. For both residents, although their Physician Orders for Life Sustaining Treatment (POLST) forms indicated 'Do Not Attempt Resuscitation (DNR),' there were no corresponding physician orders entered into the electronic health record system as required by facility policy. The Director of Nursing (DON) confirmed during interviews and record reviews that the DNR orders were missing from the residents' medical records and acknowledged that these orders should have been entered into the Point Click Care system. One resident was admitted with diagnoses including vascular dementia, a left femoral neck fracture, and acute respiratory failure with hypoxia. The other resident had an original admission date several years prior. In both cases, the POLST forms clearly documented the residents' wishes regarding resuscitation, but the absence of a physician order in the medical record represented a failure to maintain accurate and complete documentation in accordance with accepted professional standards.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two of nineteen sampled residents, as required by facility policy. During observations, one resident was found lying in bed with the call light clipped and secured near an electrical outlet, making it inaccessible. In another instance, a resident was observed sleeping in bed with the call light on the floor behind the bed and out of reach. These deficiencies were confirmed during concurrent interviews and observations with the Director of Nursing, who acknowledged that the call lights were not accessible to the residents as required.
Failure to Administer Ordered Insulin and Monitor Blood Glucose Leads to Resident Death
Penalty
Summary
The facility failed to provide ordered morning medications, including sliding scale insulin, and did not monitor blood glucose levels as ordered for a resident with type 1 diabetes, Parkinson's disease, and hypertensive heart disease with heart failure. The resident was admitted with a care plan that required administration of medications and blood sugar monitoring as ordered. On the night in question, there was no licensed nurse present on the skilled unit from 2 a.m. to 7 a.m. due to staff call-offs, and the scheduled 5 a.m. to 6:30 a.m. medications were not administered. Staffing records confirmed the absence of licensed nurses during this period, and interviews with staff indicated that multiple attempts to notify facility leadership about the staffing shortage went unanswered. Review of the resident's medication administration record showed no documentation of insulin administration or blood glucose monitoring for the scheduled morning dose. Nursing progress notes indicated the resident was sleeping and unable to receive medication, but there was no documentation of further attempts to administer medication, no blood sugar checks, and no physician notification. When the day shift nurse arrived, she was informed by a CNA that no licensed nurse had been present overnight, and she did not check the resident's blood sugar until the resident became unresponsive later that morning. The glucometer then displayed a reading of "HI," indicating critically high blood glucose. The resident was found unresponsive and was transferred to the emergency room, where hospital records indicated severe hyperglycemia, altered mental status, and a glucose reading greater than 650. The resident was admitted to the ICU, placed on comfort care, and subsequently passed away. The facility's policies required medications to be administered safely and as prescribed, and for care plans to describe services necessary to maintain the resident's well-being, but these were not followed in this instance.
Failure to Provide 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide 24-hour licensed nursing staff coverage in the skilled nursing unit, resulting in a five-hour period without a licensed nurse present for a census of 73 residents. According to the facility's own policy, licensed nurses and certified nursing assistants are required to be available at all times to ensure resident safety and to provide necessary care. On the night in question, two licensed nurses scheduled for the overnight shift called in and did not report to work. The two nurses from the previous shift extended their hours but left at 2:00 a.m., leaving the unit without licensed nurse coverage from 2:00 a.m. to 7:00 a.m. Interviews with staff confirmed that attempts were made to contact the DON, Director of Staff Development, and the Administrator to find replacements, but no licensed nurse arrived to cover the shift. The staffing scheduler acknowledged that a third name was incorrectly added to the staffing sheet without verification or an employee signature, confirming that this individual did not work the shift. As a result, the skilled nursing unit was left without the required licensed nurse coverage for five hours.
Failure to Administer and Document Insulin and Blood Glucose Monitoring
Penalty
Summary
The facility failed to administer prescribed insulin doses and monitor blood glucose levels as ordered for five out of seven sampled residents with diabetes mellitus type 2. For each of these residents, physician orders specified insulin administration according to a sliding scale and required regular blood glucose monitoring. On a specific date, the Medication Administration Records (MARs) for all five residents showed no documentation of insulin administration or blood glucose checks for the scheduled early morning dose. Additionally, there was no documentation in the nursing progress notes explaining the missed doses, nor any evidence that the attending physicians were notified of these omissions. The affected residents had complex medical histories, including conditions such as hemiplegia, chronic kidney disease, heart failure, osteomyelitis, and recent fractures, in addition to diabetes. Their care plans consistently included interventions to administer diabetes medications as ordered, monitor for side effects and effectiveness, and report abnormal findings to the physician. Despite these care plan directives, the required insulin and blood glucose monitoring were not performed or documented for the specified dose. Interviews with facility staff confirmed that there was no licensed nurse present in the skilled unit during the relevant time frame, resulting in the omission of scheduled medications for multiple residents. The Interim Director of Nursing acknowledged the blank MARs and confirmed that staff should have documented the reason for any missed doses in the progress notes. Facility policies reviewed by surveyors required medications to be administered as prescribed, all services to be documented, and any medication omissions to be recorded as errors.
Failure to Train Licensed Nurse on Electronic Documentation System
Penalty
Summary
The facility failed to ensure that a licensed nurse was trained and competent in using the electronic Point Click Care (PCC) system for documentation and care coordination. According to the facility's policy and procedure, competency evaluations, including training on documentation tools and equipment, were to be conducted upon hire, annually, and as needed. However, during interviews, a licensed nurse supervisor reported not receiving any formal training on the PCC system, and the interim director of nursing confirmed that there were no available records indicating that staff had received such training. This lack of documented training and competency evaluation led to the deficiency.
Failure to Develop Care Plan for Skin Discoloration on Admission
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who was admitted with skin discoloration, specifically two bruises to the left lateral ribs. According to the facility's policy and procedure, an individualized comprehensive care plan with measurable objectives and timetables should be created for each resident to address identified problem areas. Upon review of the resident's admission record and condition on admission, it was confirmed that no care plan was developed to address the resident's skin bruising. This was acknowledged by both the Medical Records staff and the Director of Nursing during interviews and record reviews.
Failure to Develop and Implement Comprehensive Care Plans for New Admissions
Penalty
Summary
A deficiency was identified regarding the facility's failure to develop and implement a comprehensive, person-centered care plan for residents as required by federal regulations. Specifically, the report notes that a resident was admitted to the facility and did not have a care plan developed to address their treatments upon admission. This omission was discovered during a review of new admissions, where it was found that several newly admitted residents with treatment orders did not have corresponding care plans in place. The lack of care plans for these residents meant that their medical, nursing, and psychosocial needs, as identified in their comprehensive assessments, were not formally addressed through measurable objectives and timeframes. The report does not provide additional details about the specific medical history or conditions of the affected residents at the time of the deficiency, but it does confirm that the required documentation and planning for their care was not completed as mandated.
Plan Of Correction
PLAN OF CORRECTION (2567) FOR CA00954971 (F tag: 656) SS= D (DEVELOPMENT/IMPLEMENT COMPREHENSIVE CARE PLAN)
Failure to Re-evaluate Fall Risk on Readmission
Penalty
Summary
The facility failed to conduct a fall risk re-evaluation for a resident upon readmission, despite the resident's prior history of falls. The resident, an elderly male with acute toxic encephalopathy, lack of coordination, and cervical disc degeneration, experienced a fall on 12/18/24, which resulted in right hip pain, bruising, and swelling. This incident led to the resident being transferred to the emergency room on 12/21/24. Upon the resident's return to the facility, there was no documentation of a fall risk re-evaluation, which was confirmed by the Director of Nursing during a record review and interview. The facility's policy and procedures on falls, revised in 9/2021 and 12/2007, require staff to re-evaluate the situation and consider other possible reasons for falls if a resident continues to fall. Additionally, the policies mandate monitoring and documenting each resident's response to interventions aimed at reducing falls. However, these protocols were not followed in the case of the resident, as evidenced by the lack of a fall risk re-evaluation upon readmission, despite the resident's unsteady gait and poor balance noted in the weekly nursing notes.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after the resident experienced a fall and sustained injuries. The resident, who has multiple diagnoses including cerebral palsy, epilepsy, and quadriplegia, was found face down on the floor next to the bed with injuries including an abrasion on the right temple, bruising on the forehead, and redness on the left knee. Despite the incident, the care plan, which was initiated prior to the fall, was not updated to address the specific circumstances of the fall or to implement new interventions to prevent future falls. The facility's policy and procedure for managing falls and fall risk require that staff identify and implement interventions based on the resident's specific risks and causes to prevent falls and minimize complications. However, the Director of Nursing acknowledged that there was no care plan revision following the resident's fall. The facility's failure to update the care plan placed the resident at a higher risk for future falls and injuries, as the existing interventions were not reassessed or modified in response to the incident.
Medication and Procedure Lapses in Resident Care
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding medication management and administration for Resident 1. Medications were left unsecured and unsupervised when a licensed nurse (LN 2) left medication cups on a bedside table in Resident 1's room and exited the room. This action was against the facility's standard practice, which requires medications to be returned to the cart and stored if the resident is not ready. Additionally, medications were administered by another licensed nurse (LN 3) who did not verify the doctor's orders or the Medication Administration Record (MAR) before administering them, which is not in line with the facility's policy that requires the administering nurse to verify the right resident, medication, dose, time, and method before administration. The facility also failed to follow the doctor's order during the administration of medication through a gastrostomy tube. LN 2 administered medication by pushing it through the tube without verifying the placement of the tube, which is against the facility's policy that requires medications to be administered by gravity unless there is a specific doctor's order for a slow push. LN 2 admitted to not having checked the tube placement before administering the medication, which poses an aspiration risk. The facility's policy mandates checking tube placement before medication administration, which was not adhered to in this instance. Furthermore, the facility did not label the oxygen tubing used by Resident 1, which is required by the facility's policy to ensure the tubing is changed every week to prevent infection. The lack of labeling meant that staff could not determine how long the tubing had been in use, which could lead to the accumulation of debris and dried mucus. The Director of Nursing confirmed that the policy is to change and label the tubing weekly, but this was not done, indicating a failure in following the facility's infection prevention procedures.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the local law enforcement as required by federal regulations. The facility's policy and procedure, titled 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program,' mandates the investigation and reporting of any allegations within the required timeframes. However, the facility's investigation report, dated December 23, 2024, indicated that the incident was not reported to the local police department. Additionally, the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) confirmed that a telephone report was not made to law enforcement. During an interview, the Administrator stated that the incident was not reported because the facility concluded the allegation was not substantiated.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, which could have resulted in the resident not receiving needed care. During an observation and interview, the resident was found sitting in a wheelchair next to the bed, with the call light located on the far side of the bed, out of reach. The resident indicated that the call light could not be reached. A certified nursing assistant admitted to being in a hurry and forgetting to move the call light. The Director of Nursing confirmed that the call light should have been placed within the resident's reach. The facility's policy and procedure require staff to ensure the call light is accessible to the resident before leaving the room.
Kitchen Sanitation and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen and food storage sanitation, as evidenced by several observations and interviews. A pair of used gloves was found on the food preparation counter, indicating a lapse in cleanliness and hygiene standards. Additionally, one of the two ice machines was not maintained according to the manufacturer's guidelines. Calcium deposits were observed on the ice machine tray, and there was no cleaning log available, which was confirmed by the maintenance supervisor. The facility's policy required regular cleaning and sanitizing of the ice machine every three months, but this was not adhered to. Furthermore, a kitchen staff member was observed handling food and cleaning surfaces without wearing gloves or performing hand hygiene between tasks. This included cooking mixed vegetables and meatballs, transferring food trays, and wiping down the stove top and counters. The dietary supervisor acknowledged that the staff member should have used clean gloves and performed hand hygiene between these activities. These failures increased the risk of food-borne illness for residents due to potential contamination.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as observed during a survey. Resident 443 was found lying in bed with one side of the bed pushed against a wall and the other side blocked by a locked transfer chair. The resident expressed that their family wanted the chair positioned there for safety reasons, due to a previous fall in the facility. However, there was no physician order for this setup, and the resident had not been assessed for their ability to move the chair. Additionally, no care plan had been developed to address this situation. Licensed Nurse 4 acknowledged that the placement of the chair was a family request and admitted it was not appropriate. The Director of Nursing confirmed that the arrangement restricted the resident's movement, constituting a physical restraint. The facility's policy on restraints requires that any restraint use must be medically justified, with informed consent obtained, and alternative measures considered. The policy also mandates regular reviews of residents on restraints to explore less restrictive options or eliminate restraints altogether. In this case, these procedures were not followed, leading to the deficiency.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to potential inadequacies in care. For Resident 8, the MDS assessments dated 7/14/24 and 7/17/24 inaccurately indicated that the resident was not taking anticoagulant medication, despite an active order for Warfarin Sodium, a medication prescribed to prevent blood clots. This discrepancy was confirmed during a review with a licensed nurse, who acknowledged the oversight. For Resident 13, the MDS assessment dated 6/20/24 incorrectly documented the resident as comatose. However, during an observation and interview, the resident was found to be alert and capable of communication. This error was confirmed by the same licensed nurse during a subsequent review. The facility's policy requires all individuals completing any portion of the MDS to attest to the accuracy of the information, which was not adhered to in these cases.
Failure to Implement and Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure comprehensive person-centered care plans were developed and implemented for two residents. For Resident 79, the care plan intervention for managing the risk of shortness of breath was not followed. The resident was admitted with diagnoses including heart failure and sleep apnea, and the physician's orders specified oxygen inhalation at 2 liters per minute (lpm) via nasal cannula to maintain oxygen saturation above 90 percent. However, during an observation, it was found that the oxygen was set at 5 lpm instead of the prescribed 2 lpm, which was acknowledged by a licensed nurse as a deviation from the care plan. For Resident 13, the facility did not develop a care plan to address the resident's hearing needs. The resident was admitted with diagnoses including cerebral infarct, encephalopathy, heart disease, and unspecified hearing loss. During a review, it was confirmed by the MDS licensed nurse and the director of nursing that there was no care plan for hearing loss in the resident's electronic medical record or paper chart. This lack of a care plan for hearing needs was a failure to meet the resident's identified needs as per the facility's policy on comprehensive person-centered care plans.
Failure to Implement Dietitian's Recommendations for Tube Feeding
Penalty
Summary
The facility failed to ensure adequate nutrition for a resident, identified as Resident 43, who was receiving gastrostomy tube feedings. The Registered Dietitian (RD) recommended an increase in the resident's gastrostomy tube feeding to address significant weight loss and increased nutrient needs related to wound healing. Despite these recommendations, the necessary changes to the feeding regimen were not ordered or implemented. The resident experienced a weight loss of 11 pounds over six months, which was a 7.6% decrease in weight, and the feeding remained at 50ml/hr instead of the recommended 55ml/hr. The RD's recommendations were not communicated effectively to the physician for order implementation. The RD explained that after writing recommendations, they are given to the nurses, who are responsible for notifying the physician to obtain the order. However, this process was not followed in June, and the RD did not follow up, assuming the nurses would handle it. The facility's policy required dietary recommendations to be completed within three days of receiving the RD's report, but this was not adhered to, contributing to the deficiency.
Unsigned POLST Form for a Resident
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) form for one of the sampled residents, Resident 68, was signed by a physician. During an interview and record review, it was observed that the POLST, dated May 9, 2024, lacked a physician's signature. A licensed nurse, LN 2, acknowledged the missing signature and noted that the form was flagged with a sticker to indicate the need for a signature. This oversight had the potential to affect Resident 68's healthcare wishes during a medical emergency, as the POLST is a critical document for communicating a resident's treatment preferences.
Medication Storage Temperature Deficiency
Penalty
Summary
The facility failed to maintain an optimal temperature in the medication storage refrigerator located in Nurse Station One. During an observation and interview, a licensed nurse confirmed that the refrigerator thermostat read 50 degrees Fahrenheit, which is above the recommended temperature range for storing refrigerated medications. The facility's policy and procedure for medication storage and labeling specifies that drugs requiring refrigeration should be stored between 36 and 46 degrees Fahrenheit. This discrepancy in temperature control was identified as a potential issue that could result in refrigerated medications being less effective.
Lack of Qualified Dietary Supervisor in Absence of Full-Time Dietitian
Penalty
Summary
The facility failed to employ a qualified dietary supervisor in the absence of a full-time registered dietitian to oversee its kitchen and food service operations. During an interview, the dietary supervisor (DS 1) revealed that he had been employed at the facility for several years and had assumed the position of dietary supervisor a month and a half ago, but he was not certified as a dietary supervisor. A review of the kitchen staff credentials showed that DS 1 was only certified as a Food Handler, which indicates completion of a food safety course approved by the state. The facility's administrator confirmed that the registered dietitian was not employed full-time and that DS 1 had attended a dietary supervisor training program, but no documentation of this training was available. The facility's job description for the Director of Food Services required the individual to be a graduate of an accredited course in dietetic training approved by the American Dietetic Association and to be registered as a Food Service Director in the state. This deficiency had the potential to result in residents not receiving correct diets and an increased risk of food-borne illness due to the lack of proper staff education and training.
Infection Control Deficiency in Oxygen Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection control measures for storing oxygen therapy equipment for two residents. During an observation and interview with the Infection Preventionist Nurse, it was noted that Resident 83's nasal cannula was found on the floor while still connected to the oxygen concentrator. Additionally, Resident 57's nasal cannula was observed on the bedside table, and the nebulizer mask was on the side table. Both pieces of equipment had plastic bags provided for storage when not in use, but they were not stored in them. The Infection Preventionist Nurse acknowledged these findings and confirmed that the equipment should have been stored in the provided plastic bags, as per the facility's policy and procedures dated October 2017, which stated that tubing, masks, and cannulas should be placed in a labeled plastic bag.
Failure to Document COVID-19 Vaccination Offer and Education
Penalty
Summary
The facility failed to provide documentation indicating that it had offered or explained the risks and benefits of a COVID-19 vaccination to one of the sampled residents, identified as Resident 443. The review of Resident 443's admission record revealed that the resident was admitted to the facility on an unspecified date and was later diagnosed with COVID-19, with an onset date of June 7, 2024. During a concurrent record review and interview with the Infection Preventionist (IP), it was confirmed that there was no documentation showing that Resident 443 had been offered the COVID-19 vaccine, refused it, or had previously received it prior to admission. The facility's policy and procedure titled 'Refusal of COVID-19 Vaccination' states that all residents should be offered vaccines unless medically contraindicated, for religious beliefs, or if the resident has already been vaccinated. The policy also requires that residents or their legal representatives be provided with information and education regarding the benefits and potential side effects of vaccinations, and that this provision of education be documented in the resident's medical record. Additionally, all new residents should be assessed for their current vaccination status upon admission, and any refusal of the COVID-19 vaccine should be documented in detail in the resident's medical record. The lack of documentation for Resident 443 indicates a failure to adhere to these procedures.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 12, which could potentially lead to unmet needs or delayed care. During an observation, the call light was found on the floor and out of reach of Resident 12, who was lying in bed. This was confirmed during a subsequent observation and interview with a Certified Nursing Assistant (CNA 1), who acknowledged that the call light should not have been on the floor and was indeed out of reach of the resident. The facility's policy and procedure titled 'Answering the Call Light,' dated October 2020, states that when a resident is in bed or confined to a chair, the call light should be within easy reach. This policy was not adhered to in the case of Resident 12, as evidenced by the observations and CNA 1's confirmation.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for three unsampled residents, which had the potential to negatively impact their psychosocial status. During an observation and interview with the maintenance supervisor, it was noted that Resident 9's and Resident 12's rooms had portions of the wall with peeling paint and missing plaster, while Resident 14's room had a ceiling with cracked and peeling paint. The maintenance supervisor confirmed the disrepair in these areas and acknowledged that these issues had not been reported by staff or logged in the facility maintenance log. The facility's policy and procedure documents indicated a commitment to providing a safe, functional, and comfortable environment, and maintaining the building in good repair and free from hazards.
Failure to Develop Baseline Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was assessed as high risk for falls within 48 hours of admission. The facility's policy and procedures require that a baseline care plan be developed for each resident within 48 hours of admission to provide effective and person-centered care. However, during a review of the resident's records, it was confirmed that no baseline care plan for fall risk was documented for this resident. The resident, who was admitted with diagnoses including polyneuropathy, hypertension, and atherosclerotic heart disease, had a fall risk assessment score indicating a high risk for falls. Despite this, the facility did not implement its fall prevention program, which includes identifying high-risk residents with a yellow star sticker and a yellow-colored name band. An observation revealed that the yellow star sticker was not posted outside the resident's room, and the Director of Nursing acknowledged that this was an oversight.
Violation of Resident's Right to Self-Determination and Privacy
Penalty
Summary
The facility failed to honor the resident's right to self-determination and privacy, resulting in a deficiency concerning Resident 2. The facility did not allow Resident 2 to choose their shower time, as evidenced by an incident where a Certified Nursing Assistant (CNA 2) insisted on giving Resident 2 a shower despite their refusal. Resident 2, who has a BIMS score of 12 indicating moderate cognitive impairment, expressed a desire to delay the shower while watching a game, but CNA 2 was persistent and did not respect the resident's wishes. Additionally, the facility did not maintain Resident 2's privacy during the showering process. Resident 2 was left fully naked in a shower chair at the foot of their roommate's bed, with the blinds open, leading to feelings of humiliation. This was corroborated by Resident 1, who witnessed the event, and Resident 2's family member, who reported that Resident 2 was upset about the lack of privacy. The facility's policy requires residents to be covered and their privacy maintained during such procedures, which was not adhered to in this case.
Failure to Monitor Resident After Allegation of Mistreatment
Penalty
Summary
The facility failed to monitor a change in behavior for a resident following an allegation of staff mistreatment. The incident involved a certified nursing assistant (CNA) who was reportedly rough with the resident during shower time, as noted in the Nursing Notes. The resident expressed dissatisfaction with the CNA's behavior, and the family and Director of Nursing (DON) were informed. However, there were no subsequent entries in the resident's records to indicate that the facility monitored the resident for any psychosocial changes after the incident. During an interview, the DON confirmed that the facility did not implement a Change of Condition (COC) monitoring for the resident, which should have been done for 72 hours to assess any behavioral changes following the mistreatment allegation.
Incomplete Medical Records for Resident's Shower Day Skin Inspection
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 2, when a Shower Day Skin Inspection was not documented for a shower provided on May 4, 2024. According to the facility's policy and procedure titled 'Shower/Tub Bath,' dated October 2010, specific information should be recorded on the resident's ADL record and/or medical record, including the date and time of the shower, the name and title of the individual(s) assisting, and any assessment data such as skin changes. During an interview on May 15, 2024, the Director of Nursing confirmed that Resident 2 received a shower on the specified date. However, a review of the resident's Shower Day Skin Inspection forms for April and May 2024 revealed no record for May 4, 2024. Both the Director of Nursing and the Director of Staff Development confirmed the absence of the required documentation, acknowledging that it should have been present in the resident's file.
Inaccurate Medication Administration Record
Penalty
Summary
The facility failed to maintain accurate medical records for a resident when it was documented that a medication was administered twice when it was not. Specifically, the Medication Administration Record (MAR) for a resident indicated that Clobazam 30 mg, a controlled medication prescribed for seizures, was administered at 9 p.m. on two separate days, even though the medication was not available and therefore not given. This discrepancy was confirmed by both Licensed Nurses involved, who acknowledged that the medication was not administered due to its unavailability. The facility's policy and procedure for medication administration required that medications be charted immediately after each administration. However, the MAR inaccurately reflected that the medication was given, and the Record of Controlled Substances showed no signatures for the medication being dispensed on the specified dates. Interviews with the Licensed Nurses confirmed the medication was not administered, and one nurse admitted to overlooking and signing the MAR incorrectly.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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