Socal Post-acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Whittier, California.
- Location
- 7931 S. Sorenson Ave., Whittier, California 90606
- CMS Provider Number
- 055168
- Inspections on file
- 29
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Socal Post-acute Care during CMS and state inspections, most recent first.
Two residents who had undergone orthopedic surgery did not receive proper care during transfers due to CNAs lacking competency and knowledge of required precautions. One resident suffered a new fracture after staff failed to follow transfer instructions, while another had physician orders disregarded regarding positioning. Staff interviews and record reviews revealed that CNAs had not been assessed for competency in transferring residents with recent orthopedic procedures, and facility policies requiring individualized transfer methods and demonstrated competencies were not followed.
Two residents experienced deficiencies in medication management, including a missing bubble pack of Dilaudid for a resident with amputations and neuropathy, and improper administration and documentation of Alprazolam for a resident with dementia. Staff failed to consistently verify medication quantities and document administration as required, leading to discrepancies between medication records and actual counts.
A resident with dementia and osteoarthritis experienced a fall and reported ankle pain, leading to a physician-ordered x-ray. The facility failed to follow up with the radiology company to obtain the x-ray results, resulting in a delay of several days before the fracture was identified and the physician was notified. Multiple nurses did not communicate or escalate the missing report, and the DON was unaware of the issue until after the delay, contrary to facility policy requiring timely notification of changes in condition and test results.
The facility failed to manage its trash disposal, resulting in an overflowing trash bin and scattered trash in the parking lot, visible from residents' windows. The Dietary Director and Maintenance Director acknowledged the issue, noting that trash should be in the container to prevent attracting pests. The Director of Nursing reviewed the facility's policy, emphasizing the need for a clean and homelike environment.
The facility failed to label an open pack of ground beef in the freezer with an opening date, as required by its policy. The Dietary Director acknowledged the oversight, noting the potential risk of food-borne illnesses if residents consume the unlabeled meat. The DON emphasized the importance of labeling to prevent serving expired food, which could lead to health issues for the 54 residents receiving meals from the facility's kitchen.
A resident's Advance Directive Acknowledgment Form was not completed upon admission, despite the resident's inability to make decisions due to medical conditions. The Social Services Designee confirmed the oversight, which could lead to misinformation about the resident's medical care and treatment preferences.
A facility failed to ensure a resident with diabetes received appropriate care upon readmission from a hospital. The resident did not receive necessary insulin and blood sugar monitoring due to a lack of verification of discharge orders with the attending physician. The Director of Nursing confirmed the absence of orders, and interviews revealed that the admitting nurse did not verify the continuation of insulin orders, despite the resident's history of diabetes management.
A facility failed to ensure the accuracy of the MDS for a resident with diabetes mellitus, leading to the absence of physician orders for diabetes management. Despite the resident's MDS indicating an active diagnosis of diabetes and insulin administration, there were no current orders for diabetic management upon readmission. The DON confirmed the lack of orders and the MDSN admitted to miscoding the MDS, highlighting a failure to accurately assess the resident's status.
A facility failed to update a resident's care plan for diabetes management upon readmission, resulting in the absence of physician orders for insulin and blood sugar checks. Despite having a history of diabetes mellitus, the care plan was not revised to reflect current orders, potentially impacting the resident's treatment. The DON confirmed the oversight, highlighting the need for clarification with the physician to ensure proper diabetes management.
A facility failed to conduct a comprehensive nutritional assessment for a resident with diabetes mellitus, leading to the absence of appropriate dietary orders upon readmission. The resident, who had been receiving insulin prior to readmission, did not have orders for diabetic management, which the DON confirmed could result in uncontrolled blood sugar levels. The CD missed the diabetes diagnosis during the nutritional assessment, leading to an incorrect diet being prescribed.
A resident with chronic respiratory failure was not receiving the correct oxygen flow rate as ordered by their physician. The resident's oxygen machine was set at 4.5 LPM, exceeding the prescribed 2 to 4 LPM range. This was confirmed by an LVN and acknowledged by the DON, who emphasized the importance of correct oxygen dosing to prevent hyperoxygenation. The facility's policy on oxygen administration was reviewed, but the deficiency in practice was evident.
A facility failed to ensure that a physician responded to a consultant pharmacist's recommendation for lab monitoring for a resident with Type 2 diabetes and major depressive disorder. Despite the pharmacist's suggestion for a Basic Metabolic Panel, there was no documented response from the physician, and the Director of Nurses confirmed the lack of communication. This deficiency highlights a failure to adhere to the facility's policy on medication regimen reviews.
A facility failed to limit PRN orders for Ativan to 14 days for a resident with anxiety, lacking a stop date or rationale for extension. The resident's order, initiated without an end date, was not evaluated by the attending physician as required by facility policy, increasing the risk of adverse effects.
A facility failed to maintain infection control by not ensuring proper PPE use and disposal in a resident's Enhanced Barrier Precautions (EBP) room. An LVN was unaware of PPE requirements during high-contact care and disposed of soiled PPE outside the resident's room, contrary to facility policy. Interviews with the DON and infection prevention nurse confirmed the importance of proper PPE use and disposal to prevent infection spread.
A resident with dementia and high fall risk experienced two unwitnessed falls shortly after admission, resulting in a head laceration. The facility failed to increase supervision or update the care plan after the first fall, and did not consistently assist with toileting. Staff interviews revealed inadequate monitoring and documentation, and the DON acknowledged the need for more frequent supervision.
A resident dependent on staff for personal hygiene and toilet use was left wet with urine for an extended period, contrary to the care plan and facility policies. The resident reported multiple instances of not receiving timely assistance after activating the call light, leading to feelings of frustration and humiliation. Interviews with staff revealed that call lights were not answered promptly, as required by facility policy.
Failure to Ensure CNA Competency in Post-Orthopedic Surgery Transfers
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) were competent in providing appropriate care and services during resident transfers for two residents who had undergone orthopedic surgery. For one resident with a recent left femur fracture and surgery, records indicated that the care plan required immobilization of the affected joints and assistance with transfers. However, during a transfer observed by a family member, two nurses twisted the resident's left leg, resulting in the resident yelling in pain and subsequently being found to have sustained a new fracture, necessitating a second surgery. The family member reported that the physical therapist had provided specific instructions for safe transfers, which were not followed by the staff involved. Another resident, admitted after joint replacement surgery, had physician orders specifying that two folded pillows should be placed under the heel while in bed and that no pillow should be placed under the knee. Despite these orders, a family member observed that nurses repeatedly placed a pillow under the resident's knee, contrary to the physician's instructions. Interviews with CNAs revealed a lack of knowledge regarding the type of surgery the resident had undergone and the necessary precautions for safe transfers. One CNA incorrectly stated that the resident's leg should be crossed during transfers, which was contradicted by the physical therapist, who emphasized the importance of keeping the legs aligned. A review of staff competency files showed that the facility had not conducted skill competencies for CNAs regarding resident transfers, particularly for those who had undergone hip or knee surgery. The Director of Staff Development confirmed that such competencies were not part of the CNA skill competency list. The facility's policies required staff to follow individualized transfer methods as identified in the care plan and to demonstrate specific competencies necessary for resident care, but these requirements were not met in practice.
Failure to Account for and Administer Medications as Ordered
Penalty
Summary
The facility failed to properly account for and administer medications as ordered by physicians for two residents. For one resident with a history of bilateral leg amputations, neuropathy, and significant pain, the facility did not account for a full delivery of Dilaudid 4 mg tablets. Pharmacy records and delivery sheets confirmed that 120 tablets were delivered in two bubble packs, but only one bubble pack and one Controlled Medication Count Sheet (CMCS) were present and accounted for. Staff interviews revealed confusion and lack of verification regarding the number of bubble packs and the corresponding CMCS, with some staff only checking the quantity upon initial receipt and not during subsequent shift counts. The Director of Nursing confirmed that staff were not consistently verifying the total quantity received and remaining, as required by facility policy, which led to a missing bubble pack and incomplete documentation. For another resident with severe cognitive impairment, dementia, and psychosis, the facility failed to administer Alprazolam 0.25 mg as ordered by the physician. The medication was given 55 minutes earlier than prescribed, and this administration was not documented in the Medication Administration Record (MAR), although it was recorded on the CMCS. The resident's care plan required anti-anxiety medications to be administered as ordered, with monitoring for side effects and effectiveness. Staff interviews and record reviews confirmed the discrepancy between the CMCS and the MAR, and the Director of Nursing acknowledged that the failure to document the administration in the MAR was a violation of facility policy. Observations and interviews with nursing staff indicated inconsistent practices in medication counting, documentation, and verification. Staff often focused on the number of medications left rather than the total quantity received, leading to discrepancies and missing medications. Facility policies required reconciliation of controlled substances upon receipt, administration, and at each shift change, but these procedures were not consistently followed. The deficiencies resulted in a lack of accountability for controlled substances and improper administration and documentation of medications.
Delayed Follow-Up on X-Ray Results After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide care and services as ordered by the physician and as indicated in facility policy for a resident who experienced a fall and subsequently reported pain. The resident, who had a history of dementia and osteoarthritis and required assistance with daily activities, fell and later complained of ankle pain. An x-ray was ordered by the physician, and the imaging was performed the following day. However, the facility did not follow up with the radiology company to obtain the x-ray results in a timely manner. The x-ray, which revealed a nondisplaced complete transverse fracture of the medial malleolus and distal fibula, was not received by the facility until two days after it was performed. Multiple nursing staff members failed to follow up on the pending x-ray report, and there was a lack of communication and endorsement between shifts regarding the need to obtain the results. One nurse contacted the radiology company and learned of technical issues delaying report delivery but did not escalate the issue to the DON or ensure the physician was notified within the facility's required timeframe. As a result, the physician was not notified of the abnormal x-ray findings until several days after the imaging was performed, delaying the resident's transfer to the hospital for further care. The facility's policy required that changes in a resident's condition and test results be reported to the physician within 24 hours, but this standard was not met in this case.
Overflowing Trash Bin in Facility Parking Lot
Penalty
Summary
The facility failed to ensure that its trash bin was not overflowing, leading to trash being disposed of on the ground in the facility's parking lot. This was observed during a concurrent observation and interview with the Dietary Director (DD) and the Maintenance Director (MNTD). Both directors acknowledged the presence of various types of trash, including open boxes, broken containers, wooden pallets, and broken decorations, scattered on the parking lot floor within view of residents' windows. The DD and MNTD both stated that trash should be disposed of in the trash container and not on the ground, as it could potentially attract animals and bugs. During a concurrent interview and record review with the Director of Nursing (DON), the facility's policy and procedure titled 'Homelike Environment' was reviewed. The policy indicated that residents should be provided with a safe, clean, comfortable, and homelike environment, which includes a clean, sanitary, and orderly setting. The DON stated that seeing trash outside the window or scattered in the parking lot does not create a homelike environment and could make residents feel like the facility is dirty.
Failure to Label Opened Food Items
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the labeling and dating of food items, as evidenced by an observation of an open pack of ground beef in the facility's freezer without an opening date. During an interview, the Dietary Director acknowledged the absence of an opening date on the ground beef, expressing concern about not knowing how long the item had been opened, which could potentially lead to food-borne illnesses if consumed by residents. The Director of Nursing confirmed the importance of labeling opened food items to track their freshness and prevent the serving of expired or old food, which could result in health issues such as food poisoning and vomiting for the 54 residents who receive meals prepared in the facility's kitchen.
Incomplete Advance Directive Acknowledgment Form
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive Acknowledgment Form was completed upon admission. The resident, who was admitted with conditions including hemiplegia, hemiparesis, dysphagia, and abnormalities of gait and mobility, did not have the capacity to understand and make decisions. Despite this, the Advance Directive Acknowledgment form was incomplete and not signed by the resident or their responsible party. During a review, the Social Services Designee confirmed that the form was not completed and acknowledged that it should have been filled out entirely to ensure that the resident's wishes were known in case of an emergency. The facility's policy indicates that residents have the right to formulate an Advance Directive, and these directives should be honored according to state law and facility policy. The failure to complete the form could lead to misinformation regarding medical care and treatment, potentially not honoring the resident's wishes when they or their responsible party are unable to make healthcare decisions.
Failure to Verify Diabetic Management Orders for Readmitted Resident
Penalty
Summary
The facility failed to ensure that Resident 53, who was readmitted from a General Acute Care Hospital (GACH), received treatment and care in accordance with professional standards of practice and the facility's policy. Resident 53, diagnosed with Type 2 diabetes mellitus, did not receive the necessary diabetic management and medications from 12/8/2024 to 1/12/2024. The facility did not verify all appropriate discharge orders from GACH 1 with the attending physician upon the resident's readmission, resulting in a lack of insulin administration and blood sugar monitoring. Upon review of Resident 53's medical records, it was found that prior to readmission, the resident was receiving insulin aspart injections according to a sliding scale for blood sugar management. However, after readmission, there were no physician orders for insulin or blood sugar checks documented in the Order Summary Report. The Director of Nursing (DON) confirmed the absence of these orders and acknowledged that the orders should have been clarified with the attending physician to ensure proper diabetic management. Interviews with the nursing staff revealed that the admitting nurse did not verify the continuation of insulin orders with the attending physician, despite the resident's history of diabetes management. The attending physician, Physician 1, stated that he expected the licensed nurse to inform him of any changes in medication orders. The facility's policy requires that physician orders for immediate care be available at the time of admission to meet the resident's care needs, which was not adhered to in this case.
Inaccurate MDS Assessment for Diabetic Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident diagnosed with diabetes mellitus, which resulted in the absence of physician orders for diabetes management. The resident, who had a history of diabetes mellitus, acute pulmonary edema, and end-stage renal disease, was readmitted to the facility without orders for insulin or blood sugar monitoring. Despite the resident's MDS indicating an active diagnosis of diabetes mellitus and the administration of insulin, the facility's records did not reflect any current orders for diabetic management. The Director of Nursing (DON) confirmed that the resident had a diagnosis of diabetes mellitus but acknowledged the lack of physician orders for insulin or blood sugar checks upon readmission. The DON stated that the purpose of clarifying orders with the physician was to ensure the resident's need for insulin was addressed. However, the DON admitted that there was a failure to clarify these orders with the physician, which could lead to uncontrolled blood sugar levels. The Minimum Data Set Nurse (MDSN) also verified that the resident had an active diagnosis of diabetes mellitus but admitted to miscoding the MDS. The MDSN explained that the MDS assessment should accurately reflect the resident's status for reimbursement purposes. The facility's policy on the accuracy of assessments emphasized the need for assessments to represent an accurate picture of the resident's status, but this was not achieved in this case.
Failure to Revise Care Plan for Diabetes Management
Penalty
Summary
The facility failed to revise the care plan for a resident diagnosed with diabetes mellitus, which resulted in the absence of physician orders for diabetes management. The resident, who had a history of diabetes mellitus, acute pulmonary edema, and end-stage renal disease, was readmitted to the facility without orders for insulin or blood sugar checks. Despite having an active care plan for diabetes management, the care plan was not updated to reflect the current physician orders, leading to a potential gap in the resident's diabetes treatment. The resident's medical records indicated that prior to readmission, insulin was administered according to a sliding scale. However, upon readmission, the Order Summary Report did not include any orders for insulin or blood sugar monitoring. The Director of Nursing (DON) confirmed the absence of these orders and acknowledged the need for clarification with the physician to ensure proper diabetes management. The facility's policy requires that care plans be revised when a resident is readmitted from a hospital stay. However, the Minimum Data Set Nurse (MDSN) verified that the care plan did not reflect the current physician orders, emphasizing the importance of updating the care plan to guide staff in managing the resident's diabetes. This oversight in revising the care plan could lead to the resident not receiving appropriate treatment for diabetes management.
Failure to Conduct Comprehensive Nutritional Assessment for Diabetic Resident
Penalty
Summary
The facility failed to ensure a comprehensive nutritional assessment for a resident diagnosed with diabetes mellitus, which could potentially result in the resident not receiving the appropriate diet and nutritional needs. The resident, who had a history of diabetes mellitus, was readmitted to the facility without a proper assessment of her dietary needs related to her condition. The facility's records indicated that the resident had been receiving insulin as per a sliding scale prior to her readmission, but upon her return, there were no orders for insulin or blood sugar checks. The Director of Nursing (DON) confirmed that there were no physician orders for diabetic management upon the resident's readmission, which could lead to uncontrolled blood sugar levels. The DON acknowledged that the orders should have been clarified with the physician to ensure the resident's diabetes was managed appropriately. Additionally, the Consultant Dietitian (CD) admitted to missing the resident's diabetes diagnosis during the nutritional assessment, resulting in an incorrect diet being prescribed. The facility's policy required a nutritional assessment to be conducted by a multidisciplinary team, identifying clinical conditions and risk factors affecting the resident's nutritional status. However, the oversight in recognizing the resident's diabetes diagnosis and the lack of appropriate dietary orders demonstrated a failure in adhering to this policy. This deficiency highlights the need for accurate and comprehensive assessments to ensure residents receive the necessary care for their medical conditions.
Oxygen Flow Rate Mismanagement for Resident with Chronic Respiratory Failure
Penalty
Summary
The facility failed to ensure that a resident with chronic respiratory failure was receiving the appropriate oxygen flow rate as ordered by the attending physician. The resident, who was admitted with diagnoses including chronic respiratory failure and pulmonary embolism, had a physician order to receive oxygen at 2 to 4 liters per minute (LPM) via nasal cannula continuously. However, during an observation, it was noted that the resident's oxygen machine was set at 4.5 LPM, exceeding the prescribed range. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the oxygen setting was not in accordance with the physician's order. The resident's care plan and medication administration record both indicated the need for oxygen therapy at the specified rate, yet the facility's failure to adhere to this order posed a risk of hyperoxygenation. The Director of Nursing (DON) confirmed the importance of administering the correct oxygen dose to prevent potential adverse effects such as hyperoxygenation, which could lead to seizures and injury. The facility's policy on oxygen administration was reviewed, highlighting the need for proper oxygen flow adjustment, but the deficiency in practice was evident in the observed deviation from the prescribed oxygen flow rate.
Failure to Communicate Pharmacist's Recommendation
Penalty
Summary
The facility failed to ensure that the attending physician responded to a recommendation made by the consultant pharmacist regarding laboratory monitoring for a resident. The resident, who was admitted and readmitted to the facility with diagnoses including Type 2 diabetes mellitus and major depressive disorder, had the capacity to understand and make decisions. The consultant pharmacist conducted a medication regimen review and recommended that the resident's primary physician clarify if it was clinically appropriate to perform a Basic Metabolic Panel (BMP) lab test. However, there was no documented response from the attending physician to this recommendation. The Director of Nurses confirmed during an interview that there was no documentation indicating that the facility had informed the resident's physician of the consultant pharmacist's recommendation. The facility's policy on medication regimen reviews, revised in August 2019, states that findings and recommendations should be reported to the director of nursing and the attending physician. The lack of communication and documentation regarding the pharmacist's recommendation represents a deficiency in the facility's adherence to its own policies and procedures.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that PRN orders for the psychotropic medication Ativan were limited to a duration of 14 days and evaluated for continued use for a resident taking psychotropic medications. The resident's physician order for Ativan, which was initiated on 12/17/2024, did not include a stop date. This oversight was identified during a review of the resident's Order Summary Report dated 1/11/2025, which indicated the medication was prescribed to be taken as needed for anxiety-related symptoms without a specified end date. During an interview and concurrent record review with the Director of Nursing (DON), it was confirmed that the Ativan order did not include a stop date or a rationale for extending the medication beyond the 14-day limit. The facility's policy requires that PRN psychotropic medications be renewed every 14 days and evaluated by the resident's attending physician before renewal. The lack of adherence to this policy increased the risk of adverse effects for the resident, who had a history of hemiplegia, hemiparesis, and type 2 diabetes mellitus.
Inadequate PPE Use and Disposal in EBP Room
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the spread of infections, as observed in the case of a resident with Enhanced Barrier Precautions (EBP) due to a gastrostomy tube. The Licensed Vocational Nurse (LVN) responsible for the resident was not fully aware of the requirements for wearing personal protective equipment (PPE) during high-contact care activities, such as using the feeding tube. During a medication administration observation, the LVN initially did not have access to an isolation cart with PPE at the entrance of the resident's room and had to find an isolation gown elsewhere. This indicates a lack of proper PPE availability and awareness of EBP protocols. Additionally, the LVN improperly disposed of the soiled PPE by exiting the resident's room and discarding the gown in a soiled linen bin across the hall, rather than in a disposal bin inside the resident's room. This action was contrary to the facility's policy, which required PPE to be disposed of inside the resident's room to prevent the spread of infection. Interviews with the Director of Nursing and the infection prevention nurse confirmed the importance of wearing PPE during high-risk activities and disposing of it properly to protect both staff and residents. The facility's policy and signage also emphasized these practices, highlighting the deficiency in adherence to infection control protocols.
Inadequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to a resident with dementia, Guillain-Barre syndrome, and a high risk for falls. The resident experienced two unwitnessed falls shortly after admission, resulting in a laceration to the back of the head that required medical attention. The facility did not increase the resident's supervision needs or develop an individualized care plan after the first fall, as required by their policy. The facility also failed to implement the resident's care plan for monitoring and frequent visual checks after the initial fall. The staff did not analyze the risk or identify trends in the resident's fall incidents, which were associated with frequent attempts to get out of bed and an inability to void. The resident required assistance with toileting, but this was not consistently provided, contributing to the falls. Interviews with staff revealed that the facility did not have a system in place to indicate the frequency of monitoring, and documentation of the resident's whereabouts was insufficient. The Director of Nursing acknowledged that the care plan was not updated to reflect the resident's continuous fall risk, and additional interventions such as one-to-one supervision were not implemented, which could have potentially prevented the second fall.
Failure to Provide Timely Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident's ability to perform activities of daily living (ADL) did not diminish. The resident, who was dependent on staff for personal hygiene and toilet use, was left wet with urine for an extended period, contrary to the care plan and facility policies. The resident, who had no cognitive impairment and was at risk for skin breakdown due to incontinence, reported multiple instances of not receiving timely assistance after activating the call light. The resident expressed feelings of frustration and humiliation due to being left in a wet diaper. Interviews with facility staff revealed that the call lights were not answered promptly, as required by the facility's policy. The Interim Director of Nursing acknowledged the incident, stating that the CNA was busy with another resident at the time. The Director of Staff Development emphasized the importance of answering call lights immediately, as delays could pose life-threatening risks. A CNA confirmed finding the resident wet and frustrated, with urine on the floor, after the call light had been activated multiple times without response.
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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