South Coast Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Ana, California.
- Location
- 1030 W Warner Ave, Santa Ana, California 92707
- CMS Provider Number
- 055653
- Inspections on file
- 34
- Latest survey
- October 29, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at South Coast Post Acute during CMS and state inspections, most recent first.
The facility did not conduct thorough investigations into two separate abuse allegations, as required by policy. In both cases, potential resident witnesses who may have observed the incidents were not interviewed, and there was no documentation explaining the omission. The DON confirmed that these interviews should have been conducted to ensure a complete investigation.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to proper transition planning.
Two residents' Out on Pass Logs were found to have missing entries, including times of departure and return as well as nurse initials, despite facility policy requiring complete and accurate documentation. The DON confirmed that nurses were expected to sign the log, and both the DON and Administrator acknowledged the incomplete records during the survey.
Two residents with histories of aggressive behavior engaged in a physical altercation in their shared room, resulting in minor injuries. Both had documented behavioral issues, including aggression and responding to internal stimuli, and staff were aware of these risks. The facility did not effectively intervene to prevent the incident, as required by its abuse prevention policy.
A resident's medical record lacked a signed admission physician's order in the EHR after readmission and discharge to a hospital. The signed order was not found during review, and when later produced, it was signed after the fact and pre-dated, resulting in inaccurate documentation.
A resident with a documented history of aggressive behavior pushed another resident into a wall after being bumped in the hallway, causing facial injuries and a cervical spine injury. Despite prior incidents and requests for separation, the two residents were not adequately separated, and staff did not intervene effectively to prevent the altercation.
The facility did not report suspected abuse and resident-to-resident altercations to authorities within the required timeframe. Incidents included a resident with visible injuries after alleged physical abuse by staff, another resident reporting verbal abuse by staff, and two residents involved in repeated physical altercations, with one sustaining injuries. Facility leadership acknowledged that these incidents were not reported as required by policy.
The facility did not follow its abuse investigation policies for multiple residents, including failing to remove a staff member accused of assault, not interviewing witnesses, delaying the start of investigations, and not separating residents involved in repeated altercations. These actions resulted in unaddressed allegations and visible injuries among residents.
Surveyors found that the facility did not develop or update care plans for three residents: one with repeated falls and physician-ordered floor mats, another with severe unaddressed weight loss, and a third who sustained facial abrasions after an altercation. The DON and Registered Dietician confirmed that these care needs were not reflected in the residents' care plans.
A resident sustained facial and neck bruising, swelling, and scratches after staff used manual restraint during a de-escalation incident involving aggressive behavior over access to water. Staff and DON confirmed the injuries occurred during a physical struggle when attempts at therapeutic communication failed, and the resident was restrained on the ground.
A LTC facility failed to ensure safe IV therapy for four residents, leading to potential complications. A resident's IV tubing contained air bubbles, another's midline dressing was not labeled or monitored, a third resident's PIV line was not discontinued after therapy, and a fourth's PIV site was undated. These deficiencies risked infection and other complications.
The facility failed to maintain food safety and sanitation standards, with observations of trash and clutter in food preparation areas, unclean equipment, and unlabeled personal food items in residents' rooms. These deficiencies posed a risk of foodborne illnesses for residents consuming food prepared in the facility.
A facility failed to obtain informed consents for the administration of psychotropic medications to a resident upon readmission. The medications, including olanzapine, quetiapine, and valproic acid, were prescribed for managing psychosis and mood lability. Facility staff confirmed the absence of informed consents in the resident's medical record, despite policy requirements for obtaining and verifying consent prior to medication administration.
A facility failed to maintain a copy of a resident's advance directive in their medical record, as required by their policies. Despite the resident having an advance directive, there was no documentation in the medical record, nor evidence of follow-up to obtain it. The Social Services Assistant confirmed the absence of the document and the lack of follow-up documentation, which was acknowledged by the Director of Nursing.
The facility failed to accurately complete PASRR Level 1 assessments for two residents, leading to a risk of inappropriate care. One resident had diagnoses of major depressive disorder and schizoaffective disorder, with prescriptions for quetiapine and lorazepam, while another had mood disorder and psychosis, with prescriptions for quetiapine and olanzapine. The MDS Coordinator confirmed the errors in the assessments.
A resident with severe cognitive impairment was not provided with an individualized and ongoing activity program, as required by the facility's policy. Observations showed the resident lying awake in bed without engagement in preferred activities like watching TV or listening to music. The Activity Director admitted to scheduling room visits only three times a week due to insufficient staff, and the Participation Record showed gaps in activity provision. Interviews confirmed the lack of daily activities for the resident, which was acknowledged by the DON and Administrator.
A resident with severely impaired cognition did not receive proper gastrostomy tube (GT) care as the LVN failed to check GT placement before administering medications and water, contrary to facility policy. The LVN also used improper technique by pushing the syringe's plunger instead of allowing gravity flow, potentially risking complications. The DON acknowledged these findings.
The facility failed to provide appropriate respiratory care for two residents. A resident's humidifier was not labeled or dated, and there was no physician's order for oxygen use. Another resident received oxygen at a rate exceeding the physician's order. These deficiencies were confirmed by staff and acknowledged by the Administrator.
The facility failed to provide adequate pharmaceutical services, leading to discrepancies in controlled medication reconciliation for three residents and one medication cart. A resident's oxycodone administration was not documented in the MAR, another resident's digoxin was administered without checking the apical pulse, and a medication cart had missing narcotic shift count signatures. Additionally, a resident's medication count sheets were inaccurately maintained, with errors in tablet strength and missing co-signatures for wastage.
The facility failed to monitor two residents for the use of psychotropic medications. One resident was not monitored for orthostatic blood pressure as ordered, with identical readings suggesting incorrect documentation. Another resident was given quetiapine without documented non-pharmacological interventions or behavioral monitoring, and no AIMS assessment was completed. These actions did not adhere to the facility's policies, potentially impacting the residents' well-being.
A facility's medication error rate was found to be 25.93%, significantly above the acceptable threshold. An LVN administered medications via GT with residue left in cups and used the wrong form of Keppra. An RN prepared an IV antibiotic with air bubbles in the tubing, requiring intervention to ensure safe administration. Both staff acknowledged the errors.
The facility failed to properly store, label, and dispose of medications, with expired items found in Medication Rooms A and C, and Medication Cart B. Treatment Carts A and B also contained expired items and cleanliness issues. These deficiencies were verified by LVNs and acknowledged by the DON.
The facility failed to properly dispose of waste, with food residues and trash found near dumpsters and in storage areas, posing pest risks. Two soiled linen barrels were uncovered and overfilled with trash, contrary to facility policy requiring tight-fitting lids. The Maintenance Director and Administrator acknowledged these deficiencies.
The facility failed to implement proper infection control practices, including the use of PPE and hand hygiene during medication administration for residents with indwelling medical devices. Additionally, a shared restroom was found to be unsanitary, posing a risk for infection transmission. These deficiencies were acknowledged by facility staff.
The facility failed to document medication administration for two residents, leading to incomplete medical records. A resident's piperacillin-tazobactam administration was not recorded on multiple occasions, and another resident's monitoring for antipsychotic side effects and schizoaffective disorder episodes was not documented. These lapses were confirmed by staff and acknowledged by the DON and Administrator.
A resident in an LTC facility was physically abused by another resident, resulting in a broken nose and a subdural hematoma. The incident occurred when the aggressor punched the victim in the face, leading to significant injuries. Despite the facility's policy against abuse, the aggressor, who had a history of aggression, was found with blood on his knuckles and admitted to the act. The victim was cognitively intact and required hospital evaluation for his injuries.
A resident with cirrhosis and fractures experienced inadequate care after developing swelling and abdominal issues post-IV fluids. The facility failed to assess and monitor the resident's condition upon return from the hospital, did not obtain weekly weights as ordered, and lacked a comprehensive care plan. Interviews with staff confirmed the absence of necessary assessments and documentation, leading to the deficiency.
The facility failed to implement proper infection control practices by not properly storing and labeling personal hygiene items such as bedpans, basins, and urinals. Unlabeled items were found in restrooms occupied by multiple residents, posing a risk of cross-contamination. The DON confirmed these findings, indicating a lapse in adherence to the facility's infection prevention and control policies.
A resident experienced significant unplanned weight loss, dropping from 115 lbs to 89 lbs over several months. Despite recommendations to monitor lab tests and weights, no lab work was ordered or completed, and no further IDT meetings were held after March. The resident was dependent on staff for eating and consumed only 50% to 70% of meals. Interviews confirmed the weight loss and lack of lab work, indicating a failure to adhere to the facility's weight management policy.
The facility failed to maintain effective infection control practices, as staff did not wear disposable gowns or perform proper hand hygiene during care for a resident under Enhanced Standard Precautions. Staff misunderstood policy requirements, leading to lapses during wound care and feeding activities, which were confirmed by the Infection Preventionist.
A resident developed a Stage 4 pressure ulcer on the right buttock after admission. The facility did not follow the physician's wound care orders, which included applying Santyl ointment and packing with xeroform gauze. An LVN failed to pack the wound as ordered, and the DON acknowledged the need to follow physician's orders.
The facility failed to ensure timely responses to residents' call lights, affecting four residents' dignity and well-being. Residents reported waiting over 30 minutes to an hour for assistance, particularly during shift changes and evenings. Staff interviews revealed systemic issues, including late assignments and lack of support from non-nursing staff, contributing to the delays.
The facility failed to provide reasonable accommodations for two residents by not responding to call lights in a timely manner. One resident waited for assistance after a bowel movement, and another was not informed of the wait time for a transfer back to bed. Multiple staff members failed to address the call lights promptly.
The facility failed to ensure a resident's medications were administered as per the physician's order due to unavailability. An LPN borrowed medication from another resident's supply, and the pharmacy did not deliver a prescribed medication. There was no documentation of physician notification or refill requests, and the MAR was signed for a medication that was not administered.
The facility failed to ensure a resident's physician's order for Seroquel had a diagnosis justifying its use, did not implement nonpharmacological interventions prior to drug use, and did not monitor targeted behavior and side-effects. The resident, diagnosed with dementia, was administered Seroquel following a fall without proper documentation or adherence to facility policy.
A facility failed to ensure a resident's privacy, resulting in the resident being exposed and visible from the hallway. The resident had requested assistance after a bowel movement but was left uncovered. Staff interviews confirmed that the facility's policy on dignity and privacy was not followed.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to thoroughly investigate abuse allegations involving two residents. In the first incident, a resident alleged being struck on the face by another resident. Although both residents were separated and the alleged victim received first aid, the facility did not interview the alleged victim's roommate, who was present in the room and could have been a witness. There was no documentation explaining why this potential witness was not interviewed, and the Director of Nursing (DON) confirmed that the interview should have occurred. In the second incident, another resident was struck on the back of the neck by a peer while waiting in the patio. Although staff intervened and separated the residents, the facility did not interview other residents who were present and may have witnessed the event. The DON acknowledged that these potential witnesses were not interviewed, stating that staff relied on their own observations. In both cases, the facility's investigation documentation did not include interviews with all possible witnesses as required by policy.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident-centered care and safe transition planning.
Incomplete Documentation on Resident Out on Pass Logs
Penalty
Summary
The facility failed to ensure that the Resident Out on Pass Log was accurately and completely filled out for two of four sampled residents. For both residents, multiple entries on the Out on Pass Log were missing critical information, including the time the resident went out, the time they returned to the facility, and the nurse's initials. These omissions were identified through a review of the medical records and facility documents, which showed repeated instances where required documentation was left blank on several dates for both residents. Facility policy requires that nursing documentation be concise, clear, pertinent, and accurate, and that all resident information be entered in the appropriate section of the clinical record following established guidelines. The Out on Pass policy further specifies that residents or their responsible persons must sign out and back in on the log, and that nurses are to sign the entries. During interviews, the DON confirmed that the logs for the two residents had blank entries and acknowledged that nurses were supposed to sign the log. The Administrator and DON both acknowledged these findings during the survey.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them in their shared room. Both residents alleged that the other initiated the altercation and admitted to hitting each other in the face in self-defense. Staff assessments found one resident with a small abrasion on the lip and the other with a swollen lip. The facility's policy on abuse prevention required staff to identify, correct, and intervene in situations where abuse is more likely to occur, including understanding behavioral symptoms that may increase the risk of abuse. Medical record reviews revealed that one resident had a documented history of physically aggressive and assaultive behaviors, including multiple incidents of verbal threats, striking staff, punching walls, and previously striking another resident. The other resident also had a care plan for aggressive behavior, with documented episodes of agitation, responding to internal stimuli, threatening staff, and physical aggression such as punching walls and plexiglass. Interviews with facility leadership and the residents confirmed ongoing behavioral issues, including command hallucinations and medication changes that may have contributed to escalating behaviors prior to the altercation.
Failure to Maintain Accurate and Complete Medical Record
Penalty
Summary
The facility failed to ensure the accuracy and completeness of a resident's medical record by not maintaining a signed copy of the admission physician's orders in the electronic health record (EHR). Upon review, it was found that after the resident was readmitted and subsequently discharged to an acute care hospital, the signed Order Summary Report was missing from the EHR. The Health Information Manager (HIM) confirmed that paper records are shredded after scanning, and the signed order should have been present in the EHR but was not. Later, a signed Order Summary Report was produced by the Medical Records Clerk, but the physician confirmed he had signed it only that morning, despite the document being pre-dated. This sequence of events resulted in the resident's medical record containing inaccurate and incomplete information at the time of review.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in one resident sustaining multiple injuries after being pushed by another resident. The incident occurred when one resident, who had a documented history of aggressive and assaultive behaviors, reacted to being bumped in the hallway by forcefully pushing the other resident into a wall, causing an abrasion to the forehead and a laceration to the left eyelid. The injured resident required assessment and was sent to an acute care hospital for further evaluation, where imaging revealed a cervical spine injury. Prior to the incident, the aggressive resident had a known history of similar behaviors, including previous assaults on peers at both the current and prior facilities. Documentation indicated that this resident had been placed on 1:1 supervision in the past due to high risk for violence and had requested a unit change, expressing ongoing frustration with the other resident's behavior. Despite these known risks and repeated requests for separation, the two residents were not adequately separated, and the aggressive resident was not moved to another unit. Staff interviews and medical record reviews confirmed that the aggressive resident had previously assaulted the same peer and had communicated intentions to harm if the situation persisted. The facility's policies required identification and intervention in situations where abuse was likely, as well as immediate reporting and investigation of such incidents. However, the facility did not implement sufficient measures to prevent further altercations, resulting in the resident's injuries.
Failure to Timely Report Suspected Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or theft, as well as the results of investigations, to the appropriate authorities for four out of ten sampled residents. According to the facility's Abuse Prohibition Policy, allegations of abuse must be reported within two hours of the allegation being made. However, in multiple instances, this policy was not followed, resulting in delayed notifications to the California Department of Public Health (CDPH) Licensing & Certification (L&C) Program and local law enforcement. One incident involved a resident who alleged physical abuse by a mental health worker (MHW), stating that the staff member choked and slammed the resident's face into the ground. The resident was observed with visible injuries, including bruising and scratches. The DON acknowledged the incident and confirmed that the reporting was not completed within the required timeframe. In another case, a resident reported verbal abuse by a staff member who mocked his stutter and made derogatory comments. The DON was informed of the allegation but did not report it within the mandated period. Additionally, the facility failed to report a resident-to-resident altercation in which one resident admitted to physically assaulting another on two separate occasions. Both residents were cognitively intact and had psychiatric diagnoses. The second incident resulted in visible injuries to the assaulted resident, and interviews revealed that the first incident had not been reported as required. Facility leadership acknowledged these reporting failures during interviews.
Failure to Implement Abuse Investigation Policies and Procedures
Penalty
Summary
The facility failed to implement its abuse investigation policies and procedures for four of ten sampled residents. In one case, a resident alleged that a mental health worker (MHW) choked and assaulted him, resulting in visible injuries such as bruising and scratches on the face and neck. Despite the allegation and physical evidence, the MHW was not immediately removed from duty, and no investigation was conducted. Other residents who witnessed the incident were not interviewed, and the DON dismissed the allegation as false without following the required investigative process. Another resident reported that a staff member mocked his stutter and that other staff called him derogatory names. The DON acknowledged the allegation but did not initiate an investigation or report the incident within the required two-hour timeframe. The facility later submitted a report, but it was acknowledged as late by the Administrator and DON. Additionally, two residents were involved in two separate physical altercations, with one resident sustaining visible injuries. The facility failed to conduct a thorough investigation after the first incident, did not report the initial allegation, and did not separate the residents until after the second incident. Interviews revealed that staff and residents were aware of the altercations, but appropriate actions to ensure safety and compliance with policy were not taken. The DON and Administrator acknowledged these failures during interviews.
Failure to Develop and Revise Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and revised as required for three residents. For one resident with a history of falls and a physician's order for bilateral floor mats, the care plan did not include this intervention, despite documented falls and the presence of the mats during observation. The Director of Nursing (DON) confirmed that the care plan lacked this intervention. Another resident experienced a significant, unplanned weight loss of 24 lbs (17.91%) over a period of less than three months. Although the resident's care plan noted a nutritional problem, it did not address the severe weight loss, and both the Registered Dietician and DON acknowledged the omission. A third resident, who was cognitively intact, sustained facial abrasions following a physical altercation. While the care plan identified the resident as a victim of assault, it did not include interventions for the facial injuries. The DON confirmed that there was no care plan or interventions for the injuries, and agreed that the injuries represented a change in condition. The Administrator and DON acknowledged these findings during the survey.
Resident Injured During Manual Restraint in De-escalation Incident
Penalty
Summary
The facility failed to ensure a resident was free from injury during a de-escalation process, resulting in the resident sustaining multiple bruises and scratches to the face and neck. According to the facility's policy, the least restrictive method should be used to resolve situations, with manual restraint reserved for acute episodes of dangerous behavior. On the date of the incident, the resident became verbally aggressive and attempted to pour out a community water jug. Staff attempted therapeutic communication, which was unsuccessful, and the situation escalated to physical contact. During the struggle, the resident and staff fell to the ground, and staff manually restrained the resident by holding his limbs until he calmed down. Medical examination documented small bruises on the resident's left eyebrow and neck, as well as bruising and swelling around the nose bridge and a scratch on the forehead. Observations confirmed these injuries, and the resident reported being taken to the ground, choked, and having his head smashed into the ground by staff. Staff interviews corroborated that a physical altercation occurred, resulting in the resident being restrained on the ground. The DON confirmed that the injuries were not present upon admission and occurred during the incident on the patio.
IV Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the safe administration and maintenance of intravenous (IV) therapy for four residents, leading to potential complications. Resident 932's IV tubing contained multiple air bubbles, which were not removed before the administration of the antibiotic Zosyn. Despite attempts by RN 1 and the QA RN to remove the air bubbles, they were unsuccessful, and it was recommended to change the IV tubing. This oversight posed a risk of air embolism to the resident. Resident 184's midline dressing was not dated or labeled, and there was no documentation of the midline site being monitored for patency or complications such as infection or displacement. The resident was receiving IV medication for a foot infection, but the lack of proper labeling and monitoring could lead to catheter-related infections. Additionally, there was no evidence of a physician's order for flushing the midline to maintain its patency. Resident 983 had a peripheral IV (PIV) line that was not discontinued after the completion of antibiotic therapy, and there was no physician's order for maintenance flushes. The PIV line remained in place without a clear indication, increasing the risk of infection. Similarly, Resident 733's PIV site was not dated or labeled, which is necessary for infection control and to ensure timely site changes. These deficiencies highlight the facility's failure to adhere to IV therapy protocols, potentially compromising resident safety.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by multiple observations of unsanitary conditions in the kitchen and food preparation areas. White plastic trash was found on the floor, in the sink area, and in the main food preparation hallway. Additionally, gloves and dietary menu forms were improperly placed in clean serving areas. The top surface of the soup machine was cluttered with unwashed cabbages, cooking mittens, basins, and a cutting board, which should have been cleared. Vegetables that fell on the floor were picked up and placed on a food cart without being cleaned, posing a risk of contamination. Further observations revealed that equipment and utensils were not properly cleaned. Fryer baskets and a serving utensil had food residues, and a can opener had brownish-orange residues. Microwaves used by residents in various stations had dried food residues, and the Station 4 refrigerator had food residue and a dried brown liquid spill. The lack of an air gap in the kitchen sink also violated sanitation guidelines, as it could lead to backflow contamination. Personal food items stored in residents' rooms were found unlabeled and undated, which is against the facility's policy. Residents 205, 222, and 133 had food items in their rooms that were not labeled with the resident's name, date brought, or use-by date, increasing the risk of food contamination. These deficiencies in food safety and sanitation practices posed a risk for foodborne illnesses among the residents who consumed food prepared in the facility's kitchen.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for the administration of psychotropic medications to a resident, identified as Resident 147, who was readmitted to the facility. The medications in question were olanzapine, quetiapine, and valproic acid, which were prescribed for managing psychosis and mood lability. The facility's policy and procedure required that informed consent be obtained by the prescriber prior to the initiation of psychotropic medication and verified by the facility before administration. However, upon review, it was found that no informed consents were obtained for these medications upon the resident's readmission. Interviews with facility staff, including an LVN, the Health Information Manager, and the Director of Nursing (DON), confirmed the absence of informed consents in the resident's medical record. The Health Information Manager noted that new orders and informed consents are required if a resident is readmitted after a week from an acute care hospital. The DON acknowledged the findings and stated that informed consent must be obtained for each psychotropic medication prior to its initiation. This oversight had the potential to leave the resident unaware of the risks associated with the medications, which could have adverse side effects detrimental to the resident's well-being.
Failure to Maintain Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to maintain a copy of an advance directive in the medical record for one of the residents reviewed for advance directives. This deficiency was identified during a review of the facility's policies and procedures, which stated that a copy of the advance directive should be maintained as part of the resident's medical record. The review of Resident 184's medical record revealed that although the resident had an advance directive, there was no copy of it in the medical record, nor was there any documentation indicating that the facility had requested a copy from the resident or their representative. Interviews and concurrent medical record reviews with the Social Services Assistant (SSA) confirmed the absence of the advance directive in the resident's medical record and the lack of documentation regarding any follow-up actions to obtain it. The SSA acknowledged that the facility's procedure was to request a copy of the advance directive and to document any follow-up actions if the resident or their representative could not provide it. However, no such documentation was available for Resident 184. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency.
Inaccurate PASRR Level 1 Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the PASRR Level 1 assessments for two residents, which is a federal requirement to prevent inappropriate placement in nursing homes. Resident 132's PASRR Level 1 Screening Form indicated no serious mental illness and no prescribed psychotropic medications, despite the resident having diagnoses of major depressive disorder and schizoaffective disorder. The resident's medical records showed prescriptions for quetiapine and lorazepam, which are used to manage symptoms of these conditions. Similarly, Resident 147's PASRR Level 1 Screening Form also inaccurately indicated no serious mental illness and no prescribed psychotropic medications. However, the resident had diagnoses of mood disorder and psychosis, with medical records showing prescriptions for quetiapine and olanzapine to manage symptoms such as hallucinations and agitation. The MDS Coordinator confirmed these discrepancies and acknowledged the errors in the PASRR Level 1 assessments, which posed a risk of the residents not receiving appropriate specialized care and services.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of a resident, identified as Resident 147, which potentially affected the resident's psychosocial well-being. Observations on multiple occasions revealed Resident 147 lying awake in bed, staring at the wall, with the television turned off, indicating a lack of engagement in preferred activities. The resident's medical records indicated severe cognitive impairment and dependency on staff for activities of daily living. The Recreation Comprehensive Assessment highlighted the importance of engaging the resident in activities such as watching TV, exercising, and listening to music, yet these preferences were not consistently met. The facility's policy stated that residents should be encouraged to choose activities based on their preferences and medical conditions, but the Activity Director admitted that due to insufficient staff, the resident was only scheduled for room visits three times a week. The Participation Record for February showed gaps in activity provision, with no activities recorded on several days. Interviews with the Activity Director and a CNA confirmed the lack of daily activities for the resident, with the CNA noting that the resident was unable to attend the activity room and had not received in-room activities. The Director of Nursing and the Administrator acknowledged these findings.
Failure in GT Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for a resident, identified as Resident 735, who was part of the final sample. The deficiency was observed during a medication administration session where the Licensed Vocational Nurse (LVN) did not check the GT placement before administering medications and water. This was contrary to the facility's policy and procedure, which required checking the tube placement by inserting air and listening for gurgling sounds, as well as aspirating stomach contents. The LVN acknowledged the oversight and stated that the check would be done later, which was not in compliance with the established protocol. Additionally, the LVN administered medications and water flushes by pushing the syringe's plunger instead of allowing them to flow via gravity, as required by the facility's procedures. This improper technique could potentially lead to complications such as tube dislodgement or trauma. The resident involved, Resident 735, had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 1, indicating an inability to understand and make decisions. The Director of Nursing (DON) was informed of these findings and acknowledged the issues.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their care. For Resident 96, the facility did not ensure that the humidifier was labeled and dated, and there was no documented physician's order for the use of oxygen, as required by the facility's policies and procedures. During an observation, it was noted that Resident 96 was using oxygen without a physician's order, and the humidifier was not properly labeled. The Licensed Vocational Nurse (LVN) confirmed these findings and acknowledged the need for a physician's order for oxygen use. For Resident 161, the facility did not adhere to the physician's order for oxygen administration. The order specified that oxygen should be administered at 2 liters per minute via nasal cannula, with the possibility to titrate up to 3 liters per minute. However, during an observation, Resident 161 was found to be receiving oxygen at 5 liters per minute, which exceeded the physician's order. The Infection Preventionist (IP) verified this discrepancy, and the Administrator acknowledged the findings. These failures had the potential to impact the respiratory health and well-being of the residents.
Pharmaceutical Service Deficiencies in Medication Reconciliation and Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in discrepancies in the reconciliation of controlled medications for three residents and one medication cart. For Resident 40, the facility did not ensure that the administration of oxycodone-acetaminophen was accurately documented in the Medication Administration Record (MAR), despite being signed out on the controlled drug record. This discrepancy was verified by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the lack of documentation for the administered doses. Resident 735, who had severe cognitive impairment, was prescribed digoxin with a specific order to hold the medication if the apical pulse was below 60 beats per minute. However, the LVN administering the medication failed to obtain the apical pulse before administration, as required by the physician's order. This oversight was confirmed during an observation and interview with the LVN. Additionally, the facility did not maintain accurate narcotic shift counts for Medication Cart A, with a missing signature for a specific shift. For Resident 27, the facility failed to maintain accurate controlled medication count sheets, leading to discrepancies in the documentation of oxycodone administration and wastage. The DON confirmed that the count sheets were incorrectly maintained, with errors in tablet strength and missing co-signatures for medication wastage.
Failure to Monitor Psychotropic Medication Use and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure proper monitoring and implementation of non-pharmacological interventions for two residents receiving psychotropic medications. Resident 146 was not monitored for orthostatic blood pressure as ordered by the physician, despite being administered quetiapine fumarate for psychosis. The medical records showed that the orthostatic blood pressure readings were identical for lying and sitting positions, which is unlikely and suggests incorrect documentation or monitoring. This lack of proper monitoring could not confirm whether Resident 146 experienced orthostatic hypotension. Resident 147 was administered quetiapine without documented evidence of non-pharmacological interventions being attempted first, as required by the facility's policy. Additionally, there was no behavioral monitoring or AIMS assessment completed after the resident's readmission, which is necessary to evaluate the effects and necessity of the psychotropic medication. Interviews with facility staff confirmed these findings, indicating a failure to adhere to the facility's policies on psychotropic medication use. The facility's policy requires that psychotropic medications be used only after non-drug approaches have been attempted and that residents' behaviors be monitored. The failure to follow these protocols for Residents 146 and 147 had the potential to negatively impact their well-being, as the necessary assessments and interventions were not conducted to ensure the safe and appropriate use of psychotropic medications.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 25.93%. During a medication administration observation, LVN 3 administered medications to a resident via a gastrostomy tube (GT) and left residue in the medication cups, indicating incorrect dosage administration. Additionally, LVN 3 did not follow the physician's order for the form of Keppra, administering a solution instead of the prescribed tablet. LVN 3 acknowledged these errors and stated that the order should have been updated in the electronic health record (EHR) upon receiving a different medication form from the pharmacy. RN 1 was observed preparing and administering an intravenous (IV) antibiotic, Zosyn, to another resident. During the process, multiple air bubbles were found in the IV tubing, which RN 1 initially attempted to remove by priming the tubing, risking medication waste. The QA RN and DON 1 were consulted, and it was decided to replace the IV tubing to ensure safe administration. RN 1 acknowledged the error and stated that a new Zosyn and tubing should have been prepared to prevent the medication error.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, as observed during inspections of various medication and treatment areas. In Medication Room A, expired vancomycin bags were found in the refrigerator, and bisacodyl suppositories were stored without an open date. Additionally, the refrigerator's temperature was significantly below the recommended range. In Medication Room C, several expired medications, including clotrimazole cream and various vitamins, were not discarded. Medication Cart B contained an expired bottle of vitamin C liquid. Further deficiencies were noted in Treatment Carts A and B. Treatment Cart A contained an opened bottle of sterile saline, expired antifungal powder, and culture swabs, along with unclean conditions in the last drawer. Treatment Cart B also had expired antifungal powder and shampoo, with similar cleanliness issues. These findings were verified by the respective LVNs present during the inspections, and the Director of Nursing acknowledged the issues upon being informed.
Improper Waste Disposal and Handling
Penalty
Summary
The facility failed to ensure the proper disposal and handling of waste, leading to potential safety and pest contamination risks. Observations revealed scattered food residues on the ground next to the food waste dumpster and trash, including disposable cups with orange liquid and tortilla plastic containers, in the open space storage area. These areas were not maintained in accordance with the USDA Food Code 2022, which requires refuse to be stored in a manner that is inaccessible to insects and rodents. The Maintenance Director confirmed these findings and acknowledged that the surrounding areas of the dumpster should be clear of trash to prevent pest attraction. Additionally, two of the six soiled linen barrels were found with trash inside, uncovered, and without lids. One barrel was overfilled with trash bags, and the other contained two bags of trash with a milky substance spilled at the bottom. The Maintenance Director stated that these barrels were intended for trash and were not covered because the trash was placed in plastic bags. The facility's policy requires all garbage and refuse containers to have tight-fitting lids or covers, which were not adhered to in this instance. The Administrator and DON acknowledged these findings, indicating a lapse in compliance with established waste management protocols.
Infection Control Deficiencies in Medication Administration and Sanitation
Penalty
Summary
The facility failed to implement appropriate infection control practices for several residents, leading to potential risks of infection transmission. For Resident 184, who had a midline catheter, the facility did not ensure that the Licensed Vocational Nurse (LVN) wore the necessary personal protective equipment (PPE) such as gloves and gowns during medication administration. This was despite the resident's need for Enhanced Barrier Precautions (EBP) due to the presence of an indwelling medical device. Additionally, there was no EBP sign outside the resident's room to indicate the need for such precautions. In other instances, the facility failed to ensure proper hand hygiene during medication administration. LVN 5 did not perform hand hygiene before and after donning and doffing gloves while administering eye medication to Resident 151. Similarly, LVN 3 did not perform hand hygiene after removing gloves and before preparing medication cups for Resident 735. Furthermore, RN 1 did not disinfect the septum of a Zosyn antibiotic vial before connecting it to a normal saline bag for Resident 932, which is a critical step in preventing contamination and infection. The facility also neglected to maintain a sanitary environment in shared restrooms. Residents 64 and 118's shared restroom had a strong foul odor, and the toilet rim was visibly soiled with dried yellow urine. This lack of cleanliness poses a risk for the transmission of disease-causing microorganisms. These observations were verified by staff members, including the Director of Nursing (DON) and the Maintenance Director, who acknowledged the deficiencies in infection control practices.
Incomplete Documentation of Medication Administration for Two Residents
Penalty
Summary
The facility failed to ensure complete documentation of medication administration for two residents, leading to potential gaps in their care. For Resident 184, the administration of piperacillin-tazobactam was not documented on several occasions, including specific times on 2/16/25, 2/17/25, 2/18/25, and 2/26/25. RN 1 admitted to administering the medication on 2/26/25 but failed to document it, and there was no explanation for the missing documentation on the other dates. The pharmacist confirmed that there should have been eight doses left if the medication had been administered as ordered, which was verified by RN 1 during an observation of the IV cart. For Resident 132, the facility failed to document monitoring for antipsychotic side effects and episodes of schizoaffective disorder as ordered by the physician on 1/13/25 during the evening shift. The orders included monitoring for side effects of quetiapine and documenting non-pharmacological interventions for schizoaffective disorder. RN Supervisor 1 confirmed the missing documentation and stated that the monitoring was performed but not recorded in the MAR. These documentation failures were acknowledged by the Director of Nursing (DON) and the Administrator, indicating a lapse in adherence to the facility's policies and procedures for medication administration and documentation. The lack of complete medical records for these residents could potentially impact the quality of care provided, as the clinical information was not fully captured.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in significant injuries. Resident 1 was punched in the face by Resident 2, leading to a broken nose, bruising around the left eye, and a subdural hematoma. The incident occurred when Resident 1 was in his room, and staff heard him yelling. Upon investigation, Resident 1 accused Resident 2 of hitting him, which was corroborated by the presence of blood on Resident 2's knuckles and bed. Resident 1 was cognitively intact and had the capacity to make medical decisions. After the incident, Resident 1 was transferred to an acute care hospital for further evaluation, where a CT scan confirmed multiple nasal bone fractures and a subdural hematoma. Resident 2, who was also cognitively intact, had a history of physical and verbal aggression, as noted in his care plan. Despite denying the assault, Resident 2 was found with blood on his knuckles, and another resident confirmed that Resident 2 admitted to hitting Resident 1 because he would not be quiet. The facility's policy prohibits abuse of any kind, yet the incident highlights a failure to protect residents from harm. Interviews with staff and residents confirmed the sequence of events, and the facility's documentation supported the findings. The Director of Nursing and the Administrator acknowledged the incident and the associated findings during a review of the medical records.
Failure to Monitor and Document Resident's Condition
Penalty
Summary
The facility failed to provide adequate care and monitoring for a resident, identified as Resident 4, who was admitted with diagnoses including unspecified fractures and cirrhosis of the liver. After receiving intravenous fluids, Resident 4 developed bilateral lower extremity swelling and was transferred to the hospital for abdominal pain and increased abdominal girth. Upon returning to the facility, the staff failed to assess and monitor the resident's swelling and abdominal girth, and did not obtain weekly weights as ordered by the physician. These omissions were contrary to the facility's policies and procedures for weight management and nursing documentation. The facility's policies required baseline weight measurements and ongoing monitoring, especially when a resident's condition warranted it. However, Resident 4's weight was not consistently recorded, with only two entries documented despite physician orders for weekly monitoring. Additionally, the facility's nursing documentation policy emphasized the need for clear and timely documentation of a resident's condition and interventions, which was not adhered to in this case. The lack of a comprehensive care plan addressing Resident 4's cirrhosis, abdominal pain, and edema further contributed to the deficiency. Interviews with facility staff, including RN 1 and the DON, confirmed that a change in condition assessment was not completed for Resident 4's symptoms following the administration of IV fluids. The staff acknowledged that such assessments are crucial for alerting nurses to monitor residents for 72 hours to determine if symptoms improve or worsen. The physician also expected the facility to assess and monitor the resident's condition upon return from the hospital, which was not done. The failure to follow through with these assessments and documentation led to inadequate care for Resident 4.
Infection Control Deficiency Due to Improper Storage and Labeling
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by the improper storage and labeling of personal hygiene items such as bedpans, basins, and urinals. During an initial tour, surveyors observed two unlabeled bedpans and one unlabeled basin in the restroom of Room A, which was occupied by two residents. Additionally, an unlabeled basin was found touching the clean toilet paper seat dispenser in Room B, occupied by four residents. In Room C, an unlabeled urinal was placed on top of the toilet tank, with two residents occupying the room. These observations were verified by the Director of Nursing (DON), who acknowledged that all bedpans, basins, and urinals should be properly stored and labeled to prevent cross-contamination. The facility's policies and procedures for infection prevention and control, as well as the protection of residents' personal property, were not adhered to, leading to potential risks of cross-contamination and the spread of infections among residents.
Failure to Monitor and Address Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) effectively evaluated and monitored the nutritional status of a resident who experienced significant unplanned weight loss. The resident, who was admitted with a diagnosis including a pressure injury, showed a progressive weight loss from January to April, dropping from 115 lbs to 89 lbs. Despite the IDT's recommendation to monitor laboratory tests and weights, there was no evidence of laboratory work being ordered or completed from March to April, and no further IDT meetings were conducted after March to address the weight loss. Observations revealed that the resident was dependent on staff for eating and consumed only 50% to 70% of meals. Interviews with the registered dietician (RD) and the director of nursing (DON) confirmed the significant weight loss and the lack of laboratory work. The facility's policy on weight management required collaboration and action in the event of significant weight changes, which was not adhered to, leading to the deficiency in maintaining the resident's nutritional status.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Standard/Barrier Precautions for a resident. Specifically, staff did not wear disposable gowns when providing care to a resident who required such precautions due to an order for Enhanced Standard Precaution. This was observed during wound care and feeding activities, where staff members did not don the necessary protective equipment, despite clear signage and policy requirements. Interviews with staff revealed a misunderstanding of the policy, with one staff member incorrectly believing gowns were only necessary for residents with tubes or catheters. Additionally, the facility failed to ensure proper hand hygiene practices were followed during wound care procedures. A staff member was observed changing gloves multiple times without performing hand hygiene in between, which is a critical step in preventing the spread of infections. These observations were confirmed through interviews with the involved staff and the facility's Infection Preventionist, who acknowledged the lapses in following the established infection control protocols.
Failure to Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for a resident. The resident developed a Stage 4 pressure injury to the right buttock after admission. The facility did not adhere to the physician's order for wound care, which included applying Santyl ointment, cleansing with normal saline, patting dry, packing lightly with xeroform gauze, and covering with a dry dressing every day shift for 30 days. During an observation, a Licensed Vocational Nurse (LVN) cleaned the wound and applied Santyl ointment but failed to pack the wound with xeroform gauze as ordered. The Director of Nursing (DON) acknowledged that wound care should be performed as per the physician's orders.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure that residents' call lights were answered in a timely manner, which compromised the dignity and respect of four nonsampled residents. Resident A reported that it usually took more than 45 minutes for staff to respond to her call light, leaving her uncomfortable in a wet diaper. Resident B experienced delays of over an hour during shift changes or evenings, particularly when needing assistance with transfers. Resident C also reported waiting more than 30 minutes to an hour for diaper changes during the evening shift. Resident D stated that she sometimes waited more than an hour for assistance during the night shift, which upset her as she needed help with colostomy care after a bowel movement. Interviews with staff revealed systemic issues contributing to the delays. CNA 1 mentioned the challenge of attending to multiple residents needing total care simultaneously. LVN 1 indicated that he and the CNAs often received their assignments late, making it difficult to respond to call lights promptly. The DSD confirmed that the schedules for the 3 pm to 11 pm shifts were missing, and the staff coordinator was unavailable to address the issue. The Director of Activity acknowledged that residents had raised concerns about call light delays during a resident council meeting, but there was no documentation of follow-up actions. Further interviews with CNAs and RNs highlighted additional problems. CNAs 3, 4, and 5 noted that they received their assignments late and could not see call lights in other stations when busy with their assigned residents. They also mentioned that non-nursing staff and some charge nurses did not assist with answering call lights, even for non-nursing tasks. RN 1 stated that the next shift staff might not have their schedules, causing delays in care as the RN on duty had to remake the schedules. These systemic issues led to significant delays in responding to residents' call lights, negatively affecting their physical and emotional well-being.
Failure to Timely Respond to Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the care needs of two residents regarding the timely response to call lights. For Resident 1, the call light was observed to be on for an extended period without being answered. Despite multiple staff members passing by the room, the call light remained on until a CNA finally responded. Resident 1 reported that she had pressed the call light button because she needed assistance after a bowel movement and had been waiting for a long time without any staff coming to assist her. The PT who had checked the room earlier did not notice the call light was on, and the LVN confirmed that everyone was responsible for answering call lights, but the system failed in this instance. For Resident 3, the call light was answered by the MDS Coordinator, who turned off the light and informed the LVN that the resident needed to be transferred back to bed. However, the MDS Coordinator did not inform Resident 3 of the expected wait time for assistance. The LVN did not communicate with Resident 3 about the delay or seek alternative assistance, resulting in the resident waiting without knowing when help would arrive. The Administrator and DON acknowledged these findings and confirmed that call lights should be answered immediately by any available staff member.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure that Resident 2's medications were administered as per the physician's order due to a lack of availability of the medications. LVN 1 did not ensure that Resident 2's Lasix supply was available for scheduled administration and borrowed the medication from another resident's supply. Additionally, the pharmacy failed to deliver Resident 2's prescribed Entresto medication, and there was no documented evidence that the physician was notified of the missed doses from 4/17 to 4/19/24. Furthermore, LVN 1 signed the MAR indicating that Refresh Tears ophthalmic solution was administered to Resident 2, although it was not actually given. These failures posed a risk for negative health outcomes for Resident 2. During the medication administration observation, LVN 1 acknowledged that Resident 2's Entresto medication was not available and planned to follow up with the pharmacy after the medication pass. LVN 1 also admitted to borrowing Lasix from another resident's supply to administer to Resident 2. The medical record review confirmed that Resident 2 was not administered Entresto as ordered by the physician and that there was no documentation of a refill request or physician notification regarding the unavailability of the medication. The pharmacist confirmed that the Entresto supply was not delivered due to a potential drug allergy and lack of response from the facility for clarification. Interviews with LVN 1 and the DON revealed that the licensed nurses were responsible for following up with the pharmacy, checking the E-kit, and notifying the physician if a medication was unavailable. However, there was no documentation to show that these steps were taken for Resident 2's Lasix and Entresto medications. Additionally, LVN 1 admitted to signing the MAR for Refresh Tears eye drops without administering them. The DON acknowledged the findings and stated that the facility was working with a new pharmacy and had issues with their fax machine and electronic physician's orders integration.
Failure to Justify and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Resident 2's physician's order for Seroquel, an antipsychotic medication, had a diagnosis justifying its use. Additionally, the facility did not implement nonpharmacological interventions prior to the drug use, nor did it monitor the targeted behavior and side-effects of the medication. These failures were identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy mandates a holistic approach to behavior management, including thorough assessments and non-drug interventions before resorting to psychotropic medications. However, these steps were not followed for Resident 2, who was administered Seroquel for restlessness without documented evidence of a proper diagnosis or prior nonpharmacological interventions. Resident 2, who was admitted to the facility with a diagnosis of dementia and no capacity to make decisions, experienced a fall on 4/17/24. Following this incident, an on-call physician recommended starting Seroquel 12.5 mg with the family's consent. Despite this recommendation, the medical record lacked documentation of a diagnosis justifying the use of Seroquel, nonpharmacological interventions, and monitoring of targeted behavior and side-effects. Interviews with LVN 1 and RN 1 confirmed these findings, indicating that the necessary steps were not taken before administering the medication. The Administrator and DON were informed and acknowledged these deficiencies.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure the privacy of a resident, leading to a violation of the resident's right to dignity and privacy. During an initial tour, the resident was observed lying in bed with their lower extremities and adult brief exposed and visible from the hallway. The resident had pressed the call light for assistance after a bowel movement but had not received help for an extended period. The resident expressed discomfort and embarrassment about being exposed and stated that a blanket could have been used to cover them. Interviews with the staff revealed that the CNA had given the resident a bed bath earlier, and the therapist had placed the resident back in bed without covering them or drawing the curtain. The therapist admitted to not covering the resident to avoid dirtying the sheets and acknowledged that the curtain should have been drawn for privacy. The facility's policy on dignity and privacy was not followed, as confirmed by the CNA and the therapist. The Administrator and DON were informed of these findings and acknowledged the deficiency.
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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