South Pasadena Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in South Pasadena, California.
- Location
- 904 Mission St, South Pasadena, California 91030
- CMS Provider Number
- 555908
- Inspections on file
- 40
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 58
Citation history
Health deficiencies cited at South Pasadena Care Center during CMS and state inspections, most recent first.
A resident with leukemia and prostate cancer, cognitively impaired and needing partial assistance with ADLs, had a PRN order for O2 via NC or mask to maintain SpO2 ≥ 92%, with a requirement to record saturation before administration. On one occasion, the resident was found unresponsive and an LVN administered O2 at 10 L/min via mask, but this intervention and the required O2 saturation were not documented on the MAR or the SBAR communication form. This omission occurred despite a facility policy requiring that all services provided and changes in condition be recorded in the medical record to support team communication.
A resident with paraplegia, a stage 4 sacral pressure ulcer, and osteomyelitis experienced a witnessed fall during a transfer, landing with both knees on the floor and striking a foot on the wheelchair footrest. Staff obtained X‑ray orders for the foot and hips/pelvis, but not the knees. Over the next day, the resident reported knee swelling, warmth, and a burning sensation to CNAs and an LVN, and a family member later observed swollen knees and was told only back and foot X‑rays had been done. The LVN assumed the existing X‑ray orders covered the whole leg and did not notify the physician of the new knee complaints, and no specific knee X‑ray was ordered until later. The DON confirmed that policy required licensed nurses to assess and notify the physician of such changes in condition and that the facility’s change-in-condition policy required notification of the physician and representative after accidents with potential need for physician intervention.
A resident with paraplegia, bilateral lower extremity impairment, and multiple stage 4 pressure ulcers to the sacrococcyx, ischium, and hip had care plans and facility policy requiring turning and repositioning q2h to protect skin integrity. Observations found the resident lying on his back in bed, and the resident reported staff had not offered or assisted with repositioning. A CNA admitted the resident could not move his legs, required staff to carry and align a leg brace during turns, was supposed to be repositioned q2h, but was only repositioned once during an 8‑hour shift with no other staff assisting. The DOR and DON confirmed the resident’s dependence on staff for repositioning and the requirement to provide q2h positioning per care plan and policy, which was not implemented.
The facility failed to maintain a safe environment when smoke from a burnt HVAC unit filter entered an interior hallway after roofing workers used a torch that ignited the HVAC filter. Multiple staff, including the DON, LVNs, CNA, Activity Director, maintenance staff, and the receptionist, reported smelling something burning, seeing haze or smoke in the hallway, and noting that the smoke detector did not alarm. Maintenance traced the source to an HVAC unit above the hallway, and the ADM confirmed the filter was partially burnt and that smoke had traveled down the vent into the building. Staff closed residents’ doors and paramedics on-site for a resident’s change of condition assisted by opening the front door and using fans, while the facility’s own policy required a safe and secure environment for staff and residents.
A resident with non-Hodgkin lymphoma, end stage renal disease, and heart failure did not receive a scheduled oncology appointment due to insurance issues. Facility staff did not notify the primary care physician or reschedule the appointment, resulting in the resident not receiving an evaluation and treatment plan for cancer, contrary to facility policy.
A facility allowed a family member to remotely control a tablet camera in a shared room, resulting in continuous video and audio monitoring of three residents, including during personal care activities. Residents and staff reported discomfort, loss of privacy, and concerns about unauthorized disclosure of medical information. Facility policies requiring privacy and care planning for device use were not followed, and the situation was acknowledged by the DON as invasive.
A resident with multiple chronic conditions and severe cognitive impairment experienced ongoing generalized itching, with visible scratch marks and skin irritation. Despite repeated complaints and observations by staff, an LVN did not promptly notify the physician or provide treatment, and no care plan was developed to address the issue, contrary to facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident experienced a significant medication error due to a failure in the medication administration process.
Two residents with significant physical and cognitive impairments were found to have their call devices out of reach—one with hand contractures had the call pad hanging below the bed, and another with severe cognitive impairment had the call pad on the floor. Staff confirmed that the devices were not accessible as required by facility policy, which states call lights must be within easy reach for residents needing assistance.
Two residents receiving IV therapy did not receive care in accordance with facility policy: one had unlabeled IV tubing, and another did not have required shift-by-shift IV site monitoring and documentation by nursing staff. These failures were confirmed through observation, staff interviews, and record review.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
Two dumpsters were found with lids not completely closed, leaving garbage and refuse exposed to the environment. The Maintenance Supervisor confirmed this was against facility policy, which requires dumpster lids to remain closed to prevent pest access.
Two residents with severe cognitive and physical impairments did not have properly coordinated or documented hospice care, as required by physician orders and facility policy. Hospice visit calendars and sign-in sheets were incomplete or missing, and staff could not confirm that scheduled visits by RNs, LVNs, or NAs occurred. Facility staff and the DON acknowledged the lack of required documentation and communication with hospice providers, resulting in a failure to ensure that hospice services were delivered as ordered.
A deficiency was identified when an LVN disposed of blood-soiled dressings from a resident's sacral wound in a clear plastic bag and black bin, rather than using red bags as required by facility policy. The Infection Prevention Nurse confirmed that the facility did not have color-coded bins for hazardous waste, and that the disposal practice did not follow the written procedures for handling items contaminated with blood.
Lint was found in a dryer lint trap and laundry logs were incomplete or inaccurately documented, with a future-dated water temperature entry. Additionally, urine was observed on a toilet seat riser chair and floor in a resident's room and restroom, with staff confirming these conditions were unsanitary and not in line with facility policy.
A resident with dementia, Parkinson's disease, and quadriplegia was assisted with eating by a CNA who stood above the resident's eye level, rather than sitting or adjusting the bed to maintain eye contact, as required by facility policy. Staff interviews confirmed that this practice does not respect resident dignity, and the RN present did not correct the CNA's actions.
A resident with multiple chronic conditions was found to have a bed sheet with over thirty small holes, leading to discomfort and dissatisfaction. Staff confirmed that such damaged linen is not consistent with a homelike environment and acknowledged the issue, which was observed during a survey.
A resident with dementia, depression, and anxiety disorder was prescribed PRN Lorazepam for anxiety for 30 days without a documented rationale for extending use beyond the facility's 14-day policy limit. Staff interviews and record reviews confirmed that the required psychiatric documentation was missing, resulting in non-compliance with facility policy regarding psychotropic medication orders.
Three residents did not have individualized care plans developed for their specific clinical needs, including a fluid restriction for a resident with ESRD, IV antibiotic administration for a resident with a surgical wound infection, and the use of a bolster low air loss mattress for a resident at risk for pressure ulcers. Staff and nursing leadership confirmed that these care plans were missing, despite physician orders and ongoing interventions.
A resident with a sacral pressure ulcer and limited mobility was provided with a bolster low air loss mattress to prevent falls and pressure injuries, but staff failed to obtain a physician's order for this specific equipment. Nursing staff and the DON confirmed the mattress was in use based on interdisciplinary team decisions, yet documentation and facility policy did not reflect this practice.
A resident with a GTube, dependent on tube feeding and with severely impaired cognitive skills, was observed receiving only 5 cc of water flush after medication administration, instead of the physician-ordered 30-50 cc. The LVN acknowledged not following the order, and the facility's policy required adherence to prescribed enteral nutrition protocols.
A resident with ESRD and heart failure, receiving dialysis and under a physician-ordered fluid restriction, did not have their daily fluid intake monitored or documented as required. Nursing staff failed to record intake amounts on the MAR or elsewhere, and the resident's chart lacked any intake documentation for an extended period, despite facility policy and physician orders mandating such monitoring.
Staff failed to consistently and accurately document shift-to-shift narcotic counts for controlled medications, leaving multiple blank entries on required forms for several medication carts. This incomplete documentation was confirmed by interviews with nursing staff and the DON, and affected a resident with severe cognitive impairment and complex medical needs, resulting in an inability to ensure proper accounting and administration of controlled substances.
A resident with a GTube and complex medical needs did not receive the prescribed amount of water flush between medications, as an LVN administered only 5 cc instead of the ordered 10-15 cc between each medication. This resulted in three medication errors out of 25 observed opportunities, causing the facility's medication error rate to exceed the 5% threshold. The care plan, physician's orders, and facility policy all required the correct water flush amount, which was not followed.
A resident with diabetes and multiple care needs was tested for blood sugar using expired glucose test strips by an LVN, despite facility policy requiring current supplies. The DON confirmed that expired strips should not be used, and the facility's procedures mandate checking expiration dates before use.
Two residents experienced deficiencies in medical record documentation, including missing and inaccurate entries for IV therapy and G-tube water flushes. In one case, a resident's IV site checks were not documented for several days, and a nurse recorded an IV flush after the IV had been removed. In another case, a resident did not receive the ordered water flushes with medications, and the MAR was inaccurately completed by a nurse who did not perform the task. Facility policy requires accurate and complete documentation, which was not followed in these instances.
The facility did not post current nurse staffing information in a visible location, with outdated data remaining displayed for several days. Staff interviews revealed confusion over responsibility for daily postings, resulting in a lack of up-to-date staffing information accessible to residents and visitors, contrary to facility policy.
A resident who required substantial assistance with bathing and dressing due to muscle weakness and diabetes was taken from the shower room with only the front of their body covered, leaving the sides and back exposed. The CNA involved acknowledged the lapse, and the DON confirmed that full coverage with a poncho was required. The resident reported feeling disrespected, and facility policy mandated shielding residents during personal care to maintain dignity and privacy.
A resident reported to an RN that another resident physically assaulted him, but the incident was not reported to the State Agency, ombudsman, or law enforcement within the required two-hour window. Both residents, one with muscle weakness and diabetes and the other with schizophrenia and insomnia, remained in the same room for nearly six hours after the allegation, contrary to facility policy requiring immediate separation during abuse investigations.
A resident dependent on gastrostomy tube feeding for nutrition and hydration did not receive the prescribed volume of enteral feeding due to staff failure to restart the feeding at the scheduled time. The resident, with a history of malnutrition, pressure ulcer, and stroke with dysphagia, was observed to have their tube feeding off when it should have been running, and the LVN confirmed forgetting to turn it back on as ordered.
A resident with multiple chronic conditions and moderate cognitive impairment was unable to sleep due to a roommate's loud television volume, leading to a verbal confrontation. Staff interviews confirmed that the television should have been kept at a comfortable level during quiet hours, but this was not done, violating the resident's right to dignity and comfort as outlined in facility policy.
The facility failed to provide two residents with written information regarding their right to formulate an advance directive. Resident 16, with intact cognitive skills, and Resident 286, with severely impaired cognitive skills, both lacked the necessary documentation in their medical records. The absence of advance directive acknowledgment forms was confirmed by the Admission Coordinator and Social Services Director, despite facility policy requiring such information to be provided upon admission.
Two residents with severe cognitive and physical impairments did not receive necessary grooming care, as their long fingernails were not trimmed by staff, contrary to facility policy. Observations and interviews revealed that CNAs failed to document refusals of care, and the facility did not adhere to its procedures for maintaining residents' hygiene.
The facility failed to pad side rails for three residents with seizure disorders, despite physician orders and care plans requiring this precaution. Observations showed unpadded side rails, and staff confirmed the necessity of padding to prevent injury during seizures.
The facility failed to provide necessary care for two residents, leading to potential health risks. A resident with a Foley catheter was not monitored as per the physician's order, with missing documentation indicating lapses in care. Another resident with a suprapubic stoma had a dressing that was not changed daily, contrary to the physician's order, increasing the risk of infection. These deficiencies highlight failures in adhering to care plans and documentation protocols.
The facility failed to follow its policy on oxygen administration for two residents. One resident received oxygen at a higher rate than ordered, while another had an unlabeled nasal cannula and a dirty oxygen concentrator. Staff confirmed these discrepancies, highlighting lapses in following physician orders and infection control practices.
The facility failed to properly seal food containers and maintain cleanliness in a refrigerator designated for residents' food, as observed by the Dietary Supervisor and Infection Preventionist. This non-compliance with the facility's food safety policies posed a risk of food contamination and potential illness for residents.
The facility failed to accommodate the needs of two residents, leading to potential safety risks. A resident with Parkinson's disease struggled with a low toilet seat, which was not adjusted despite staff awareness. Another resident with hemiplegia was unable to reach his call light due to improper placement, despite being dependent on assistance. These issues violated facility policies on accommodating resident needs and ensuring call light accessibility.
A resident with severe cognitive impairment and mobility issues was found to have fecal matter on the floor next to their bed, which was not cleaned promptly, posing an infection control concern. The facility's policies on maintaining a clean and homelike environment were not followed, as noted by the Infection Prevention Nurse and Director of Nursing.
The facility failed to implement a care plan for a resident with epilepsy by not using padded side rails as ordered, and did not develop a care plan for another resident's suprapubic stoma site care. Observations showed the side rails were not padded, and the stoma site was not cleaned or dressed as required, contrary to physician orders and facility policy.
A resident with aphasia and other conditions was not provided with a communication board in their language, as required by their care plan. Despite the facility's policy to ensure communication in a language the resident understands, the board was missing from the resident's room, potentially delaying care.
The facility failed to ensure correct settings for low air loss mattresses for two residents, one with existing pressure ulcers and another at high risk for skin breakdown. Observations showed the mattresses were set higher than the residents' weights, contrary to physician orders and facility policy, potentially affecting wound healing and ulcer prevention.
A resident with generalized weakness and neuromuscular dysfunction did not receive ordered RNA services for range of motion exercises, as there was no documentation of these services being performed. Despite a physician's order for RNA services to start, interviews confirmed the absence of records, indicating non-compliance with the facility's policy. The resident expressed concerns about losing physical function, highlighting the importance of RNA services in maintaining joint function.
A resident with chronic kidney disease was not provided the required two liters of water daily as per physician's orders. The care plan lacked interventions for hydration, and staff were unaware of the resident's fluid needs. Observations showed the resident was often thirsty, with no cups available for drinking. The facility's documentation did not accurately record fluid intake, contrary to its hydration policy.
A resident with Parkinson's disease did not have their heart rate checked before receiving metoprolol, contrary to the physician's order. The LVN administering the medication failed to follow the order, which required withholding the drug if the pulse was below 60. This oversight was confirmed by the MDS nurse and DON, highlighting a lapse in adhering to prescribed medication protocols.
A resident admitted with generalized weakness and neuromuscular dysfunction of the bladder did not have RNA services documented as required. Despite an order for RNA services to begin, there was no log of services provided. RNA 2 admitted to signing the log retrospectively, and the Director of Rehab confirmed that missing documentation indicates services were not performed. The Director of Nursing stressed the need for immediate documentation to ensure accuracy, as per facility policy.
A resident admitted to hospice care in an LTC facility did not receive a comprehensive assessment for the plan of care, including the frequency of hospice staff visits. Despite being placed on hospice care, there were no physician orders or hospice calendar entries indicating the frequency of visits. The resident received hospice visits on only two occasions, with no visits documented for several days. The facility's policy required hospice services to be provided upon physician order, and the agreement with the hospice required collaboration and documentation of care.
Two residents were affected by infection control deficiencies in a facility. An LVN failed to disinfect a shared blood pressure cuff after use on a resident with a history of UTI, risking cross-contamination. Another LVN did not wear PPE while administering medication to a resident with a gastrostomy tube on Enhanced Barrier Precautions, and mishandled the tube connection, risking infection. Facility policies on disinfection and aseptic techniques were not followed.
Failure to Document PRN Oxygen Administration and Assessment
Penalty
Summary
The deficiency involves the facility’s failure to accurately and completely document the administration of oxygen therapy and related assessments for one resident, as required by facility policy and professional standards. The resident was admitted with chronic lymphocytic leukemia of B-cell type not in remission and malignant neoplasm of the prostate, and was assessed on the MDS as cognitively impaired with a need for partial/moderate assistance for oral, toilet, and personal hygiene. The resident had an order, dated 1/23/2026, for oxygen at 2–4 L/min via nasal cannula or 5–10 L/min via mask to maintain O2 saturation ≥ 92%, with a requirement to record O2 saturation before administration. On the date of the incident, the MAR for the resident showed the PRN oxygen order but was blank for any oxygen administration on that day, and the SBAR communication form completed that afternoon did not indicate that oxygen had been given when the resident was found unresponsive. During a concurrent review of the MAR and SBAR, the LVN reported that at approximately 3:30 PM he administered oxygen at 10 L/min via mask to the resident upon finding him unresponsive but forgot to document this on both the MAR and the SBAR, and also did not record the O2 saturation as required. The facility’s Charting and Documentation policy stated that all services provided and any changes in the resident’s condition must be documented in the medical record to facilitate communication among the interdisciplinary team, which was not followed in this instance.
Failure to Notify Physician of Resident’s Post-Fall Knee Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to follow its "Changes in Resident Condition" policy by not notifying the physician when a resident reported altered knee sensation after a witnessed fall. The resident, who had diagnoses including paraplegia, a stage 4 sacral pressure ulcer, and osteomyelitis, was cognitively intact and required assistance with mobility. On the date of the fall, an SBAR documented that the resident experienced an unavoidable witnessed fall during a transfer, slipping from a CNA’s grasp and striking the left foot on the wheelchair footrest. An order was obtained for X‑rays of the left foot, second toe, and bilateral hips/pelvis, but no knee X‑ray was ordered at that time. In the days following the fall, the resident and family reported symptoms involving the knees that were not promptly communicated to the physician. The family member stated that when visiting about two days after the fall, the resident’s knees were very swollen, and the resident reported hearing a crack at the time of the fall and feeling a hot burning sensation in the knees for two days. The family member reported that when asking a nurse about X‑rays, the nurse said X‑rays had been done on the back and foot, and the family member then requested staff to contact the physician for a knee X‑ray. The resident stated that he landed on both knees, heard a crack, and that about an hour after the fall his right leg became swollen and warm, and by the next morning he felt a burning sensation in his legs, which he reported to two CNAs and an LVN. Staff interviews and record review confirmed that the physician was not notified of the resident’s new knee symptoms as required by policy. CNAs described seeing the resident with both knees on the floor and feet under the wheelchair, and one CNA observed redness of the upper shins after the fall. An LVN who worked the day after the fall stated the resident reported his knees did not feel normal and did not want his legs moved; the LVN reviewed the orders, saw an existing X‑ray order for the foot and hips/pelvis, and assumed it covered the whole leg. The LVN acknowledged that there was no specific knee X‑ray order and that she should have messaged the physician about the resident’s knee complaints. The DON stated that licensed nurses were required to assess and notify the physician of changes in condition, including when the resident reported burning sensations in the knees, and that the facility’s policy required notifying the resident, physician, and representative when an accident results in injury and has potential to require physician intervention.
Plan Of Correction
F580 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 02/09/2026 Resident 1's attending physician was notified of residents complain of “burning sensation and pain on both knees” with orders for X-Ray on both knees. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. From 02/26/2026 thru 02/27/2026 The Director of Nurses (DON) and Quality Assurance Nurse (QAN) conducted an audit of all residents who experienced a fall, injury, or change in condition within the last 30 days to ensure timely physician notification occurred in accordance with the facility's policy and procedure titled "Changes in Resident Condition"; no otherresidents were identified to have been affected bythis deficient practice.What measures will be put into place or whatsystemic changes will the facility make to ensurethat the deficient practice does not recur. On 02/27/2026 DON re-educated all licensednursing staff (LVNs and RNs) on the facility'spolicy and procedure titled "Changes in ResidentCondition", with specific emphasis on: therequirement to notify the attending physicianimmediately upon any change in condition,including new or altered pain, swelling, or sensorycomplaints following an accident or fall. How the facility plans to monitor its performanceto make sure that solutions are sustained. Beginning 03/09/2026 the DON or designee willconduct weekly audits of all fall/incident SBARscompleted during the prior week to verify that:physician notification is documented within therequired timeframe. All reports or findings of non-compliance shall be presented by Admin anddiscussed in the Quality Assurance PerformanceImprovement meetings (QAPI). QAPI committeeshall review and monitor the effectiveness of theseplans monthly and then quarterly after 3 months. The effectiveness of the plan shall be measured bythe occurrences and non-occurrences of the sameissues or problems. QAPI Committee shall focusand discuss further actions by developingPerformance Improvement Plan (PIP) for areas orissues identified as recurring or trendingnegatively to implement a new and more effectiveplan of actions.
Failure to Reposition Resident With Multiple Stage 4 Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services to prevent the formation and promote the healing of pressure injuries by not ensuring a resident was repositioned every two hours as care planned. The resident was initially admitted and later readmitted with multiple stage 4 pressure ulcers, including to the sacral region, left hip, right buttock, and left buttock. The resident’s care plans, dated 11/7/2025 and 2/3/2026, documented impaired skin integrity with stage 4 pressure injuries to the sacrococcyx, left ischium, and left posterior hip, with interventions that included keeping affected areas clean and dry, monitoring for adverse changes, and turning and repositioning every two hours or as needed. The MDS dated 2/5/2026 indicated the resident had intact cognitive skills for daily decision making, bilateral lower extremity impairment, required supervision or touching assistance for rolling, and had stage 4 pressure ulcers. On observation, the resident was seen lying on his back in bed on multiple occasions. During an interview, the treatment nurse stated the resident needed help with repositioning while awake and that, although the resident previously used a timer on his phone while asleep, he now needed significantly more help due to wearing a leg brace. In a concurrent observation and interview, the resident reported that staff had not offered or assisted with repositioning. The CNA interviewed confirmed that the resident could not move his legs, required staff to carry his legs when repositioning from side to side, and was supposed to be repositioned every two hours to avoid pressure injuries and prevent current wounds from worsening. The CNA further stated that during his 7 AM to 3 PM shift he had only repositioned the resident once around 9 AM and that no other staff had repositioned the resident during that time. He acknowledged that the resident was not efficient with repositioning himself, needed assistance with managing the leg brace during turns, and that he did not follow the standard procedure of repositioning the resident every two hours during his eight-hour shift. The Director of Rehabilitation confirmed the resident was paraplegic, unable to use his lower extremities, wore a knee brace that limited movement, and required staff to hold the leg during repositioning. The DON stated the resident needed staff assistance with repositioning every two hours and that staff were required to offer repositioning even if residents declined. The facility’s policy on Prevention of Pressure Injuries, revised 7/12/2023, directed staff to reposition residents as indicated on the care plan, which was not followed in this case.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 02/25/2026 Resident 1 was offered to be repositioned but declined the assistance. The resident was educated on the importance of repositioning every two (2) hours to promote wound healing and prevent further skin breakdown and instructed to use the call light to request assistance when ready to be repositioned. CNA 1 was provided with reeducation on 02/27/2026 regarding policy and procedure titled "Prevention of Pressure Injuries", with specific emphasis on the requirement to turn and reposition residents per care plan and with emphasis on facility's responsibility to continue to offer and encourage repositioning every two (2) hours regardless of resident's preference. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. From 02/26/2026 thru 02/27/2026 The DON and QAN identified of all residents with elevated risk for pressure injury development and those with active pressure ulcers to ensure plan of care is being followed; no other residents were identified to have been affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. On 02/27/2026 DON and Director of Staff Development re-educated all licensed nursing staff (LVNs and RNs) and Certified Nursing Assistants (CNA) on the facility's policy and procedure titled "Prevention of Pressure Injuries", with specific emphasis on the requirement to turn and reposition residents per care plan. How the facility plans to monitor its performance to make sure that solutions are sustained. Beginning 03/09/2026 the DSD will conduct rounds of the facility and observe CNAs during ADL care to ensure residents plan of care is being followed. All reports or findings of non-compliance shall be presented by Admin and discussed in the Quality Assurance Performance Improvement meetings (QAPI). QAPI committee shall review and monitor the effectiveness of these plans monthly and then quarterly after 3 months. The effectiveness of the plan shall be measured by the occurrences and non-occurrences of the same issues or problems. QAPI Committee shall focus and discuss further actions by developing Performance Improvement Plan (PIP) for areas or issues identified as recurring or trending negatively to implement a new and more effective plan of actions.
Smoke Infiltration from Burnt HVAC Filter Due to Roofing Torch Work
Penalty
Summary
The facility failed to ensure a safe environment free of accident hazards when smoke from a burnt HVAC unit filter entered an interior hallway leading to the front lobby. On 1/10/2026, multiple staff, including the DON, LVNs, CNA, Activity Director, maintenance staff, and the receptionist, reported smelling something burning, detecting smoke or haze in the hallway, and noting a burnt or plastic-like odor. The DON stated he was notified at 10:59 AM by an RN that there was smoke inside the facility, and paramedics who were on-site for a resident’s change of condition also noticed smoke in the building. Staff reported that the smoke detector did not alarm during the event. The Maintenance Director reported that maintenance staff informed him of smoke and a burning smell, traced to a ceiling vent connected to HVAC unit 15. During observation with the Administrator, HVAC unit 15’s filter was found partially burnt, and the Administrator explained that roofing workers using a torch to patch the roof ignited the HVAC filter, causing smoke to travel down the vent into the facility. Staff interviews confirmed that residents’ doors were ordered closed in response to the smoke and that paramedics assisted by opening the front door and turning on fans in the hallway. The DON and LVNs acknowledged that smoke inhalation is harmful and can cause respiratory distress, particularly for residents with underlying respiratory conditions. Review of the facility’s Accidents/Incidents policy indicated the facility is required to provide a safe and secure environment for staff and residents, which was not maintained when smoke entered the occupied hallway and the smoke detection system did not alarm.
Failure to Ensure Timely Oncology Follow-Up for Resident with Cancer
Penalty
Summary
The facility failed to ensure that a resident with non-Hodgkin lymphoma received all necessary services, specifically a scheduled oncology appointment as prescribed upon discharge from an acute care hospital. The resident, who also had end stage renal disease, heart failure, and adult failure to thrive, was admitted with orders for outpatient treatment with rituximab and a follow-up appointment with an oncologist. Documentation showed that the resident did not attend the scheduled oncology appointment due to insurance issues, and there was no evidence in the medical record that the primary care physician was notified of the missed appointment or that the appointment was rescheduled. Interviews with the DON and the resident's primary care physician confirmed that facility staff did not follow protocol to notify the physician or reschedule the missed specialist appointment. The facility's policy required timely and coordinated referrals to medical specialists, including documentation and follow-up, but these steps were not taken. As a result, the resident did not receive an evaluation and treatment plan for their cancer as prescribed.
Failure to Protect Resident Privacy Due to Unrestricted Camera Use in Shared Room
Penalty
Summary
The facility failed to secure privacy for three residents by allowing a responsible party (RP) to remotely control a tablet with a camera in a shared resident room. The RP used the device to monitor his family member continuously, including during personal care activities such as bathing, toileting, and dressing. Staff interviews confirmed that the RP could see and hear not only his family member but also the other residents and staff in the room, including during private care activities. The RP also insisted on keeping curtains open to maximize the camera's view, further compromising the privacy of all residents in the room. Residents expressed discomfort and concern about being watched and having their privacy invaded. One resident with intact cognitive skills explicitly stated she did not consent to the surveillance and felt uncomfortable using the restroom due to the camera. Another resident reported sleep disturbances and distress due to the camera being on at all times and the associated light and noise. Staff also reported feeling uncomfortable and observed that the camera captured images and audio of all residents and staff in the room, raising concerns about HIPAA violations and the privacy of medical information. A review of facility policies revealed that there was no care plan addressing the use of the electronic device in the room, despite the facility's policy requiring protection of resident privacy and dignity. The policy also specified the use of headphones for video calls, which was not followed. The Director of Nursing acknowledged that the current situation did not respect the privacy and dignity of the residents and that the RP's actions were invasive to both residents and staff.
Failure to Assess, Notify Physician, and Develop Care Plan for Resident's Generalized Itching
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Parkinson's disease, chronic kidney disease, type II diabetes mellitus, and anxiety disorder, experienced ongoing generalized itching without receiving appropriate assessment, care, or timely physician notification. The resident, who had severely impaired cognitive function and required substantial assistance with daily activities, repeatedly complained of itching and was observed with scratch marks and red, flaky skin over several months. Despite these complaints and visible symptoms, there was no evidence that licensed staff performed a thorough skin evaluation or developed a care plan specific to the resident's itching. On multiple occasions, staff, including a Licensed Vocational Nurse (LVN), failed to notify the physician promptly about the resident's worsening condition. The LVN acknowledged not informing the physician immediately after the resident reported whole-body itching and did not provide any treatment or medication for the symptoms. Certified Nurse Assistants (CNAs) observed and reported the resident's persistent scratching and skin damage but only applied lotion without further escalation or intervention. Record reviews confirmed that no medication or treatment orders were in place for the resident's itching, and there was no care plan addressing the issue. The facility's policy required notification of the physician and care plan updates for significant changes in a resident's condition, but these steps were not taken. The Director of Nursing confirmed that the lack of physician notification and absence of a care plan for the resident's itching constituted a failure to provide necessary care and treatment as required by facility policy.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Maintain Call Devices Within Easy Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call devices were maintained within easy reach for two residents with significant physical and cognitive impairments. For one resident with encephalopathy, cerebral palsy, and bilateral hand contractures, the call pad was observed hanging below the bed and out of reach, despite the resident's dependence on staff for all activities of daily living and the need for the call pad to be positioned near the chest area due to hand contractures. Both a CNA and an LVN confirmed that the call pad was not accessible and should have been placed within easy reach to allow the resident to request assistance. For another resident with epilepsy, dysphagia, and Alzheimer's disease, the call pad device was found on the floor near the head of the bed, making it inaccessible. This resident had severe cognitive impairment and required substantial to maximal assistance with daily care. An LVN confirmed that the call pad was not within easy reach and should have been accessible to ensure timely care. The facility's policy requires that call lights be within easy reach for residents in bed or confined to a chair, but this was not followed in these cases.
Failure to Follow IV Therapy Protocols and Documentation Requirements
Penalty
Summary
The facility failed to follow its own policies and procedures regarding intravenous (IV) therapy for two residents. For one resident with diagnoses including type 2 diabetes and osteomyelitis, the IV tubing used to administer Ceftriaxone was observed to be unlabeled during a room visit. The licensed vocational nurse confirmed the tubing was not labeled and acknowledged that labeling is required to track the age of the tubing and prevent bacterial contamination. The Director of Nursing also verified that the facility's policies require IV tubing to be labeled with the date and time for infection control purposes, and that failure to do so violates both the infection prevention and administration set/tubing change policies. For another resident with a history of ESBL-resistant Klebsiella infection and Alzheimer's disease, the care plan required IV site monitoring every shift while receiving Ertapenem. Review of the IV therapy medication record revealed that there were no registered nurse initials indicating that the IV site was checked during multiple night shifts. Interviews with nursing staff confirmed that the IV site was not checked or flushed as required, and the MDS nurse verified that documentation was incomplete, stating that if it was not documented, it was not done. The facility's policy specifies that the venous access site must be monitored and documented at least every shift. These deficiencies were identified through observation, interviews with staff, and review of medical records and facility policies. The failures included not labeling IV tubing and not consistently monitoring and documenting IV site assessments as required by the facility's infection control and IV therapy protocols.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Improper Disposal of Garbage and Refuse Due to Uncovered Dumpsters
Penalty
Summary
Two of four dumpsters in the facility's garbage area were observed with lids left exposed and not completely closed, as confirmed by the Maintenance Supervisor during an observation and interview. The Maintenance Supervisor acknowledged that the dumpsters were full and that the lids should have been closed according to facility policy, which is intended to prevent pests from accessing the trash. A review of the facility's Policy & Procedures on Sanitation and Infection Control: Waste Control and Disposal indicated that outside trash dumpster lids are required to be kept closed. No information about specific residents or their medical conditions was provided in relation to this deficiency.
Failure to Coordinate and Document Hospice Services for Two Residents
Penalty
Summary
The facility failed to ensure proper coordination of care between facility staff and hospice providers for two residents who were receiving hospice services. For one resident with a history of cerebral infarction and intracerebral hemorrhage, the facility did not maintain complete hospice nursing visitation calendars or documentation for June and July. The hospice binder lacked required sign-in sheets and care notes from registered nurses, licensed vocational nurses, and nurse aides, as stipulated by the hospice agreement. The only available documentation was a social worker's signature for one date, and the facility's designated staff confirmed that without proper documentation, it was unclear if visits occurred or what care was provided. For another resident with Alzheimer's disease and hemiplegia, the facility was unable to verify that scheduled hospice visits by registered nurses and licensed vocational nurses took place in June and July. The hospice visiting calendar and sign-in forms were incomplete, and there were no corresponding nursing notes. Facility staff, including licensed vocational nurses, reported not seeing hospice nurses visit the resident, and the medical records director could not locate any hospice notes or sign-in information for the scheduled visits. The director of nursing acknowledged that the facility should have ensured collaborative communication and documentation between facility and hospice staff, as required by policy and the hospice agreement. Facility policy required coordination of care, communication, and documentation between facility and hospice staff to ensure residents' needs were met. The policy also designated specific staff to coordinate hospice care and required that hospice staff sign in and provide visit notes. The lack of documentation and incomplete records for both residents indicated that the facility did not follow its own policies or the hospice agreement, resulting in a failure to ensure that hospice care and services were provided as ordered by the physician.
Failure to Properly Dispose of Medical Waste According to Facility Policy
Penalty
Summary
A deficiency occurred when standard infection prevention and control practices were not followed during the disposal of medical waste. During wound care for a resident with a sacral wound that was bleeding profusely, an LVN discarded soiled dressings and blood-saturated gauze into a clear plastic bag, which was then placed in a separate black bin rather than in a designated medical waste container. The LVN stated that the resident had previously been on contact isolation for a stage four pressure ulcer, but the isolation had been discontinued two days prior. The Infection Control Nurse (IPN) confirmed that no red bags were used for disposing of the medical waste, citing the discontinuation of contact isolation as the reason, and stated that the facility did not have color-coded bins or containers for hazardous or medical waste. A review of the facility's policy and procedure on medical waste handling indicated that items soiled with visible blood must be placed in red plastic bags or containers, and either saturated with a bleach solution or incinerated. Despite this policy, the IPN acknowledged that the facility lacked the required color-coded bins for proper disposal of medical waste. The failure to follow the facility's own policy and procedure for the safe and appropriate handling of medical waste was observed and confirmed through staff interviews and record review.
Deficiencies in Laundry Maintenance, Documentation, and Environmental Cleanliness
Penalty
Summary
The facility failed to maintain proper cleaning and documentation procedures in the laundry area and did not ensure cleanliness in resident restrooms and rooms. Specifically, lint was found in the lint trap of one dryer during observation, despite facility policy requiring lint removal after each use or every three hours. The lint removal log for the specified date was incomplete, with a blank entry for a scheduled time, and staff could not explain the omission. Additionally, the laundry water temperature log contained a future-dated entry, indicating that the required temperature checks were not performed at the scheduled times, as confirmed by staff and the maintenance supervisor. In another instance, yellow-brownish fluid, identified as urine, was observed on the toilet seat riser chair and the floor in a resident restroom and adjoining room. The infection prevention nurse and DON confirmed that the presence of urine on these surfaces was unsanitary and not in accordance with facility policy, which requires a clean and safe environment for residents. The facility's policies on laundry maintenance, water temperature, and maintaining a homelike environment were not followed as observed and confirmed through staff interviews and record reviews.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency was identified when a certified nurse assistant (CNA) was observed standing above a resident's eye level while assisting with mealtime, rather than sitting or positioning themselves at eye level with the resident. This occurred during breakfast in the resident's room, with a registered nurse (RN) present who did not intervene or instruct the CNA to adjust their position. The facility's policy requires staff to provide care in a manner that respects and enhances each resident's dignity, including maintaining eye-level interaction during assistance. The resident involved had diagnoses of dementia, Parkinson's disease, and quadriplegia, and required varying levels of assistance with activities of daily living, including eating. Interviews with staff confirmed that proper practice is to be at eye level with residents during feeding to show respect and maintain dignity. The failure to follow this practice was acknowledged by multiple staff members, and the facility's policy supports the expectation of maintaining resident dignity during care.
Failure to Provide Clean, Undamaged Bed Linen
Penalty
Summary
A deficiency was identified when a resident was found to have bed linen that was damaged with over thirty small holes near the bottom of the sheet. The resident, who had chronic obstructive pulmonary disease, type 2 diabetes mellitus with chronic kidney disease, and muscle weakness, required varying levels of assistance with daily activities but had no cognitive impairment and was able to make his own decisions. During an observation, the damaged bed sheet was noted, and the resident expressed discomfort and dissatisfaction with the condition of the linen. Interviews with staff confirmed that the damaged sheet was uncomfortable and could negatively affect residents' self-esteem, and that such conditions do not provide a homelike environment. The facility's policy requires that residents be provided with clean and good condition linens as part of a safe, clean, and comfortable environment. The failure to provide undamaged bed linen was observed and acknowledged by both direct care staff and facility management.
Failure to Document Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from unnecessary psychotropic drug use by not documenting a rationale for extending a PRN (as needed) Lorazepam order beyond 14 days, as required by facility policy. The resident, who had diagnoses including dementia, depression, and anxiety disorder, was prescribed Lorazepam PRN for anxiety manifested by repetitive verbal outbursts, with an order set for 30 days. The psychiatric follow-up note indicated continued use of Lorazepam to assist with behavior management, but did not provide a documented rationale for extending the PRN order beyond the 14-day policy limit. Interviews with facility staff, including a Licensed Vocational Nurse, Pharmacy Consultant, and the Director of Nursing, confirmed that the Lorazepam order was not limited to 14 days and lacked the required documentation for extension. The facility's policy specified that PRN psychotropic medication orders should be limited to 14 days unless a prescriber documents the rationale for extension and specifies the duration. In this case, there was no psychiatrist documentation justifying the extension prior to the 30-day order, resulting in non-compliance with the facility's policy and procedures.
Failure to Develop Individualized Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents with specific clinical needs. For one resident with end stage renal disease and dependence on dialysis, the physician ordered a daily fluid restriction of 1,000cc. Despite this order being documented in the resident's records, there was no care plan created to address the fluid restriction. Both the LVN and the DON confirmed that a care plan should have been in place to guide staff in managing the resident's fluid intake and to prevent complications related to fluid overload. Another resident, who was readmitted with diagnoses including cellulitis, long-term antibiotic use, and a deep incisional surgical infection, was receiving intravenous antibiotics as ordered by the physician. The medication administration record confirmed that the resident was receiving IV Vancomycin and Ceftriaxone for a surgical wound infection. However, there was no individualized care plan initiated to address the administration of IV antibiotics. The DON and the MDS nurse both acknowledged that a care plan should have been developed to ensure all staff were aware of the resident's needs, goals, and interventions related to IV therapy. A third resident, with a history of pressure ulcers, abnormal posture, and muscle weakness, was observed using a bolster low air loss mattress. While the resident had a care plan for the use of a low air loss mattress for skin and wound maintenance, there was no care plan specifically addressing the use of the bolster feature. Staff interviews and record reviews confirmed the absence of a care plan for the bolster mattress, which was used to prevent the resident from sliding or falling out of bed. The DON verified that a care plan should have included monitoring the placement of the bolster to ensure safety and prevent additional skin issues.
Failure to Obtain Physician Order for Bolster Low Air Loss Mattress
Penalty
Summary
A deficiency occurred when a resident with a history of a sacral pressure ulcer, abnormal posture, and muscle weakness was provided with a bolster low air loss mattress (LALM) without a corresponding physician's order. The resident was assessed as being at moderate risk for pressure sores, requiring substantial to maximal assistance with daily activities, and was observed using the bolster LALM in bed. Staff interviews confirmed that the mattress was in use to prevent the resident from sliding or falling out of bed, but review of the resident's active orders revealed that only a standard low air loss mattress was ordered, not the bolster version. Further interviews with nursing staff and the DON confirmed that the decision to use the bolster LALM was made by the interdisciplinary team for the resident's safety, but the specific order for this equipment was not documented in the physician's orders. Additionally, the facility was unable to provide a policy and procedure specific to the use of bolster low air loss mattresses, and the existing policy only addressed general air mattress use for pressure ulcer prevention and healing.
Failure to Administer Prescribed Water Flush for GTube Resident After Medication
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube (GTube) did not receive the prescribed amount of water flush after medication administration. The resident, who was dependent on tube feeding for all nutrition and hydration and had severely impaired cognitive skills, was observed receiving only 5 cc of water flush after medications, despite physician orders and the care plan specifying 30-50 cc of water before and after medication administration. The resident's care plan also included interventions to ensure adequate hydration and nutrition through proper tube flushing. The Licensed Vocational Nurse (LVN) responsible for administering the medications acknowledged that the correct amount of water flush was not provided and stated awareness of the importance of following the physician's order to prevent tube clogging and ensure proper medication administration. The facility's policy on enteral nutrition also required that nutritional support be provided as ordered. The Director of Nursing confirmed that water flushes are to be given as ordered, but the observation and record review demonstrated that the prescribed protocol was not followed for this resident.
Failure to Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to monitor and document the daily fluid intake for a resident with end stage renal disease (ESRD) and heart failure who was on dialysis and had a physician-ordered fluid restriction of 1000cc per day. The resident's care plan specified the distribution of fluids across nursing shifts and meals, and the order included instructions that no water pitcher be kept at the bedside. However, review of the Medication Administration Record (MAR) and interviews with nursing staff revealed that there was no documentation of the resident's actual fluid intake for any shift over a two-week period. The MAR only allowed staff to acknowledge the fluid restriction order, not to record intake amounts, and there was no alternative location for this documentation. Multiple licensed nursing staff confirmed that fluid intake amounts were not recorded as required, and the resident's chart lacked any notes indicating intake for the period in question. Staff acknowledged that without accurate and complete intake records, it was not possible to ensure the resident's fluid intake remained within the prescribed limits. The Director of Nursing also confirmed that monitoring and documentation of fluid intake should have occurred according to policy and physician orders. Review of facility policy indicated that special care monitoring, including fluid restriction, is required for residents on dialysis.
Failure to Accurately Document Controlled Medication Counts at Shift Change
Penalty
Summary
The facility failed to provide a consistent and accurate account of controlled medications by not ensuring staff completed documentation of narcotic counts at each shift change. Record reviews revealed multiple blank entries on Narcotic Release Forms for several medication carts across various dates, indicating that staff did not always document the required shift-to-shift narcotic counts. Interviews with licensed nurses and the Director of Nursing confirmed that the forms were incomplete and should have been filled out according to facility policy, which requires two licensed nurses to conduct and document a physical inventory of all controlled medications at each shift change. One resident involved had significant medical needs, including a feeding tube, severe cognitive impairment, and dependence on staff for daily activities. The incomplete documentation of controlled medication counts meant there was no way to ensure that narcotics were properly accounted for or administered safely and accurately to residents. The Director of Nursing acknowledged that the lack of complete and accurate forms could result in discrepancies in the amount of narcotics available for residents and potentially delay treatments.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Water Flushes
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with three medication errors identified out of 25 observed medication administration opportunities, resulting in a 12.5% error rate. Specifically, a Licensed Vocational Nurse (LVN) did not administer the prescribed amount of water flush (10-15 cc) between each medication given via gastrostomy tube (GTube) to a resident, instead using only 5 cc of water between medications. This was observed during medication administration at the resident's bedside, and the LVN acknowledged the error, stating that the correct amount of water should have been used as per the physician's order. The resident involved had significant medical needs, including gastrostomy status, moderate protein-calorie malnutrition, aphasia, and severely impaired cognitive skills, and was dependent on tube feeding for nutrition and hydration. The resident's care plan and medication administration record both specified the need for 10-15 cc water flushes between medications. The facility's policy also required medications to be administered as prescribed. The Director of Nursing confirmed that water flushes should be given as ordered to ensure proper medication administration.
Expired Glucose Test Strips Used During Blood Sugar Testing
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) used expired glucose test strips to check a resident's blood sugar during medication administration. The LVN was observed at the resident's bedside using test strips from a bottle that was past its expiration date. Upon interview, the LVN acknowledged that the strips were expired, should not have been used, and should have been discarded from the medication cart. The facility's Director of Nursing (DON) confirmed that facility protocol requires all glucose test strips in use to be current and discarded once expired, as expired strips can provide inaccurate results. The resident involved had a history of type 2 diabetes mellitus, peripheral vascular disease, and a gastrostomy, and was dependent on staff for all activities of daily living. The resident's medication administration record indicated the use of insulin based on blood glucose readings. The facility's policy and procedure required checking expiration dates prior to administering medications and ensuring safe administration practices. Despite these protocols, expired test strips were used for blood sugar testing, constituting a failure to ensure drugs and biologicals were properly labeled and stored, and that expired supplies were not used in resident care.
Failure to Maintain Accurate and Complete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, resulting in deficiencies in documentation and communication among healthcare providers. For one resident with a history of ESBL resistance, Klebsiella infection, and Alzheimer's disease, the IV therapy medication record was not initialed by the night shift nurse for multiple consecutive days, indicating that required IV site checks were not documented. Additionally, the record contained inaccurate information, as a nurse documented an IV flush and site check after the resident's IV access had already been removed. The IV therapy medication record was also missing essential information such as the physician's name, allergies, and diagnoses, contrary to facility policy. Interviews with nursing staff confirmed that documentation was incomplete and, in some cases, inaccurate, with one nurse unable to explain why her initials appeared for a procedure that was not performed. Another resident, who was dependent on a gastrostomy tube for nutrition and medication administration due to severe cognitive impairment and aphasia, did not receive water flushes as ordered between and after medication administration. Observation revealed that only 5 cc of water was used for flushes, rather than the ordered 10-15 cc between medications and 30-50 cc after. The Medication Administration Record (MAR) inaccurately reflected that the correct flushes were given and was signed by a nurse who did not perform the procedure. Both the nurse who administered the flushes and the nurse whose initials appeared on the MAR confirmed the documentation was inaccurate. Facility policies require that all medical record documentation be objective, complete, and accurate, including the administration of medications, treatments, and any changes in resident condition. The Director of Nursing confirmed that only the nurse administering care should document it in the MAR, and that accurate documentation is essential for ensuring appropriate care. The failures in documentation for both residents were confirmed through interviews, record reviews, and direct observation.
Failure to Post Up-to-Date Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that accurate and up-to-date nurse staffing information was posted daily in a visible and prominent location, as required. Observations on multiple occasions revealed that the staffing information displayed at the front reception desk was outdated, showing data from several days prior rather than the current day. No updated staffing postings were found for the dates in question, and the required information was not readily accessible to residents and visitors. Interviews with facility staff indicated a lack of clarity and communication regarding responsibility for posting staffing information, particularly over the weekend. The Director of Staff Development (DSD) stated he was responsible for weekday postings, while the weekend Registered Nurse Supervisor (RNS) was supposed to handle weekend postings. However, the RNS reported she was unaware of this assignment and did not typically manage staffing postings. The facility's policy requires daily posting of direct care staffing numbers for every shift, but this procedure was not followed during the period reviewed.
Resident Exposed During Post-Shower Transfer, Violating Dignity and Privacy
Penalty
Summary
The facility failed to maintain a resident's dignity and privacy during post-shower care. Observation revealed that a certified nursing assistant (CNA) took a resident out of the shower room with only a gown covering the front of the resident's body, leaving both sides and the back exposed. The CNA acknowledged that the resident should have been fully covered during the transfer from the shower room to the resident's room. The Director of Nursing (DON) confirmed that the resident should have been covered with a poncho that would shield the entire body and shower chair for dignity. The resident, who was cognitively independent but required substantial assistance with bathing and dressing due to muscle weakness and diabetes mellitus, reported feeling disrespected and stated that a blanket should have been used for coverage. A review of the facility's policy on resident dignity and personal privacy indicated that residents should be shielded during all personal care and treatment procedures, and should be appropriately draped and dressed to avoid exposure and embarrassment. The policy specifically required covering residents during transfers to the shower or toilet. The failure to follow these procedures resulted in the resident being exposed during transfer, in violation of the resident's right to privacy and dignity.
Failure to Timely Report and Respond to Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Investigation and Reporting policy for one resident who alleged physical abuse by another resident. Specifically, after a resident reported to an RN that another resident had jumped on and hit his head, the incident was not reported to the State Agency, ombudsman, or local law enforcement within the required two-hour timeframe. The Director of Nursing confirmed that the allegation should have been reported and investigated promptly, but this did not occur, and the DON was not made aware of the incident until several hours later. Additionally, the facility did not immediately separate the two residents involved in the alleged abuse, as required by policy to prevent further harm. Both residents remained in the same room for nearly six hours after the incident was reported, despite one resident expressing discomfort about sharing a room with the alleged abuser. The facility's own policies indicated that residents should be protected from abuse and separated during investigations, but these procedures were not followed in this case.
Failure to Administer Ordered Tube Feeding to Resident
Penalty
Summary
Nursing staff failed to ensure that a resident with a gastrostomy feeding tube (GT) received the prescribed volume of tube feeding as ordered by the physician. The resident, who had diagnoses including protein calorie malnutrition, a stage 3 pressure ulcer on the left heel, and stroke with dysphagia, was dependent on tube feeding for all nutrition and hydration. The physician's order specified enteral feeding at 60 cc/hour for 20 hours daily, to be administered from 12 PM to 8 AM, providing a total of 1200 cc in 24 hours. However, during observation and interview, it was confirmed by an LVN that the tube feeding was off when it should have been running, and the LVN admitted to forgetting to restart the feeding at the scheduled time. The resident's care plan and facility policies required adherence to physician orders for tube feeding to support nutritional needs and wound healing, especially for residents at risk for or with pressure ulcers. The facility's policies also outlined procedures for preventing errors in enteral feeding administration, including verifying orders and ensuring proper connections. Despite these protocols, the failure to administer the tube feeding as ordered resulted in the resident not receiving the required nutrition during the prescribed period.
Failure to Maintain Resident Dignity Due to Loud Television Volume
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not maintaining the television volume at a comfortable level in a shared room. The incident involved a resident with chronic obstructive pulmonary disease, type 2 diabetes with chronic kidney disease, and acute respiratory failure, who was assessed as having moderately impaired cognitive skills and required varying levels of assistance with daily activities. On the night of the incident, the resident was unable to sleep due to the loud volume of the television operated by the roommate. This led to a verbal confrontation between the two residents, with the affected resident attempting to lower the volume and turning off the television at the roommate's bedside. Staff interviews revealed that facility personnel were expected to check on residents' comfort and address such issues during routine night rounds, especially during quiet hours. Both a licensed vocational nurse and a registered nurse confirmed that the television volume should have been kept at a low and comfortable setting during quiet time, and that staff should have intervened to address the noise complaint. Facility policies reviewed indicated that care should be provided in a manner that maintains resident dignity and comfort, including maintaining television settings at a level agreeable to all residents in the room. The failure to address the television volume resulted in a violation of the resident's right to a dignified and comfortable environment.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 16 and 286, were informed and provided with written information regarding their right to formulate an advance directive. This deficiency was identified through interviews and record reviews, which revealed that neither resident had an advance directive or an advance healthcare directive acknowledgment form in their medical records. Resident 16, who had intact cognitive skills for daily decision-making, was admitted and readmitted to the facility without the necessary documentation in their chart. The Admission Coordinator confirmed the absence of the advance directive acknowledgment form, which should have been included in the admission packet and followed up by the social worker. Similarly, Resident 286, who had severely impaired cognitive skills, also lacked the necessary documentation in their medical record. The Social Services Director acknowledged the absence of the advance directive acknowledgment form, which was supposed to be provided upon admission and included in the admission packet. The Director of Nursing confirmed that the advance directive should be kept in the chart, and if not available, an acknowledgment form should be present. The facility's policy and procedure on advance directives, revised in August 2023, required that residents be provided with written information about their rights to refuse or accept medical treatment and to formulate an advance directive upon admission.
Failure to Provide Grooming Care Assistance
Penalty
Summary
The facility failed to provide grooming care assistance as per its policy for two residents, leading to a deficiency in care. Resident 43, who was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and dementia, required assistance with activities of daily living (ADLs) due to severely impaired cognitive skills. Observations revealed that Resident 43 had long and yellowish fingernails, indicating a lack of grooming care. Certified Nursing Assistant (CNA) 9 confirmed that Resident 43 was unable to clip his own nails and required assistance, which was not provided. Furthermore, there was no documentation of any refusal of care by Resident 43, as required by the facility's procedures. Similarly, Resident 75, who had diagnoses of contracture, dementia, and Parkinson's Disease, was dependent on staff for personal hygiene due to severe cognitive impairment and physical limitations. Observations showed that Resident 75 had long fingernails, which were not trimmed by the facility staff. The resident's responsible party expressed concern about the lack of nail care, and CNA 9 acknowledged the resident's dependency on staff for grooming. Despite the facility's policy requiring CNAs to document refusals of care, there was no record of any such documentation for Resident 75. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility's policy required CNAs to check and clip residents' nails as needed to prevent self-inflicted injuries. However, there was no evidence of compliance with this policy for Residents 43 and 75. The facility's failure to adhere to its own policies and procedures for grooming care assistance resulted in a deficiency that could potentially impact the residents' quality of life.
Failure to Implement Seizure Precautions
Penalty
Summary
The facility failed to implement necessary interventions to prevent accidents for three residents with a history of seizures. Resident 58, who was diagnosed with epilepsy, quadriplegia, and dementia, had a physician's order to have both side rails padded for seizure precautions. However, observations revealed that only the right side rail was padded, leaving the left side rail unprotected. Interviews with staff confirmed that both side rails should have been padded according to the physician's order and facility policy. Similarly, Resident 103, who also had a diagnosis of epilepsy, was observed with only the right side rail padded, while the left side rail was missing the pad. The Licensed Vocational Nurse stated that the pad was being cleaned, but acknowledged that both side rails should be padded to protect the resident during a seizure. The facility's seizure precaution policy required side rails to be padded for residents with a history of seizures to prevent injury. Resident 28, diagnosed with epilepsy and severe cognitive impairment, was observed with unpadded side rails despite a care plan and physician's order indicating the need for padded side rails for seizure precautions. Staff interviews confirmed that padded side rails were standard practice for residents with seizures to prevent injury. The facility's policy emphasized the importance of implementing care plans and following physician orders to ensure resident safety.
Deficient Care in Catheter and Stoma Management
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to potential health risks. For Resident 106, the facility did not monitor the Foley catheter as per the physician's order. The resident, who was admitted with generalized weakness and neuromuscular dysfunction of the bladder, had a care plan that required monitoring the catheter for drainage, redness, bleeding, irritation, crusting, or pain every shift. However, documentation was missing for several shifts, indicating that the monitoring was not performed. This lack of monitoring could lead to a urinary tract infection, as confirmed by the Director of Nursing. Resident 103, who was admitted with epilepsy, had a suprapubic stoma site that required daily dressing changes as per the physician's order. However, the dressing was not changed daily, and the resident reported that it had not been changed for four days, leading to an itchy and soiled dressing. The Treatment Administration Record indicated that the dressing was last changed on a different date than recorded, and there was no care plan related to the daily dressing change. This oversight increased the risk of infection at the stoma site, as noted by the Infection Prevention Nurse. The facility's policies and procedures for Foley catheter care and documentation emphasize the importance of preventing infections and maintaining accurate records. However, the lack of documentation and adherence to care plans for both residents highlights deficiencies in the facility's care practices. The absence of proper monitoring and documentation for Resident 106's Foley catheter and Resident 103's suprapubic stoma dressing change demonstrates a failure to follow established protocols, potentially compromising the residents' health and well-being.
Deficiencies in Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding oxygen administration for two residents, resulting in deficiencies in care. For Resident 7, the facility did not ensure that the oxygen was administered at the correct ordered setting as per the physician's order. The resident, who was admitted with diagnoses including metabolic encephalopathy and chronic obstructive pulmonary disease (COPD), was observed to have their oxygen set at 5 liters per minute (LPM), which exceeded the ordered range of 2 to 3 LPM, with a possible titration to 4 LPM. This discrepancy was confirmed by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the physician's order was not being followed. For Resident 129, the facility failed to change the oxygen nasal cannula (NC) every seven days as required, and did not maintain a clean oxygen concentrator. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was observed with NC tubing and a humidifier that were not labeled or dated, and an oxygen concentrator with visible stains. The Infection Prevention Nurse (IPN) and a Registered Nurse (RN) confirmed that the NC tubing and humidifier should be changed and dated every seven days to prevent bacterial growth and potential infection. The facility's policy did not include specific instructions for changing and dating the humidifier and tubing, which contributed to the oversight. The facility's failure to follow its own policies and procedures for oxygen administration and equipment maintenance posed a risk of complications for both residents. The observations and interviews with staff highlighted lapses in adhering to physician orders and infection control practices, which are critical for ensuring the safety and well-being of residents receiving oxygen therapy.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as per their policy and procedure, leading to potential health risks for residents. During an observation in the kitchen, it was noted that a container of chicken soup base and wheat flour was not sealed properly. The Dietary Supervisor confirmed this observation, and a Dietary Staff member acknowledged that all containers should be sealed to prevent cross-contamination and insect infestation, which could lead to resident illness. Additionally, the refrigerator designated for residents' food items brought from outside was found to be unclean. The Infection Preventionist observed brownish to blackish crusted food residue on the refrigerator door and spilled milk at the bottom. The Director of Nursing confirmed that all kitchen containers should be sealed and the refrigerator should be kept clean to prevent food contamination. The facility's policies from 2019 emphasized the importance of maintaining clean and properly sealed food storage to ensure food safety.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, leading to potential safety risks. Resident 124, who has Parkinson's disease and a history of falls, reported that the toilet seat in her bathroom was too low, causing discomfort and difficulty in using it safely. Despite being aware of the issue, the maintenance staff did not adjust the toilet seat height due to opposition from other residents. Observations confirmed that Resident 124 struggled to use the toilet, and staff interviews acknowledged the risk of falls due to the low seat height. Resident 186, who has hemiplegia and hemiparesis following a stroke, was found without access to his call light, which was not within reach. This resident, who is dependent on assistance for daily activities, was observed calling for help without success because the call light was placed on the opposite side of the bed or on a dresser, making it inaccessible. Staff interviews confirmed that the call light should have been placed on the resident's left side, where he could reach it, given his right-sided weakness. The facility's policies on accommodating resident needs and ensuring call lights are within reach were not followed, leading to these deficiencies. The failure to adjust the toilet seat height for Resident 124 and to ensure the call light was accessible for Resident 186 were direct violations of the facility's procedures, potentially compromising the safety and well-being of the residents involved.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for Resident 58, as observed during a survey. Resident 58, who was admitted with diagnoses including sepsis, gastrostomy status, and quadriplegia, was found to have fecal matter on the floor next to their bed. This observation was made during a concurrent interview with a Certified Nursing Assistant (CNA), who noted that the fecal matter appeared flattened, suggesting it had been run over by a wheel, such as a shower chair or wheelchair. The resident's care plan indicated they were dependent on staff for toileting hygiene and other daily activities due to severe cognitive impairment and mobility issues. Interviews with the Infection Prevention Nurse (IPN) and the Director of Nursing (DON) highlighted the facility's expectations for maintaining a clean environment. The IPN stated that fecal matter should be disposed of properly to prevent infection spread, and the DON emphasized the need for immediate cleaning of any fecal matter in the resident's room to maintain a safe and homelike environment. The facility's policies on infection control and maintaining a homelike environment were reviewed, indicating an established program to prevent disease transmission and ensure cleanliness, which was not adhered to in this instance.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to implement a care plan for Resident 28, who has a diagnosis of epilepsy, by not using padded side rails as ordered by the physician. Despite the care plan indicating the need for padded side rails to prevent injury during seizures, observations on multiple occasions revealed that the side rails were not padded. Interviews with staff, including a licensed vocational nurse and the infection preventionist, confirmed that the facility's standard practice for residents with seizures was to use padded side rails, and the failure to do so was against the physician's orders and the care plan. For Resident 103, the facility did not develop a care plan to address the treatment of the resident's suprapubic stoma site. The physician's order required daily cleaning and dressing of the stoma site, but observations and interviews revealed that the dressing was not changed for several days, and the site was not cleaned as required. The resident was observed scratching the area, and the dressing was noted to be soiled and dirty. The wound care Treatment Administration Record indicated discrepancies in the documentation of dressing changes, and staff confirmed the absence of a care plan related to the stoma site care. The facility's policy and procedures require a comprehensive, person-centered care plan with measurable objectives and timetables to meet residents' needs. However, the lack of implementation and development of care plans for Residents 28 and 103 demonstrates a failure to adhere to these policies, potentially placing the residents at risk for injury and infection.
Failure to Provide Communication Board for Resident with Aphasia
Penalty
Summary
The facility failed to provide a communication board in the language understood by a resident diagnosed with aphasia, hemiplegia, and hemiparesis. This resident, who was dependent on assistance for various activities of daily living, was admitted and readmitted with these conditions. The resident's care plan, initiated and revised over time, indicated the need for a communication board and translation services to help the resident communicate basic needs. However, during an observation, it was noted that the communication board was not present in the resident's room. Interviews with facility staff, including a Certified Nursing Assistant and the MDS Nurse, confirmed that the resident required a communication board and that it should have been available in the room. The facility's policy on resident rights emphasized the need for communication in a language the resident understands, yet this was not adhered to in the case of the resident. This oversight had the potential to delay appropriate care and treatment due to communication barriers.
Incorrect LAL Mattress Settings for Two Residents
Penalty
Summary
The facility failed to implement appropriate treatment for the prevention of pressure ulcers by not ensuring that the low air loss mattress (LAL) was set correctly for two residents. Resident 287, who was admitted with cerebral palsy and existing pressure ulcers, had a physician's order to monitor the LAL settings every shift. However, observations revealed that the LAL was set at 120 lbs, while the resident's weight was 91 lbs. This incorrect setting was confirmed by both the resident, who expressed discomfort, and a Licensed Vocational Nurse (LVN), who acknowledged the error and its potential impact on wound healing. Similarly, Resident 46, who was at high risk for developing pressure ulcers due to severe cognitive impairment and other health conditions, also had an LAL mattress prescribed for skin breakdown prevention. The resident's weight was recorded as 105 lbs, but the LAL was observed to be set at 120 lbs. An LVN confirmed the incorrect setting, noting that the LAL should be adjusted based on the resident's weight to prevent skin breakdown. The facility's policy and procedure, as well as the manufacturer's manual, indicated that the LAL settings should be adjusted according to the resident's weight to promote healing and prevent pressure ulcers. The failure to adhere to these guidelines for both residents resulted in a deficiency, as the incorrect LAL settings could hinder wound healing and increase the risk of developing new pressure ulcers.
Failure to Provide RNA Services as Ordered
Penalty
Summary
The facility failed to provide Restorative Nursing Assistant (RNA) services to Resident 106 as indicated in the physician's order. Resident 106 was admitted with diagnoses of generalized weakness and neuromuscular dysfunction of the bladder. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and dependency on assistance for various activities. A physician's order dated 7/3/24 required RNA services for passive range of motion (PROM) for the lower extremities and active-assisted range of motion (AAROM) for the upper extremities, to be performed five days a week. Upon review, it was found that there was no documentation or log of RNA services being provided to Resident 106, despite the order for services to start on 7/4/24. Interviews with RNA 1 and the Director of Rehab (DOR) confirmed the absence of documentation, indicating that the services were not performed. The Director of Nursing (DON) emphasized the importance of immediate documentation to ensure accuracy and prevent oversight. Resident 106 reported that the last assistance received was on 7/3/24, the day of discharge from physical therapy, and expressed concern about losing physical function. The facility's policy on Restorative Nursing Services, dated July 2017, mandates that residents receive restorative care to promote safety and independence. The lack of RNA services documentation suggests a failure to adhere to this policy, potentially putting Resident 106 at risk for a decline in physical function and the development of contractures. Interviews with the DOR and a Registered Occupational Therapist (OTR) highlighted the importance of RNA services in maintaining joint function and preventing decline.
Failure to Ensure Adequate Hydration for Resident
Penalty
Summary
The facility failed to ensure that Resident 112 received the required two liters of water daily as per the physician's order. This deficiency was identified through observations, interviews, and record reviews. Resident 112, who was admitted with a diagnosis of hyperosmolality and hypernatremia, had a physician's order to drink at least two liters of water daily and to be encouraged to drink electrolytes. However, the care plan for abnormal laboratory values related to chronic kidney disease did not include this intervention, and the facility's documentation did not accurately record the resident's fluid intake. Interviews with Resident 112 and their responsible party revealed that the resident was often thirsty and not regularly offered water or fluids by the staff. Observations showed that while a pitcher of water was present, there were no cups available for the resident to use, and the resident required assistance to drink. Staff members, including CNAs and LVNs, were unaware of the specific fluid intake requirements for Resident 112, and the facility's CNA Daily Charting Form only documented whether fluids were offered, not the actual intake. The facility's policy on hydration emphasized the importance of ensuring adequate fluid intake for residents, particularly those at high risk for dehydration. However, the policy was not followed, as evidenced by the lack of intake and output monitoring for Resident 112. Interviews with staff, including the MDS nurse and the Director of Nursing, highlighted the potential risks of not adhering to the physician's order, such as abnormal blood work and kidney issues, but these concerns were not addressed in the care plan or daily practices.
Failure to Follow Physician's Order for Medication Administration
Penalty
Summary
The facility failed to adhere to a physician's order for a resident, identified as Resident 124, by not checking the resident's heart rate before administering metoprolol, a medication used to treat high blood pressure and heart conditions. This oversight was observed during a medication administration session where the Licensed Vocational Nurse (LVN 2) did not measure the resident's heart rate prior to giving the medication, despite the physician's order specifying that the medication should be withheld if the pulse rate was less than 60. The LVN acknowledged the mistake, stating that the heart rate should have been checked to prevent potential adverse effects such as a further decrease in heart rate. Resident 124, who has Parkinson's disease and requires varying levels of assistance with daily activities, was admitted and readmitted to the facility with specific physician orders regarding medication administration. The facility's policy mandates that medications be administered as prescribed, which includes following all physician instructions. Interviews with the MDS nurse and the Director of Nursing confirmed that the physician's instructions were not followed, which could have led to adverse consequences for the resident.
Failure to Document RNA Services for a Resident
Penalty
Summary
The facility failed to ensure timely and accurate documentation of Restorative Nursing Assistant (RNA) services for one of the residents, identified as Resident 106. The resident was admitted with diagnoses of generalized weakness and neuromuscular dysfunction of the bladder. The resident's care plan included RNA services for passive and active-assisted range of motion exercises to prevent contractures and maintain or improve range of motion. However, there was no documentation or log of RNA services being provided to the resident from the start date of the order. During a review of the RNA services binders and the resident's order summary report, it was found that there was no RNA services log for Resident 106, despite an order for RNA services to begin on a specific date. RNA 2 admitted to signing the RNA services log form for the resident after the fact, covering dates from the start of the order to a later date, and acknowledged forgetting to obtain and document the log for the resident. This lack of documentation was confirmed by the Director of Rehab, who stated that if the RNA services log form is not filled out or initialed, it indicates that the services did not occur. The Director of Nursing emphasized the importance of documenting tasks immediately after completion to ensure accuracy and prevent memory lapses. The facility's policy and procedure on charting and documentation require that documentation be objective, complete, and accurate. The failure to document RNA services as per the facility's policy resulted in a deficiency in maintaining accurate medical records for Resident 106.
Deficiency in Hospice Care Coordination
Penalty
Summary
The facility failed to ensure that a resident, who was admitted to hospice care, received a comprehensive assessment for the plan of care, including the frequency of hospice staff visits. The resident, who had a history of malignant neoplasm of the colon, cerebrovascular disease, and hemiplegia following a cerebral infarction, was admitted to hospice care with a diagnosis of cerebrovascular disease. Despite being placed on hospice care, there were no physician orders or hospice calendar entries indicating the frequency of visits from hospice staff, such as registered nurses, health aides, spiritual counselors, and medical social workers. Interviews and record reviews revealed that the resident received hospice visits on only two occasions, with no visits documented from 7/13/24 to 7/19/24. The Director of Nursing confirmed that the hospice calendar was incomplete, lacking entries for hospice staff visits, and there was no documentation in the coordination notes or sign-in sheets. The facility's policy indicated that hospice services should be provided upon the order of attending physicians, and the agreement with the hospice required collaboration and documentation of care. The absence of a hospice calendar and documentation resulted in the resident not receiving the expected hospice care.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement standard infection prevention control practices for two residents. In the first instance, a Licensed Vocational Nurse (LVN 8) did not disinfect a shared blood pressure cuff after using it on Resident 10, who had a history of urinary tract infection. This oversight was observed when LVN 8 attempted to use the same cuff on another resident without cleaning it, which was acknowledged by the nurse as a mistake. The Director of Nursing (DON) and the Infection Prevention Nurse (IPN) confirmed that the blood pressure cuff should be disinfected before and after each use to prevent the spread of infections. In the second instance, LVN 1 failed to wear personal protective equipment (PPE) while administering medication to Resident 57, who had a gastrostomy tube and was on Enhanced Barrier Precautions (EBP) due to their susceptibility to infections. During the observation, LVN 1 admitted forgetting to wear the gown, which is part of the EBP protocol. Additionally, LVN 6 was observed mishandling the gastrostomy tube connection by placing a non-sterile cone connector on the GT machine, which could lead to contamination. LVN 6 acknowledged the error and the potential risk of infection. The facility's policies and procedures, including those for cleaning and disinfection of resident-care items and equipment, and for maintaining aseptic techniques during enteral feedings, were not followed. The DON emphasized the importance of adhering to EBP for residents with enteral feeding or open wounds to prevent infection transmission. The failure to follow these protocols posed a risk of infection to the residents involved.
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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