Southland
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, California.
- Location
- 11701 Studebaker Road, Norwalk, California 90650
- CMS Provider Number
- 555070
- Inspections on file
- 43
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Southland during CMS and state inspections, most recent first.
A resident admitted for joint replacement surgery aftercare, with intact cognition but needing substantial/maximal assistance with ADLs, had a blank clothing and possessions inventory form at admission, despite having clothing present. Review of records showed the Resident's Clothing and Possessions form was not completed as required by the facility's Theft and Loss policy, which mandates a written personal property inventory upon admission. CNA staff confirmed the resident had belongings, and the DON acknowledged the form should not have been left blank, resulting in the resident’s possessions not being documented.
A resident with a prior femoral head arthroplasty, intact cognition, and need for substantial/maximal assistance with ADLs developed right hip pain with slight swelling, documented on a change of condition form. A radiology report later confirmed a superior lateral dislocation of the right hip. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the event met criteria for an injury of unknown origin but did not report it to CDPH, despite a facility abuse prevention policy requiring training and reporting of injuries of unknown source.
A resident with intact cognition and a history of joint replacement aftercare, who required substantial/maximal assistance with ADLs, reported right hip pain with slight swelling. An x-ray later showed a superior lateral dislocation of the right hip in the setting of a femoral head arthroplasty. The ADON interviewed only the treatment nurse and one LVN, and did not interview the resident, CNAs, or the PT who worked with the resident at the time of the complaint. The Administrator acknowledged that no investigation of the hip dislocation was conducted, despite a facility policy requiring prompt and thorough investigation of all allegations of abuse or neglect.
A resident with a UTI and intact cognition had a physician’s order for a BMP and CBC that was completed, with blood drawn and results reported. Later, a phlebotomist mistakenly drew the resident’s blood again using the same prior order, without a new physician order, after finding both white and yellow copies of the lab requisition in the lab binder. The DON and ADON described a process in which white copies should be removed after labs are drawn and yellow copies left in the binder, but older requisitions were not routinely removed, and the phlebotomist reported she did not verify the date on the requisition or consult staff. The facility had a policy for obtaining and arranging diagnostic tests but lacked a specific procedure for how phlebotomists should conduct blood draws.
Staff and visitors did not consistently follow infection control protocols, including proper use of PPE and hand hygiene, during a COVID-19 outbreak. A resident with COVID-19 required assistance, but staff were observed not wearing required gowns and gloves, improperly donning PPE, and reusing N-95 masks. Additionally, a staff member was seen without a mask inside the facility, and a delivery person entered without a mask or hand hygiene, with no infection control supplies available at the entrance.
Two residents, both with cognitive impairments, were involved in a physical altercation when one intentionally pushed her wheelchair into the other after a verbal exchange. Staff observed and reported the incident internally, but facility leadership did not report the abuse allegation to authorities within the required two-hour window, as mandated by policy, because they did not consider it abuse. This delayed reporting prevented immediate investigation by regulatory authorities.
The facility did not investigate a reported physical altercation between two residents, one with severe cognitive impairment and another with moderate impairment, after staff observed and reported the incident to nursing leadership. Despite facility policy requiring prompt investigation of alleged abuse, the Administrator did not initiate an investigation or report the event, resulting in unresolved issues between the residents.
A resident in need of pain management did not receive safe and appropriate pain management services as required.
The QAA Committee did not identify or implement corrective actions for systemic issues, including infection control lapses during the Covid-19 outbreak, inadequate assessment of dialysis patients before and after treatment, and failures in preventing, reporting, and investigating abuse allegations, affecting all residents.
Staff failed to consistently follow infection prevention protocols, including not wearing required PPE such as gowns and eye protection when providing care to residents on Enhanced Barrier Precautions or in COVID-19 isolation, not covering a peripheral venous catheter hub, and delaying contact isolation for a resident with scabies. Missing signage and improper storage in the clean linen area were also observed, with staff interviews confirming lapses in protocol awareness and adherence.
A cockroach was found in a resident's room, with housekeeping staff confirming previous sightings and the administrator identifying it as a cockroach. The DON stated that pests should not be present in resident rooms, as it compromises cleanliness and safety. Facility policy requires efforts to control pests, but this was not achieved.
Multiple residents were not treated with dignity and respect, including a resident whose catheter bag was left uncovered, another who was kept in a hospital gown and not groomed, and a resident with a colostomy who was found with soiled clothing and unclean teeth. Staff interviews and facility records confirmed that assistance with personal hygiene and grooming was not consistently provided, contrary to facility policy.
A resident with dementia was found to have multiple topical medications at her bedside and was self-administering them without a physician's order or documented assessment of her ability to do so. Nursing staff confirmed that no evaluation or authorization had been completed, and facility policy requiring assessment and documentation for self-administration was not followed.
Two residents with significant physical and cognitive impairments were found to have call lights placed out of their reach, preventing them from requesting assistance when needed. Staff confirmed the call lights should have been accessible, and facility policy required call lights to be within reach before staff left the room.
A resident with severe cognitive impairment and multiple medical conditions had a grievance filed by a family member regarding the actions of a CNA, but the facility failed to address, investigate, or resolve the complaint for over 50 days. The Social Services Director, responsible for grievance oversight, was not informed of the grievance, and the issue was not logged or followed up as required by facility policy.
Two residents did not have comprehensive care plans addressing their specific needs, including range of motion limitations after a fracture and ongoing edema. One resident's care plan lacked interventions for limited shoulder movement and did not address repeated refusals of orthopedic follow-up, with missed documentation and IDT meetings. Another resident with leg swelling had no care plan for edema, despite staff awareness. These deficiencies were confirmed through interviews, record reviews, and observations.
Two residents with significant physical and cognitive impairments did not receive necessary assistance with grooming and oral hygiene. One resident was left in a hospital gown with unkempt hair for an extended period, while another was not assisted with toothbrushing and had dirty teeth, with documentation confirming oral care was not provided as required.
A resident with diabetes and ESRD experienced multiple episodes of uncontrolled blood glucose, including hospitalization, due to the facility's failure to monitor and document self-administration of insulin via an insulin pump as required by policy. Another resident with a left arm fracture did not receive timely orthopedic follow-up, with missed and undocumented appointment refusals, leading to prolonged non-weightbearing status and delayed rehabilitation. Staff interviews revealed inconsistent processes for monitoring, documentation, and interdisciplinary communication.
A resident with a history of left humerus fracture and limited left shoulder mobility did not receive required ROM services, as quarterly joint mobility assessments failed to include the affected shoulder and no restorative nursing aide interventions were implemented, despite physician orders and ongoing limitations. Staff interviews and resident reports confirmed the lack of assistance with arm exercises, and facility policies for assessment and care planning were not followed.
A resident with an indwelling foley catheter and a history of urinary tract issues was not monitored or assessed for signs and symptoms of a urinary tract infection, despite care plan requirements and facility policy. Medical record review showed no documentation of urine assessment, and staff interviews confirmed the lack of monitoring for infection.
Several residents requiring hemodialysis did not receive care according to professional standards, including a resident who missed a scheduled dialysis session and developed fluid overload, a resident with a dialysis catheter left uncovered, another resident not properly assessed before and after dialysis, and a resident without necessary emergency supplies at the bedside. These deficiencies were confirmed through observation, record review, and staff interviews.
Two restorative nursing aides lacked competency in locating PPE for a resident on Enhanced Barrier Precautions, resulting in failure to use required isolation gowns during care. The aides were unaware of the resident's precaution status and did not know the new PPE storage location, as their training did not cover this change. The facility's infection prevention and nursing leadership confirmed the omission in competency training and the importance of proper infection control practices.
Surveyors found that the facility exceeded the acceptable medication error rate, with errors involving two residents. In one case, a nurse failed to administer vitamin B1 and gave an incorrect dose of vitamin B12, while in another, a nurse did not clarify or follow instructions for dissolving MiraLAX, using the wrong water volume. These errors occurred due to failure to follow physician orders, medication labels, and facility policy.
Two residents did not receive their prescribed medications as ordered, including missed doses of Eliquis for one resident on dialysis days and missed administration of Levothyroxine for another resident over several days. Nursing staff confirmed the medications should have been given according to physician orders, but this did not occur.
Surveyors found that medications were not consistently stored or labeled according to manufacturer specifications and facility policy. For example, a vial of eye drops was stored with rectal suppositories in a medication cart, and a bottle of ophthalmic solution lacked an open date and was not refrigerated as required. In medication room refrigerators, several drugs were kept at temperatures below recommended ranges, and a bottle of prednisolone eye drops was improperly refrigerated. Staff interviews confirmed these practices did not meet professional standards and facility policy.
Expired Italian dressing, barbeque sauce, and caramel sauce were found stored in a facility refrigerator, and several resident food items, including coffee creamers and a peanut butter sandwich, were not properly labeled with resident information as required by policy. Staff interviews confirmed that expired food should be discarded and only resident food, properly labeled, should be stored in the designated refrigerator.
A resident with a history of left humerus fracture and surgical repair did not have an accurately completed Joint Mobility Assessment, as the severity of range of motion loss in the left shoulder was not documented despite physician clearance for ROM exercises. Additionally, the resident's orthopedic consultation progress note was missing from both the physical and electronic medical records, leaving staff without access to critical recommendations and the plan of care.
The facility did not complete required McGeer's Criteria documentation for two residents who received intravenous antibiotics for infections, leaving relevant sections of the Infection Surveillance forms blank. The IPN did not verify if hospital-ordered antibiotics met the criteria, and the DON confirmed that such verification is required by facility policy.
Three residents were not properly documented as having received education, consent, or administration of influenza and pneumonia vaccines. In one case, a consent form was signed by a family member but the vaccine was not given; in other cases, there was no evidence that vaccines were offered or consented to. Interviews with the IP nurse and DON confirmed that the required documentation and tracking were not completed, despite facility policy requiring education, consent, and administration of these immunizations.
The facility did not document education or administration of the COVID-19 vaccine for two residents, including one with dementia and another with moderate cognitive impairment. In one case, a family member requested the vaccine be given later, but this was not documented, nor was the vaccine ordered. Facility policy requires documentation of education and consent for immunizations, which was not followed in these instances.
A resident with severe cognitive impairment was subjected to a nonconsensual kiss by another resident and experienced isolation due to staff actions. The facility did not assess, monitor, or provide emotional support to the resident after these incidents, nor did it follow required procedures for reporting and investigating abuse allegations.
The facility did not report two separate abuse allegations to CDPH within the required two-hour timeframe. In one case, a family member alleged that a CNA isolated a resident by taking their phone and turning up the TV, and in another, a male resident entered a room without pants and kissed another resident's arm without consent. Both residents had severe cognitive impairment, and staff interviews confirmed the incidents were not promptly reported to administration or authorities as required by policy.
The facility did not thoroughly investigate or report two separate abuse allegations involving residents with severe cognitive impairment. In one case, a family member reported that a CNA isolated a resident by taking their phone and turning up the TV, and in another, a male resident entered a room without pants and kissed another resident's arm without consent. Both incidents were not properly investigated or reported to CDPH within the required timeframe, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions was not included, nor was their family or representative, in an IDT care conference for care planning. Staff interviews and facility policy confirmed that the resident or their representative should have participated, but this did not occur, resulting in a violation of the resident's rights to be informed and involved in their care plan.
A resident with a left humerus fracture repeatedly refused orthopedic follow-up appointments, but the Case Manager did not document these refusals or notify the physician or interdisciplinary team. This led to prolonged non-weight bearing restrictions, delayed therapy, and a lack of timely reassessment, as required by facility policy.
A resident with a colostomy and severe cognitive impairment did not receive the correct colostomy bag as ordered by the wound clinic, resulting in leakage and discomfort for several days. Staff and family confirmed delays in obtaining the proper supplies, and the facility's policy requiring appropriate colostomy care was not followed.
Nursing staff failed to administer vitamin B12 and vitamin B1 according to physician orders and manufacturer specifications for two residents. A nurse gave an incorrect dose of vitamin B12 and omitted the prescribed vitamin B1, despite facility policy requiring verification of medication and dosage. The DON confirmed that staff should have checked the eMAR to ensure proper administration.
A resident with severe cognitive impairment and multiple medical conditions was present in their room while workers performed sanding and painting. Staff and leadership confirmed the incident, and it was noted that the facility lacked a policy to ensure resident safety during such maintenance activities.
A resident with severe cognitive impairment and multiple medical conditions was found to have missing personal belongings, including clothing and hospital pads. Staff confirmed there was no belongings list or tracking system in place, despite facility policy requiring an inventory of personal effects. This failure resulted in the loss of the resident's property.
A resident with type 2 diabetes was not monitored for blood glucose levels while receiving Empagliflozin, leading to diabetic ketoacidosis. The NP was unaware of the diabetes diagnosis, and the nursing staff did not question the lack of monitoring orders. The DON admitted there was no care plan for diabetic care, resulting in the resident's emergency hospitalization.
A resident with coronary artery disease did not receive the prescribed medication Ticagrelor for four days due to unavailability. The nursing staff failed to notify the physician care team about the missing medication, contrary to facility policy. This oversight increased the resident's risk of heart attack and stroke.
The QAA and QAPI committees at the facility failed to maintain corrective actions following a survey that identified deficiencies in medication availability and care planning. Despite identifying and correcting systemic issues, the facility did not effectively ensure the sustainability of these actions, as outlined in their QAPI policy, placing residents at risk.
A resident with pulmonary fibrosis and hemiplegia had two oxygen tanks standing upright in their room, posing a fire hazard. The resident expressed discomfort, and staff interviews confirmed the tanks should have been stored in the oxygen storage room. The facility's policy requires tanks to be secured, which was not followed.
A facility failed to ensure an LVN had the necessary skills to care for two residents, leading to deficiencies in medication administration and physician communication. One resident received eye drops late due to the LVN being occupied with another resident, while the second resident experienced an anxiety attack with a drop in oxygen levels. The LVN did not document the change of condition or notify the physician, contrary to facility policies.
A facility failed to develop a care plan for a resident with dry eyes, despite having a physician's order for Lubricant PM Ophthalmic Ointment. The resident, who had the capacity to understand and make decisions, did not have a care plan addressing their dry eyes, as confirmed by an LVN during a record review. The facility's policy requires a comprehensive care plan with measurable objectives, which was not followed.
A resident did not receive prescribed eye ointment due to a delay in pharmacy delivery and inadequate follow-up by nursing staff. The resident experienced dry eyes and pain, and the facility's policy for timely medication delivery was not followed.
A resident with dementia and other mental health conditions exhibited increased aggressive behaviors, but the facility failed to provide necessary psychiatric follow-up or conduct an IDT meeting. Despite documented aggressive actions towards staff, no follow-up care was arranged, and the resident's Responsible Party was not included in care plan meetings, violating their rights.
The facility failed to keep two residents' fingernails clean, resulting in a black/brown substance under their nails. One resident, who required assistance for personal hygiene, was observed eating with dirty nails. Another resident with dementia also had dirty nails. Staff acknowledged the issue but did not clean the nails immediately, despite facility policies requiring daily and as-needed nail care.
A resident was severely injured when the facility's van driver abruptly stopped, causing the resident to be thrown forward from their wheelchair. The resident was not secured with a shoulder strap, leading to multiple fractures and hospitalization. The driver was not trained to use the shoulder straps, and the facility's policy on securing residents was not adequately followed.
The facility failed to ensure that two residents were treated with respect and dignity during feeding, as staff members were observed feeding them while standing instead of at eye level, contrary to facility policy.
Failure to Complete Resident Property Inventory on Admission
Penalty
Summary
Facility staff failed to complete a Resident's Clothing and Possessions inventory form for one resident at the time of admission, despite facility policy requiring a written personal property inventory upon admission. The resident’s face sheet showed she was admitted on a specified date with a diagnosis of joint replacement surgery aftercare, and her MDS dated 2/19/2026 indicated intact cognition and a need for substantial/maximal assistance with ADLs such as bathing, dressing, and toileting. Review of the Resident's Clothing and Possessions form dated 11/6/2025 showed the form was blank, even though the facility’s Theft and Loss policy from 4/2013 required that a written personal property inventory be recorded when a resident is admitted. During interviews, CNA 1 stated that the resident did have clothing at the time of admission, confirming that belongings were present but not documented. The DON stated that the Resident's Clothing and Possessions form should not be left blank and that staff should have documented whether the resident had any belongings or not. The lack of documentation on the inventory form meant the resident’s clothing and other possessions were not recorded upon admission, and the report states this had the potential for the resident to have no recourse to recover clothing or other possessions that could be lost.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the California Department of Public Health (CDPH) for one resident who experienced right hip pain that was later found to be a dislocation. The resident had been admitted with a diagnosis of joint replacement surgery aftercare and had a femoral head arthroplasty. An MDS assessment indicated the resident’s cognition was intact and that she required substantial/maximal assistance with ADLs. A Change of Condition form documented that the resident complained of right hip pain with intact skin and slight swelling. A subsequent radiology report showed a superior lateral dislocation of the right hip involving the prior arthroplasty. Interviews with facility leadership confirmed that the event met the definition of an injury of unknown origin and that it was not reported to CDPH. The ADON stated there was initially no explanation for the hip pain until the X-ray showed a dislocation, at which point it became an injury of unknown origin, but it was still not reported. The Administrator also stated that because there was no reason for the dislocation, it was considered an injury of unknown origin. The DON stated she believed the resident had reported hearing a pop during a transfer to bed and therefore did not report it as an injury of unknown origin, but later acknowledged there was no report of how the injury occurred. The facility’s abuse prevention policy indicated staff are to be trained on reporting abuse, neglect, exploitation, misappropriation, and injuries of unknown sources, including to whom and when such events must be reported.
Failure to Investigate Resident Hip Dislocation of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin when a resident with a history of joint replacement surgery aftercare reported right hip pain. The resident, who had intact cognition and required substantial/maximal assistance with ADLs, complained of right hip pain on a Change of Condition form dated 11/21/2025, which documented intact skin with slight swelling. A radiology report the following day showed the resident had a femoral head arthroplasty with a superior lateral dislocation of the right hip. Despite this significant injury, the Assistant Director of Nursing stated that only the treatment nurse and one LVN were interviewed regarding the resident’s hip pain, and that the resident, CNAs, and the physical therapist who worked with the resident on the date of the complaint were not interviewed to obtain additional information about the pain and dislocation. The Administrator confirmed that the incident involving the hip dislocation was not investigated, even though the facility’s abuse prevention policy required that all allegations of abuse, neglect, misappropriation of resident property, or exploitation be promptly and thoroughly investigated by the Administrator or designee.
Duplicate Lab Draw Performed Without New Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to prevent an unnecessary, duplicate blood draw for one resident after the original laboratory order had already been completed. The resident was admitted with a diagnosis of a UTI, and an MDS dated 12/4/2025 indicated the resident’s cognition was intact. A physician’s order dated 12/11/2025 directed that a BMP and CBC be drawn, and laboratory records showed the blood was collected on 12/11/2025 at 4:25 a.m., with results reported on 12/12/2025 at 12:43 p.m. Despite this, on 1/12/2026 the phlebotomist drew the resident’s blood again based on the same 12/11/2025 order, without a new physician order. A nursing progress note dated 1/13/2026 documented that when the resident inquired about lab results, staff checked the lab binder and discovered the phlebotomist had mistakenly redrawn the labs on 1/12/2026 using the already-completed 12/11/2025 order. Interviews and document review showed that the facility’s lab requisition handling contributed to the error. The DON explained that lab requisition forms have a white and yellow copy kept in a lab binder; when labs are drawn, the phlebotomist is supposed to remove the white copy and leave the yellow copy to indicate completion, and the yellow copies are not removed monthly but kept until the binder is full. The comprehensive test requisition for the 12/11/2025 labs was later signed and dated by the phlebotomist on 1/12/2026 to indicate another BMP and CBC collection, even though no new requisition existed for that date. The ADON reported that the phlebotomist admitted she did not pay attention to the color of the forms and only looked at the resident’s name, and the phlebotomist stated she saw both a white and yellow copy in the binder and assumed the white copy remained because the resident had previously refused or was unavailable. The phlebotomist also stated she did not clarify the date on the requisition with staff because no one was at the nurse’s station. The facility’s policy on Diagnostic Test Results Notification addressed obtaining and arranging labs when ordered, but the facility could not produce a policy or practice describing the procedure the phlebotomist should follow when conducting blood draws.
Failure to Enforce PPE and Infection Control Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement its Infection Prevention and Control plan as outlined in its policy and procedures, specifically regarding the use of personal protective equipment (PPE) and adherence to standard and transmission-based precautions. Observations revealed that a resident admitted with COVID-19 infection required various levels of assistance from staff, yet staff did not consistently follow proper PPE protocols. For example, a Licensed Vocational Nurse was observed with her N-95 mask positioned below her chin, and a Certified Nurse Assistant (CNA) entered the COVID-19 positive resident's room without wearing a gown and gloves, later admitting she was unaware that the N-95 mask was for single use. The CNA also donned PPE incorrectly by putting on gloves before the gown, contrary to recommended procedures. Additional observations included another CNA not wearing a mask while inside the facility during a COVID-19 outbreak and a pharmacy delivery person entering the building without a mask or performing hand hygiene, with no infection control supplies available at the entrance. The Infection Prevention Nurse confirmed that all staff should wear N-95 masks upon entering the building and use appropriate PPE when indicated by signage. The facility's policy required standard and transmission-based precautions, hand hygiene, and proper selection and use of PPE, but these were not consistently followed as observed.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required two-hour timeframe after becoming aware of the incident. The event involved two residents, one with severe cognitive impairment and another with moderate cognitive impairment and a diagnosis of schizophrenia. The incident occurred when one resident, upset after being called a derogatory name, intentionally pushed her wheelchair into the other resident's wheelchair twice, causing the latter's head to move backward. Staff members who witnessed or were informed of the incident reported it up the chain of command, but the Assistant Director of Nursing and the Administrator did not consider the event to be abuse and therefore did not report it to the California Department of Public Health (CDPH) or other required authorities. The facility's policy and procedure required that all allegations or suspicions of abuse be reported immediately, but not later than two hours after the allegation is made, to both the facility Administrator and the State Survey Agency. Despite this, the Administrator acknowledged being notified of the incident but chose not to report it, as he did not consider it abuse. This failure to report resulted in the inability of CDPH to conduct an immediate investigation and created the potential for information to be lost or forgotten.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct an investigation after being made aware of a physical altercation between two residents. One resident, who had severe cognitive impairment and lacked decision-making capacity, was pushed by another resident with moderate cognitive impairment and the capacity to make decisions. The incident was witnessed by a CNA, who reported that the resident intentionally bumped her wheelchair into the other resident's wheelchair twice, causing the latter's head to move backward. The CNA reported the event to an LVN, who then informed the ADON. Despite these reports, the ADON and the Administrator did not consider the incident to be abuse and did not initiate an investigation. The facility's policy requires prompt and complete investigation of all alleged violations of abuse, neglect, exploitation, or mistreatment. However, the Administrator acknowledged being notified of the incident but chose not to report it to the appropriate authorities or begin an investigation, as he did not consider it abuse. This lack of action resulted in the facility not determining the underlying issues between the two residents or resolving the situation, contrary to facility policy and regulatory requirements.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
QAA Committee Failed to Identify and Address Systemic Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to identify and implement corrective actions for several systemic issues affecting all 114 residents. Specifically, the QAA Committee did not recognize or address deficiencies in the infection control program related to mitigating the Covid-19 outbreak, failed to ensure that residents receiving dialysis were properly assessed before leaving for and after returning from outpatient dialysis, and did not ensure that all allegations of abuse were prevented, reported, and investigated. These failures were confirmed during an interview with the Administrator, who acknowledged that these systemic issues were not identified by the QAA Committee. A review of the facility's Quality Assurance Performance Improvement (QAPI) Plan indicated a commitment to proactively identifying and correcting quality issues, but the plan was not effectively implemented in practice. The lack of action by the QAA Committee resulted in the facility not meeting its stated goals of identifying concerns, discussing them openly, and developing plans to address them, as outlined in their QAPI policy.
Infection Control Lapses in PPE Use, Isolation, and Device Management
Penalty
Summary
Multiple deficiencies in infection prevention and control were observed among staff caring for several residents. Certified Nursing Assistants and Restorative Nursing Aides failed to wear required isolation gowns while providing direct care to residents on Enhanced Barrier Precautions (EBP), including a resident with a Foley catheter and another with a gastrostomy tube. Staff members reported either not knowing about the EBP status due to missing signage or not following protocol, despite direct contact with residents. Additionally, a Licensed Vocational Nurse changed tube feeding for a resident on EBP without wearing a gown, and the required EBP signage was missing from the resident's door. Further deficiencies included improper management of a peripheral venous catheter, where a resident's catheter hub was left uncovered without a pressure cap, contrary to infection control protocols. Staff interviews confirmed awareness that a pressure cap was necessary to prevent infection. In another instance, multiple staff members, including CNAs and housekeeping, entered and exited a COVID-19 precaution room without donning all required PPE, such as gowns and eye protection, and failed to perform proper hand hygiene. Some staff also failed to change masks or sanitize hands upon leaving the room, despite facility policy requiring these measures for transmission-based precautions. Additional lapses were identified in the management of a resident diagnosed with scabies, where contact isolation was not implemented promptly after diagnosis and prescription of treatment. The facility delayed placing the resident on contact isolation, increasing the risk of transmission. Observations also revealed non-laundry items stored in the clean linen area, which was acknowledged by the Director of Nursing as inappropriate. Facility policies reviewed indicated clear requirements for PPE use, signage, and infection control measures, which were not consistently followed by staff.
Failure to Maintain Pest-Free Resident Environment
Penalty
Summary
A cockroach was observed crawling in a resident's room during a joint observation and interview with housekeeping staff, who confirmed having seen the bug before, noting it sometimes entered from the window or sink. The administrator later identified the bug as a cockroach and acknowledged it should not be present. The DON also confirmed that pests should not be inside resident rooms, as it does not provide a clean or safe environment. Review of the facility's pest control policy indicated that the facility is responsible for providing a clean environment and making all reasonable efforts to control pests. This deficiency was based on direct observation, staff interviews, and review of facility policy, demonstrating a failure to maintain a pest-free environment as required.
Failure to Ensure Resident Dignity and Respect in Personal Care and Hygiene
Penalty
Summary
The facility failed to ensure that multiple residents were treated with dignity and respect, as evidenced by several observed and documented deficiencies. One resident with an indwelling catheter did not have their catheter drainage bag concealed with a dignity bag, as confirmed by both observation and staff interview. Another resident, who required substantial assistance with personal care, was found wearing a hospital gown for an extended period against her preference and had unkempt hair due to a lack of grooming supplies and assistance. Staff confirmed the resident's appearance and the lack of grooming support. A third resident, with severe cognitive impairment and a colostomy, was observed with dirty teeth and had previously been documented as having soiled clothing due to an open colostomy bag, with feces noted on clothing on multiple occasions. Staff interviews corroborated that assistance with dental hygiene and personal cleanliness was not consistently provided. Additionally, the facility's own grievance records indicated repeated issues with soiled clothing and inadequate hygiene support for this resident. The facility's policy stated that residents should be treated with kindness, respect, and dignity, including being appropriately dressed and well-groomed. However, observations and interviews revealed that these standards were not met for several residents, resulting in undignified conditions such as visible medical devices, lack of grooming, and soiled clothing. These failures were acknowledged by facility leadership during interviews.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
A deficiency occurred when a resident was allowed to keep and self-administer multiple topical medications at her bedside without a physician's order and without an assessment to determine her capability to self-administer medications. The resident, who had a diagnosis of unspecified dementia but was assessed as having the capacity to understand and make decisions, was observed with several topical medications on her bedside table, including ammonium lactate lotion, triamcinolone acetonide cream, ketoconazole shampoo, and fluocinonide solution. The resident stated she used these medications for her dry, itchy skin and applied some of them herself. Interviews with nursing staff, including an LVN, RN, and the DON, confirmed that there was no documented assessment of the resident's ability to self-administer medications and no physician's order authorizing self-administration. Staff acknowledged that medications should not have been left at the bedside without proper assessment and orders, and that medications should have been stored in a locked treatment cart. The facility's policy required an interdisciplinary assessment and documentation in the chart before permitting self-administration of medications. Record review and staff interviews further revealed that the required procedures for evaluating and documenting the resident's ability to self-administer medications were not followed. The absence of a physician's order and lack of assessment documentation led to the resident having unsupervised access to her medications, contrary to facility policy and standard practice.
Failure to Ensure Call Lights Accessible for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible and within reach for two of four sampled residents, resulting in a delay of care and services. One resident, who had a history of urinary tract infection, cervical radiculopathy, and was assessed as a high fall risk with moderately impaired cognition, was observed lying in bed unable to reach the call light due to its placement at the top right corner of the bed, which was too high for her to access given her arm weakness. The resident stated she needed nursing assistance due to pain but could not reach the call light. A Certified Nursing Assistant confirmed the call light was out of reach and acknowledged it should have been clipped to the resident's gown or placed in her hand. Another resident, with diagnoses including encephalitis, encephalomyelitis, end stage renal disease, dependence on dialysis, dementia, and anxiety disorder, and with severely impaired cognition, was observed with the call light on the floor behind the bed, out of reach. A Registered Nurse confirmed the call light was not accessible and stated it should be within the resident's reach. The facility's policy required that call lights be within reach before staff leave the room, but this was not followed in these instances.
Failure to Address and Resolve Resident Grievance in a Timely Manner
Penalty
Summary
The facility failed to address, investigate, and resolve a grievance submitted by the family member of a resident with severe cognitive impairment and multiple medical conditions, including metabolic encephalopathy, colostomy status, and bilateral primary osteoarthritis of the knee. The grievance, filed regarding an unnamed CNA allegedly taking the resident's phone, closing the door on the resident, and turning the television volume up, was not acted upon or acknowledged for at least 54 days after submission. The Social Services Director, who was designated as the Grievance Official, was not made aware of the grievance at the time it was filed and only learned of it later through email correspondence. The facility's policy required the Grievance Official to be informed of all grievances to ensure timely follow-up and resolution. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that the grievance was not entered into the grievance log, nor was it investigated or resolved as required by facility policy. The policy stipulated that grievances should be acknowledged within three working days and that the Grievance Official was responsible for tracking, investigating, and resolving all concerns. The failure to follow these procedures resulted in the resident's grievance remaining unaddressed for an extended period.
Failure to Develop and Implement Comprehensive Care Plans for Residents with ROM Limitations and Edema
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the management of range of motion (ROM) limitations, post-fracture care, and edema. For one resident with a left humerus fracture and non-weight bearing status, the care plan did not address the resident's limited left shoulder ROM or the need for interventions to maintain or prevent decline in ROM after discharge from therapy services. Additionally, the care plan did not address the resident's repeated refusals to attend orthopedic follow-up appointments, nor was there documentation or notification to the physician or nursing staff regarding these refusals. The interdisciplinary team (IDT) failed to conduct required care conferences for the resident, missing quarterly meetings that would have facilitated updates to the care plan and communication among staff regarding the resident's ongoing needs and refusals. The case manager did not reschedule missed orthopedic appointments or document the reasons for missed appointments, and there was no evidence of physician notification. Interviews with staff confirmed that these omissions led to a lack of updated care planning and interventions for the resident's condition. For another resident with a history of deep vein thrombosis and ongoing right leg edema, the facility did not develop a care plan to address the edema, despite observations and staff acknowledgment of the condition. The absence of a care plan for edema was confirmed during interviews and record reviews, with staff stating that such a plan was necessary to monitor and guide care. The facility's policy required comprehensive, person-centered care plans for all residents, but this was not followed in these cases.
Failure to Provide Assistance with Grooming and Oral Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, with a history of major depressive disorder, difficulty walking, and rheumatoid arthritis, was observed wearing a hospital gown for two months and had unkempt, tangled hair. The resident expressed a preference for personal clothing and stated she did not have supplies to brush her hair. Staff confirmed that the resident required help with grooming and dressing, and that her hair was not groomed and she was wearing a hospital gown at the time of observation. Another resident, diagnosed with metabolic encephalopathy, colostomy status, and bilateral primary osteoarthritis of the knee, was observed with dirty teeth and reported not being assisted with toothbrushing that morning. Staff acknowledged that assistance with dental hygiene should have been provided. Documentation review revealed that this resident did not receive oral hygiene twice daily as required over a several-month period. The facility's policy indicated that residents unable to perform ADLs should receive necessary assistance, which was not followed in these cases.
Failure to Monitor Insulin Administration and Ensure Timely Orthopedic Follow-Up
Penalty
Summary
The facility failed to provide quality care and services for several residents by not adhering to physician orders, facility policies, and recommended follow-up care. For one resident with type 1 diabetes, end-stage renal disease, and dependence on hemodialysis, the facility did not monitor or document the resident's self-administration of insulin via an insulin pump as required by facility policy. There were multiple episodes where the resident's blood sugar was dangerously high, including one instance that required transfer to an acute care hospital for diabetic hyperglycemia. Nursing staff interviews revealed a lack of clarity regarding the resident's use of the insulin pump, with some staff stating the pump was not in use and others unaware of the resident's actual insulin administration method. Documentation of insulin administration was inconsistent, and the resident experienced both hyperglycemic and hypoglycemic episodes during the stay. Another resident with a left humerus fracture did not receive timely follow-up with orthopedic specialists as recommended by the consulting physician. Although an initial follow-up was scheduled, subsequent appointments were missed or refused by the resident, and these refusals were not documented or communicated to the physician or interdisciplinary team. The lack of follow-up led to prolonged non-weightbearing status on the affected arm, which was not reassessed for over eight months. Therapy staff and restorative aides were uncertain about the resident's care plan due to missing documentation and lack of updated orthopedic recommendations, resulting in a delay in progressing the resident's rehabilitation and care. Additionally, the facility failed to ensure that interdisciplinary team meetings were conducted quarterly for the resident with the humerus fracture, which would have facilitated communication about missed appointments and care plan updates. Staff interviews confirmed that the process for scheduling, documenting, and following up on physician-recommended appointments was not consistently followed. These deficiencies resulted in delays in care, lack of appropriate monitoring, and potential for further decline in residents' health and functional status.
Failure to Provide and Assess Range of Motion Services for a Resident with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate treatments and services to maintain or improve the range of motion (ROM) for a resident with a history of a left humerus fracture and limited left shoulder mobility. Despite a physician's order for physical and occupational therapy to provide ROM exercises to the resident's left shoulder and elbow, the facility did not ensure that these services were consistently provided. Occupational therapy was discontinued after a period of fluctuating participation, and no restorative nursing aide (RNA) services were initiated for the resident's left arm, even though the resident continued to have ROM limitations and required encouragement to use the left arm in daily activities. Joint Mobility Assessments (JMAs) conducted quarterly did not include an assessment of the resident's left shoulder, omitting a critical area of concern. Both the therapy department and the restorative nursing staff confirmed that the lack of assessment and absence of RNA orders for the left arm resulted in no interventions being implemented to address the resident's ongoing ROM limitations. Interviews with staff revealed that the resident would have benefitted from ROM exercises for the left arm, as she had limited mobility, pain, and required cueing to use the arm functionally. The facility's own policies required regular assessment and care planning for joint mobility, but these were not followed in this case. The Director of Rehabilitation and the Director of Nursing both acknowledged the importance of regular JMAs and the need for appropriate services when ROM limitations are identified. The resident herself reported not receiving assistance with arm exercises, and observations confirmed limited movement in the left arm. The failure to assess and provide services for the resident's left shoulder ROM was directly linked to the lack of follow-through on physician orders and internal protocols.
Failure to Monitor and Assess Catheterized Resident for UTI
Penalty
Summary
A deficiency was identified when a resident with a history of hydronephrosis and renal and ureteral calculous obstruction, who had an indwelling foley catheter, was not properly monitored or assessed for signs and symptoms of a urinary tract infection (UTI). The resident's care plan specifically required monitoring, recording, and reporting to the physician for symptoms such as pain, burning, blood-tinged urine, cloudiness, and foul-smelling urine. However, a review of the resident's medical records revealed no documentation of urine assessment or monitoring for infection. Interviews with facility staff, including an LVN and the DON, confirmed that there was an expectation for residents with foley catheters to be monitored for infection, but this was not carried out or documented for this resident. The facility's policies and job descriptions also supported the need for such assessments, but the required monitoring was not performed, resulting in a failure to follow established protocols for catheter care and infection prevention.
Failure to Provide Safe and Appropriate Dialysis Care and Services
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for several residents requiring hemodialysis, resulting in multiple deficiencies. One resident with end stage renal disease and dependence on dialysis did not receive hemodialysis as scheduled, missing a session and subsequently experiencing facial swelling. This resident required admission to an acute care hospital and was diagnosed with fluid overload due to the missed dialysis session. Documentation and interviews confirmed that the resident's dialysis schedule was not maintained, and there was no evidence that the physician was contacted to reschedule the missed session. Another resident with a Permacath for dialysis was observed without a dressing covering the catheter site, contrary to physician orders and facility policy. The absence of a dressing was confirmed by a registered nurse, who acknowledged that a dressing should have been present to prevent infection. Additionally, a third resident was not assessed by facility staff prior to being sent to dialysis or upon return from the dialysis center, as required by facility policy. The pre- and post-dialysis assessment forms were found to be incomplete for multiple dialysis days, indicating a lack of monitoring for potential complications related to dialysis therapy. A fourth resident, who had an arteriovenous shunt for dialysis, did not have the necessary emergency equipment (e-kit) at the bedside to manage potential bleeding emergencies. Nursing staff were unaware of the location of the e-kit, and acknowledged that the absence of this equipment could hinder immediate intervention in the event of shunt dislodgement or bleeding. Facility policy required ongoing communication, assessment, and documentation for residents receiving dialysis, including the presence of emergency supplies and proper site care, all of which were not consistently followed.
Failure to Ensure Staff Competency in Locating PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Restorative Nursing Aide 1 and Restorative Nursing Aide 2 were found to lack competency in locating personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) due to a physician's order related to a urinary tract infection and the presence of a Foley catheter. During a restorative nursing session, both aides entered the resident's room, donned gloves, but did not wear isolation gowns as required for EBP. They assisted the resident with range of motion exercises and, upon completion, removed their gloves, washed their hands, and exited the room. Both aides later stated they were unaware the resident was on EBP precautions, did not see the precaution signage, and did not know where to find the required PPE since it was not in the usual location outside the room. A review of the aides' competency checklists revealed that training on the location of PPE for residents on EBP precautions was not included. The Infection Prevention Nurse confirmed that PPE for EBP residents was now stored inside the resident's closet, a change from previous practice, and acknowledged there was no documented evidence that the aides had been in-serviced on this change. The Director of Nursing also emphasized the importance of staff competency in infection control protocols and PPE location. Facility policy required nursing staff to have appropriate competencies to ensure resident safety and well-being.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.54% during medication administration for two of four sampled residents. For one resident, the nurse did not administer vitamin B1 as ordered and provided an incorrect dose of vitamin B12, giving only 500 mcg instead of the prescribed 1000 mcg. The nurse prepared and administered multiple medications but omitted vitamin B1 and did not ensure the correct dosage of vitamin B12, despite the physician's orders and the medication bottles available. The nurse later acknowledged the omission and the importance of following physician orders to prevent medication errors. For another resident, the nurse failed to clarify the physician's order for MiraLAX (polyethylene glycol) before administration and did not follow the medication label and manufacturer specifications. The nurse mixed the MiraLAX powder with an incorrect volume of water, initially believing the facility's water cup held eight ounces, but later confirming it only held five ounces. The pharmacy label specified mixing the powder with eight ounces of water, but the physician's order did not specify the volume. The nurse did not measure the water accurately during administration and did not clarify the order to ensure it matched the pharmacy label, which could have affected the medication's effectiveness. Interviews with nursing staff and the Director of Nursing confirmed that medications were not administered in accordance with physician orders, manufacturer instructions, and facility policy. The facility's policy required medications to be administered as prescribed and in accordance with manufacturer specifications, but this was not followed in the observed cases. The deficiencies were identified through observation, interview, and record review, and were directly related to the actions and inactions of the nursing staff during medication administration.
Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to administer medications as ordered for two residents. One resident, with diagnoses including encephalitis, end stage renal disease, dementia, and anxiety disorder, was prescribed Eliquis 2.5 mg twice daily for atrial fibrillation. Review of the Medication Administration Record (MAR) revealed that Eliquis was not administered as ordered on several occasions in February and March, specifically on days when the resident went to dialysis. The Assistant Director of Nursing acknowledged that the administration times should have been clarified with the physician for those days, but this was not done, resulting in missed doses. Another resident, with diagnoses including metabolic encephalopathy, colostomy status, and bilateral primary osteoarthritis of the knee, was prescribed Levothyroxine Sodium Oral Tablet 88 mcg to be given once daily in the morning. The MAR showed that this medication was not administered from 9/13/2024 to 9/18/2025, despite the order. The Licensed Vocational Nurse confirmed the medication should have been given to maintain normal thyroid levels. The facility's policy and procedure required medications to be administered as prescribed, but this was not followed in these cases.
Deficient Medication Storage and Labeling Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices. In two of three medication carts, medications were not stored according to the facility's policy and professional standards. Specifically, a vial of atropine sulfate ophthalmic solution intended for sublingual use was stored in the same bin as acetaminophen rectal suppositories, contrary to the policy requiring separation of oral, ophthalmic, and rectal medications. Additionally, an unopened bottle of latanoprost ophthalmic solution was found without an open date label and was not stored in the refrigerator as required by the manufacturer's instructions. Staff interviews confirmed that these storage practices were not in line with facility policy or manufacturer requirements, and that proper labeling was necessary to ensure medication safety and efficacy. Further deficiencies were observed in the medication room refrigerators. In one refrigerator, several medications, including insulin, Tubersol, acetylcysteine, and Dupixent, were stored at 35°F, which is below the manufacturer-recommended range of 36°F to 46°F. The refrigerator also had a buildup of ice, which is not appropriate for medication storage. Staff acknowledged that these conditions could compromise the integrity of the medications. In another medication room refrigerator, a bottle of prednisolone acetate ophthalmic suspension was stored in the refrigerator, despite manufacturer instructions to store it at room temperature and protect it from freezing. Staff confirmed that this was not the correct storage method and could affect the medication's effectiveness. The facility's policy and procedure on medication storage requires that medications and biologicals be stored according to manufacturer recommendations and that internally administered medications be kept separate from externally used medications. Staff interviews consistently indicated awareness of these requirements, but observations revealed that these standards were not consistently followed. The deficiencies involved multiple residents and had the potential to affect the safety and effectiveness of their prescribed medications.
Failure to Dispose of Expired Food and Improper Labeling of Resident Food
Penalty
Summary
Surveyors observed that the facility failed to properly dispose of expired food items and did not adhere to labeling and storage policies for resident food. Specifically, Italian salad dressing and barbeque sauce were found in the refrigerator past their best by dates, and caramel sauce was stored beyond the recommended use period after opening. Both the cook and the dietary supervisor confirmed during interviews that expired food should not be stored and acknowledged the risk of illness if residents consume expired items. Additionally, four bottles of coffee creamer and a peanut butter sandwich in the resident food refrigerator were not labeled with the resident's name, date, or room number as required by facility policy. The peanut butter sandwich was labeled with a staff member's name, which is not permitted. Interviews with a CNA and the DON confirmed that only resident food, properly labeled, should be stored in the designated refrigerator, and that improper labeling makes it unclear how long food has been stored, increasing the risk of serving expired food to residents. Review of facility policies corroborated these requirements for food storage and labeling.
Failure to Accurately Document and Maintain Accessible Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation and accessibility of medical records for one resident, resulting in two specific deficiencies. First, the Joint Mobility Assessment (JMA) for the resident, who had a history of a left humerus fracture and subsequent surgical repair, was not accurately completed. Although the resident had been cleared for range of motion (ROM) exercises by a physician, the JMA did not indicate the severity of ROM loss in the left shoulder, and the therapist failed to update the diagram or document the level of severity. The therapist acknowledged that the assessment was inaccurate and that the omission could prevent proper monitoring of changes in the resident's ROM status. Second, the facility did not ensure that the resident's Orthopedic Consultation Progress Note from a follow-up appointment was readily accessible in the medical record. Despite orders and progress notes referencing the orthopedic follow-up, staff were unable to locate the consultation note in either the physical chart or the electronic record. Both the Director of Rehabilitation and the Medical Records staff confirmed the absence of this critical document, which contained recommendations and the plan of care for the resident's post-surgical management. The resident involved was admitted with a displaced fracture of the left humerus and required ongoing rehabilitation and post-operative care, including non-weight bearing restrictions and therapy interventions. The lack of accurate assessment documentation and the missing orthopedic consultation note had the potential to delay or negatively affect the delivery of necessary care and services, as staff were not fully informed of the resident's current status or care plan.
Failure to Document McGeer's Criteria for Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy for two of three sampled residents by not completing the required McGeer's Criteria documentation when antibiotics were prescribed. For one resident admitted with cellulitis and bacteremia, the physician ordered intravenous Ceftriaxone, but the Infection Surveillance form lacked documentation indicating whether the antibiotic order met McGeer's Criteria, with relevant sections left blank. Similarly, another resident admitted with sepsis and bacteremia received an order for intravenous Ceftriaxone for GBS Bacteremia, but again, the Infection Surveillance form did not document if McGeer's Criteria were met, with blank spaces in the appropriate sections. Interviews with the Infection Prevention Nurse (IPN) and the Director of Nursing (DON) revealed that the IPN did not verify if the antibiotic orders from the hospital met McGeer's Criteria, contrary to facility policy. The DON confirmed that McGeer's Criteria should be considered when verifying antibiotic orders, as outlined in the facility's antibiotic stewardship policy. The policy requires the stewardship team to optimize diagnostic testing and implement an antibiotic review process for all antibiotics prescribed in the facility.
Failure to Document and Administer Influenza and Pneumonia Vaccinations
Penalty
Summary
The facility failed to document education provided regarding the benefits and risks of influenza and pneumonia vaccinations, as well as the administration of these vaccines, for three of 21 sampled residents. For one resident, although a consent form for the pneumococcal vaccine was signed by the resident's daughter, there was no documentation that the vaccine was actually administered. Another resident's records did not contain any consent forms for influenza or pneumonia vaccines, and there was no evidence that these vaccines were offered. A third resident's care plan referenced keeping immunizations up to date, but there was no documentation of education, consent, or administration of the vaccines. Interviews with the Infection Preventionist Nurse revealed that, while the process is to offer and educate residents or their families about the risks and benefits of the vaccines and obtain signed consent forms, there was no documented evidence of vaccination, refusal, or education for the residents in question. The Infection Preventionist Nurse also stated that if there is no way to track vaccinations, residents may miss their vaccinations. The Director of Nursing confirmed that all residents should be offered influenza and pneumonia vaccines, and that documentation of acceptance or refusal is necessary, but acknowledged that this was not done for the residents identified. A review of the facility's policies and procedures indicated that it is the facility's policy to offer and administer influenza, pneumococcal, and COVID-19 immunizations to eligible residents after providing education and obtaining consent. Residents are to be screened at admission and annually for vaccine eligibility. However, the lack of documentation and tracking for the sampled residents demonstrates that these policies and procedures were not followed, resulting in a failure to ensure proper vaccination practices.
Failure to Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to document education provided regarding the benefits and risks of COVID-19 immunization and the administration of the vaccine for two of three sampled residents. For one resident with dementia and aphasia, who was dependent on staff for most activities of daily living, there was no documentation of education or vaccination status. Another resident, who had moderate cognitive impairment and required substantial assistance, was not given the COVID-19 vaccine because the resident's daughter requested it be given later; however, there was no documentation of this request or the reason for not administering the vaccine. The Infection Preventionist Nurse acknowledged not documenting the family's request or ordering the vaccine, and the Director of Nursing confirmed that vaccines should be ordered and administered promptly upon request. A review of facility policy indicated that residents are to be offered and administered immunizations, including COVID-19, after education and consent are obtained, and that documentation of education and consent is required. The lack of documentation for both the education provided and the reasons for not administering the vaccine to eligible residents represents a failure to follow facility policy and proper immunization procedures.
Failure to Protect Resident from Abuse and Inadequate Response to Allegations
Penalty
Summary
The facility failed to protect a resident from abuse in multiple instances involving both another resident and a staff member. One incident involved a resident with severe cognitive impairment who was found in another resident's room wearing only a hospital gown and disposable underwear, and kissed the resident's arm without consent. This event was witnessed by a family member and later confirmed by the resident, who reported that the other resident held her hand, kissed her arm, and sat in her room without pants. Staff interviews revealed that the incident was not immediately reported to the appropriate administrative personnel, and the affected resident was not assessed, monitored, or provided with emotional support following the allegation of abuse. A separate incident involved a grievance filed by a family member alleging that an unidentified CNA took the resident's cell phone, closed the door, and turned the television on loud, resulting in the resident feeling isolated. This grievance was not immediately addressed or resolved, and the resident was not assessed or monitored for psychosocial well-being after the allegation. Staff interviews confirmed that the required follow-up actions, such as interviewing involved staff and ensuring the resident's stability, were not performed. The facility's own policy requires immediate assessment, increased supervision, emotional support, and reporting of abuse allegations, but these procedures were not followed in either incident. The failures resulted in the resident being subjected to a nonconsensual kiss, isolation, and a lack of appropriate response to abuse allegations, as documented by interviews with staff and review of facility records.
Failure to Timely Report Allegations of Abuse to Authorities
Penalty
Summary
The facility failed to report two separate allegations of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe. The first incident involved a family member alleging that an unidentified CNA took a resident's cell phone, closed the resident's door, and turned the television on loudly, causing the resident to feel isolated. The second incident involved a family member reporting that a male resident, without pants on, entered another resident's room and kissed the resident's arm without consent. In both cases, the facility did not notify CDPH as required by regulation. Resident records indicated that both residents involved had severe cognitive impairments and required varying levels of assistance with daily activities. The staff interviews revealed that the incidents were known to some staff members, including CNAs and RNs, but were not escalated to facility administration or reported to the appropriate authorities in a timely manner. The Social Services Director and Director of Nursing both acknowledged during interviews that these incidents should have been reported to CDPH, the ombudsman, and local law enforcement within two hours, in accordance with facility policy and state regulations. A review of the facility's policy confirmed the requirement for immediate reporting of abuse allegations, specifically within two hours if the incident involved abuse or resulted in serious bodily injury. Despite this, the facility did not follow its own policy or regulatory requirements, resulting in delayed notification to authorities and a lack of timely investigation into the allegations.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report two separate allegations of abuse involving residents with severe cognitive impairment. In the first incident, a family member reported that an unidentified CNA took a resident's cell phone, closed the resident's door, and turned the television on loudly, causing the resident to feel isolated. The grievance was documented, but there was no evidence that the incident was thoroughly investigated or reported to the California Department of Public Health (CDPH) within the required timeframe. In the second incident, a family member alleged that a male resident, who was not wearing pants, entered another resident's room and kissed the resident's arm without consent. Staff interviews confirmed that the male resident was found in the other resident's room wearing only a hospital gown and disposable underwear, and that the two residents were separated. However, the incident was not immediately reported to the administrator, and the affected resident was not assessed, monitored, or provided with emotional support as required. The allegation was not thoroughly investigated or reported to CDPH within five days. Both incidents involved residents with severe cognitive impairment and required varying levels of assistance with daily activities. The facility's own policy required prompt reporting and thorough investigation of all abuse allegations, with findings submitted to the appropriate agencies within five working days. Staff interviews confirmed that these procedures were not followed in either case, resulting in a failure to meet regulatory requirements for abuse investigation and reporting.
Resident Excluded from Care Plan Meeting
Penalty
Summary
The facility failed to involve a resident in the development and implementation of their person-centered plan of care during an Interdisciplinary Team (IDT) care conference. Specifically, the resident, who had diagnoses including metabolic encephalopathy, colostomy status, and bilateral primary osteoarthritis of the knee, was not present at the quarterly IDT care conference, nor was a family member or representative. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and a need for varying levels of assistance with daily activities. Despite these needs, neither the resident nor their family was included in the care planning process as required. Interviews with facility staff, including a registered nurse and the DON, confirmed that the resident and their family should have participated in the IDT care plan meeting. Review of the facility's policy and procedure on comprehensive person-centered care planning also indicated that every effort should be made to include the resident and/or their representative in care plan meetings. The failure to involve the resident or their representative in the care conference constituted a violation of the resident's rights to be informed and to participate in their plan of care.
Failure to Report and Document Resident's Refusals for Orthopedic Follow-Up
Penalty
Summary
The facility failed to ensure that the Case Manager (CM) reported a resident's continuous refusals for orthopedic follow-up appointments to the physician, as required. The resident, who was admitted with a displaced fracture of the left humerus and had undergone surgical repair, was under orders for non-weight bearing (NWB) status and scheduled for follow-up orthopedic care. Despite these orders, the resident did not attend the recommended follow-up appointments after the initial post-operative visit, and the CM did not document the refusals or notify the physician or interdisciplinary team (IDT) of these missed appointments. The clinical record review showed that after the initial orthopedic follow-up, the resident was not scheduled for another appointment until eight months later, despite physician orders for more timely follow-up. The CM acknowledged that multiple attempts were made to schedule appointments, but the resident refused each time. These refusals were not documented in the clinical record, nor were they communicated to nursing, the physician, or the IDT. As a result, the resident remained on NWB restrictions longer than necessary, which delayed therapy and restorative services and affected the resident's mobility and physical functioning. Interviews with staff, including the Director of Rehabilitation (DOR), Restorative Nursing Aides (RNAs), and the Director of Nursing (DON), confirmed that the lack of communication and documentation regarding the resident's refusals led to a delay in reassessment and adjustment of the care plan. The facility also failed to conduct required quarterly IDT meetings, which would have provided an opportunity to address the resident's ongoing refusals and lack of follow-up care. The facility's policy required immediate notification of the physician and documentation in such cases, but this was not followed.
Failure to Provide Correct Colostomy Supplies Resulting in Leakage
Penalty
Summary
A resident with a history of metabolic encephalopathy, colostomy status, and bilateral primary osteoarthritis of the knee was admitted to the facility and required specific colostomy care. The resident's Minimum Data Set indicated severely impaired cognition and a need for assistance with various activities of daily living, including toileting hygiene. Despite orders from the Wound Clinic for a specific brand of colostomy bag, the facility provided a different brand, as confirmed by both family correspondence and wound clinic progress notes. This mismatch in supplies led to the resident experiencing colostomy leakage. Interviews with staff and family revealed that the incorrect colostomy bag was used for several days, resulting in leakage and discomfort for the resident. The family reported delays in ordering the correct supplies, and staff acknowledged that the colostomy bag was leaking for a couple of days before the appropriate product was obtained. The facility's policy and procedure required proper colostomy care, but this was not followed, leading to a negative impact on the resident's physical and mental wellbeing.
Failure to Administer Medications per Physician Orders and Manufacturer Specifications
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and manufacturer specifications for two residents. For one resident, the nurse prepared and administered only one tablet of vitamin B12 500 mcg instead of the prescribed dose of 1000 mcg, and failed to administer vitamin B1 50 mg as ordered. The nurse used bottles of vitamin B12 500 mcg and vitamin B1 100 mg, but did not follow the physician's specific instructions for dosing. The nurse later acknowledged the error, stating she thought she had given the vitamin B1 but realized it was not administered as required. The resident involved had multiple diagnoses, including difficulty walking, abnormal posture, and acute respiratory failure with hypoxia or hypercapnia, and required varying levels of assistance with activities of daily living. The facility's policy required medications to be administered as prescribed and in accordance with the manufacturer's specifications, with verification of the medication and dosage schedule against the resident's medication administration record. The Director of Nursing confirmed that nurses should have checked the electronic medication administration record to ensure the correct dose and medication were given.
Resident Exposed to Painting and Sanding During Room Maintenance
Penalty
Summary
The facility failed to ensure a safe environment for a resident with severe cognitive impairment and multiple medical conditions, including metabolic encephalopathy, colostomy status, and bilateral primary osteoarthritis of the knee. According to the resident's Minimum Data Set, the resident required significant assistance with daily activities and had severely impaired cognition. Despite these needs, workers were observed sanding and painting a patch on the wall while the resident remained in the room. Interviews and record reviews confirmed that the painting occurred while the resident was present, as stated by both a Certified Nurse Assistant and email correspondence involving the family, Administrator, and Director of Nursing. The Director of Nursing acknowledged that residents should not be present during such work for safety and comfort reasons. Additionally, it was noted that the facility did not have a policy addressing the provision of a safe, homelike environment during maintenance activities.
Failure to Track and Protect Resident's Personal Belongings
Penalty
Summary
The facility failed to account for a resident's personal belongings, resulting in missing articles of clothing and hospital pads. The resident, who was originally admitted with diagnoses including metabolic encephalopathy, colostomy status, and bilateral primary osteoarthritis of the knee, was assessed as having severely impaired cognition and required varying levels of assistance with daily activities. During a review of the resident's records, it was found that there was no belongings list in the chart, and staff confirmed there was no system in place to track the resident's possessions. A family member reported missing items, and staff interviews revealed that the facility did not maintain an inventory of the resident's personal effects as required by facility policy. The policy stated that all personal clothing, valuable articles, and items brought into the facility should be inventoried upon admission or readmission. The lack of a belongings list and tracking system led to the loss of the resident's personal property, violating the resident's right to retain and use personal possessions.
Failure to Monitor Blood Glucose in Diabetic Resident
Penalty
Summary
The facility failed to ensure proper blood glucose monitoring for a resident with type 2 diabetes who was receiving Empagliflozin, a medication to lower blood sugar. The resident was not monitored for blood glucose levels, which is crucial to assess the effectiveness of the medication and prevent complications such as hyperglycemia and diabetic ketoacidosis. This oversight occurred because there was no physician's order for blood glucose monitoring, and the nursing staff did not question the absence of such an order. The resident's Nurse Practitioner (NP) was unaware of the resident's diabetes diagnosis and did not order blood glucose monitoring. The NP stated that she had limited clinical documentation upon the resident's arrival and was not informed by the nursing staff about the need for blood sugar checks. The Licensed Vocational Nurses (LVNs) involved in the resident's care also did not recognize the need to monitor blood glucose levels despite administering Empagliflozin, which requires regular monitoring to prevent adverse effects. The Director of Nursing (DON) acknowledged the lack of a care plan addressing the resident's diabetic care, which should have included blood glucose monitoring and interventions for hyperglycemia or hypoglycemia. The failure to implement a care plan and ensure proper monitoring led to the resident developing diabetic ketoacidosis, resulting in an altered level of consciousness and requiring emergency medical intervention.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
The facility failed to ensure that a resident with a history of coronary artery disease received the prescribed medication Ticagrelor, which is used to prevent heart attacks and strokes. The resident missed seven doses of the medication over a four-day period because it was not available for administration. The medication administration record (MAR) and electronic MAR (e-MAR) notes indicated that the medication was not supplied, and the nursing staff did not notify the resident's physician care team about the unavailability of the medication. Interviews with the nursing staff revealed that they were aware of the missing medication but did not inform the physician or the nurse practitioner. The Licensed Vocational Nurses (LVNs) involved did not follow the facility's policy to notify the physician when a medication is unavailable. The Director of Nursing (DON) confirmed that there were no change of condition notes or documentation indicating that the physician was informed about the missing medication. The facility's policy requires the prescriber to be contacted for direction when medication delivery is delayed or unavailable. The facility's consultant pharmacist emphasized the importance of administering Ticagrelor as prescribed to prevent heart attacks and strokes. The pharmacist and the nurse practitioner both stated that the resident was at increased risk due to the missed doses. The facility's failure to administer the medication as ordered and to notify the physician care team placed the resident at higher risk for adverse health outcomes.
Failure in Sustaining Corrective Actions Post-Survey
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to establish effective monitoring systems to ensure that corrective actions were maintained following an abbreviated survey conducted on September 30, 2024. During this survey, deficiencies were identified in the areas of ensuring medications were available for residents and ensuring all residents had appropriate care plans. The Director of Nursing (DON) acknowledged these deficiencies and noted that the facility was expected to correct them by October 2, 2024. Interviews with the DON and the Administrator revealed that while the QAA committee identified and corrected systemic issues, they did not effectively ensure that these corrective actions were sustained. The facility's policy on QAPI, revised in December 2023, outlined the need for a comprehensive and data-driven approach to maintaining and improving safety and quality, including monitoring to ensure corrective actions are sustained. However, the facility failed to implement this aspect of the policy effectively, placing residents at risk of not receiving appropriate care and services.
Unsafe Storage of Oxygen Tanks in Resident's Room
Penalty
Summary
The facility failed to ensure the safe storage of oxygen tanks for a resident, which posed a potential fire hazard. The resident, who was admitted with pulmonary fibrosis and hemiplegia, had two oxygen tanks standing upright next to his chair in his room. The resident expressed discomfort with the tanks being in his room, citing past experiences of seeing them fall over and cause damage. This situation was observed during a survey, and the resident's concerns were confirmed by staff interviews. Interviews with facility staff, including an LVN, CNA, RNS, and ADON, revealed that the oxygen tanks should have been stored in the designated oxygen storage room when not in use. The staff acknowledged the potential danger of leaving the tanks in the resident's room, as they could fall over and explode, creating a fire hazard. The facility's policy on oxygen handling and storage also indicated that tanks must be secured in a storage rack, to the wall, or on an oxygen cart, which was not adhered to in this instance.
Deficiencies in Medication Administration and Physician Communication
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) had the necessary competency skills to care for two residents, leading to deficiencies in medication administration and communication with a physician. For Resident 1, who was admitted with major depressive disorder and had moderately impaired cognition, the LVN did not administer Cyclosporine Ophthalmic Emulsion 0.05% eye drops on time. The medication was given over one and a half hours late, which was outside the facility's policy of administering medication within one hour before or after the scheduled time. The LVN attributed the delay to being occupied with another resident, Resident 2. Resident 2, who had chronic congestive heart failure and pulmonary fibrosis, experienced an anxiety attack that resulted in a significant drop in blood oxygen levels. The LVN provided a non-rebreather mask and other interventions but failed to document the change of condition (COC) or notify the resident's physician. The facility's policy required the nurse to document the assessment and communicate with the physician using a structured communication tool like SBAR to obtain new orders or interventions. The LVN admitted to forgetting to document the COC and acknowledged the need to inform the physician for further interventions. The Director of Nursing (DON) indicated that LVN 1 should have sought assistance from other staff members to manage the situation effectively. The facility's policies on medication administration and response to significant changes in condition were not adhered to, as the LVN did not follow the procedures outlined in the job description and facility policies. This resulted in a failure to provide timely medication and appropriate documentation and communication regarding the residents' conditions.
Failure to Develop Care Plan for Resident's Dry Eyes
Penalty
Summary
The facility failed to develop a care plan for a resident who was admitted with diagnoses including Transient Ischemic Attack and anxiety disorder. The resident had the capacity to understand and make decisions, as indicated in their History and Physical and Minimum Data Set assessments. Despite having a physician's order dated 8/28/2024 for Lubricant PM Ophthalmic Ointment to be administered at bedtime for dry eyes, the care plan section of the resident's clinical record did not include any interventions addressing the resident's dry eyes. During an interview and record review on 9/5/2024, a Licensed Vocational Nurse confirmed that there was no care plan developed for the resident's dry eyes. The nurse acknowledged that a care plan should have been created to guide the nursing staff on how to care for the resident and to evaluate the effectiveness of the interventions. The facility's policy on Comprehensive Person-Centered Care Planning, dated 1/2022, requires the interdisciplinary team to develop a comprehensive care plan with measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that Resident 1 received the prescribed Lubricant PM Ophthalmic Ointment for dry eyes as ordered by the physician. Despite the order being placed on 8/28/2024, the medication was not available for administration, leading to Resident 1 experiencing dry eyes and eye pain. The resident reported the issue to the licensed nurses on 8/29/2024, but the medication was still not administered. The licensed nurses did not effectively follow up with the pharmacy to ensure timely delivery of the medication, nor did they inform the oncoming shift about the delay. Interviews revealed that the pharmacy received the medication order late on 8/28/2024, and due to the ointment being out of stock, it was not delivered until 8/30/2024. The pharmacy technician suggested that the licensed nurses should have informed the physician to order an alternative medication. The Director of Nursing was unaware of the situation and stated that the doctor and resident should have been notified to implement additional interventions. The facility's policy requires timely delivery of medications to prevent delays in administration, which was not adhered to in this case.
Failure to Provide Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of dementia and other mental health conditions. The resident, who was admitted with diagnoses including bipolar disorder, dementia, and aftercare following joint replacement surgery, demonstrated increased aggressive behaviors. Despite these changes, the facility did not provide psychiatric follow-up or conduct an interdisciplinary team (IDT) meeting to address the resident's poor safety awareness, aggressive behaviors, and noncompliance in care. The resident's Minimum Data Set (MDS) assessment and progress notes indicated a significant change in behavior, including physical and verbal aggression towards staff. The resident's aggressive actions included punching and choking staff, refusing medications, and removing medical devices. These behaviors were documented in multiple progress notes over several months, yet no follow-up psychiatric evaluation or IDT meeting was conducted to address these issues. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that there was no follow-up psychiatric appointment or IDT meeting to discuss the resident's behaviors. The resident's Responsible Party (RP) was not included in any care plan meetings, which violated the resident's and RP's rights. The facility's failure to address the resident's behavioral health needs resulted in a delay in care and services, leading to a decline in the resident's mental and physical health and increased risk for injury.
Failure to Maintain Resident Fingernail Hygiene
Penalty
Summary
The facility failed to ensure that two residents' fingernails were kept clean and neat, resulting in a black/brown substance being observed underneath their fingernails. Resident 1, who was admitted with a left humerus fracture and required partial assistance for personal hygiene and total assistance for showering, was observed with dirty fingernails while eating popcorn. Resident 1 expressed disgust at having to eat without clean hands and stated that her hands had not been washed since her last shower. CNA 1 acknowledged noticing the dirty nails but did not clean them immediately, as required by the facility's standards of care. Resident 2, who was admitted with unspecified dementia and required total assistance for personal hygiene and showering, was also observed with dirty fingernails. RN 1 confirmed that all residents' fingernails should be cleaned daily and as needed. Both the Director of Staff Development and the Director of Nursing reiterated that staff are responsible for ensuring residents' hands and fingernails are clean, especially before meals. The facility's policies and job descriptions support this standard of care, indicating that nail care should be performed on shower days and as needed, and that CNAs are responsible for assisting residents with personal care.
Failure to Secure Resident in Van Leads to Severe Injuries
Penalty
Summary
The facility failed to ensure that a resident, who was riding in the facility's van while sitting in a wheelchair, had a shoulder seat belt strap on to secure the upper body. This deficiency resulted in the resident being thrown forward with the wheelchair landing on top of them when the driver abruptly stopped the vehicle at a yellow light. The resident was admitted to a general acute care hospital and hospitalized for six days with multiple fractures, including fractures to both arms, both legs, and neck. The resident was later sent back to the hospital for anxiety related to the accident. The resident had a medical history that included a right femur pathological fracture, age-related osteoporosis, fibromyalgia, and dorsalgia. The resident was dependent on staff for various activities of daily living and did not attempt to walk or use the wheelchair due to medical conditions and safety concerns. On the day of the incident, the resident was wearing a lap belt strap but not the shoulder strap, which led to the severe injuries when the driver made an abrupt stop. Interviews with staff and the driver revealed that the driver was not trained to use the shoulder straps during transport and had not used the shoulder strap available in the van. The facility's vehicle inspection technician recommended replacing the old straps with newer, updated models, which were installed after the accident. The facility's policy and procedure indicated that residents must be secured in their wheelchair and in the vehicle before any movement, but this was not adequately followed in this case.
Failure to Feed Residents at Eye Level
Penalty
Summary
The facility failed to ensure that two residents, Resident 70 and Resident 75, were treated with respect and dignity during feeding. Resident 70, who has severe cognitive impairment and is dependent on all aspects of activities of daily living, was observed being fed by a Certified Nursing Assistant (CNA) who was standing while the resident was seated in a wheelchair. The CNA stated that she usually feeds residents while standing and did so in this instance because she had just returned from a break. This practice was contrary to the facility's policy, which requires feeding at eye level to ensure social interaction and better observation of swallowing difficulties. Similarly, Resident 75, who has moderate cognitive impairment and requires maximal assistance with eating, was also fed by the same CNA while she was standing. The CNA elevated the bed and raised the head of the bed but did not meet the resident at eye level. Interviews with other staff members, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), confirmed that feeding residents while standing is not acceptable and that eye-level feeding is important for both respect and safety. The facility's policies on feeding dependent residents and treating residents with dignity and respect were not followed in these instances.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
