St. John Of God Retirement
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2468 South St Andrews Place, Los Angeles, California 90018
- CMS Provider Number
- 055253
- Inspections on file
- 45
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at St. John Of God Retirement during CMS and state inspections, most recent first.
A resident with depression and congestive heart failure was started on Cymbalta 30 mg daily following a physician telephone order, and the MAR showed the medication was administered over several weeks. The resident was documented as cognitively capable of decision making and had a designated representative, yet there was no documentation that informed consent for the psychotropic medication was obtained from the representative. During interviews, the ADON and DON acknowledged that psychotropic drugs should not be initiated without informed consent and that this omission violated resident rights. Facility policy required staff and the physician to review non-pharmacological options, indications, risks, benefits, and the right to accept or decline treatment with the resident or representative before obtaining documented consent or refusal, but this process was not documented for this resident.
A resident with dementia, severe cognitive impairment, a fall history, and physician orders for daily wheelchair and bed alarms had consistent alarm use documented on the MAR, but the corresponding MDS did not code daily use of these alarms. The MDS nurse later confirmed that, based on the 7-day lookback period, alarms were used every day and that the assessment was not accurate, contrary to the job requirement that MDS assessments accurately reflect the resident’s condition and care.
A resident with severe cognitive impairment, poor safety awareness, and a history of multiple unwitnessed falls at the bedside was assessed as high risk for falls and had a physician order and IDT recommendation for floor mats on both sides of the bed. On observation, no floor mats were present, and a CNA reported routinely removing the mat during the day and being unsure if it was replaced later. One LVN was unaware of any floor mat orders and could not recall recent use of mats, while another LVN confirmed the order and his responsibility to carry it out but had not verified mat placement that morning. Staff acknowledged that the use of floor mats was not included in the resident’s care plan, despite facility policy requiring care plans to guide daily care and be available to all staff.
Two residents with severe cognitive impairment and known fall risks did not receive consistent implementation of ordered fall-prevention measures, including floor mats and bed/wheelchair alarms, and one did not receive a required post-fall risk evaluation. For one resident, surveyors found that ordered floor mats were not in place at the bedside, alarms ordered after prior falls were not in use, and staff had not timely documented or reported the resident’s ongoing removal of alarms to the physician, despite care plan and policy requirements. For the other resident, staff did not complete a Fall Risk Evaluation after an unwitnessed fall with reported knee pain, contrary to facility policy and the ADON’s stated expectations for immediate or 24-hour post-fall assessment.
A resident with severe cognitive impairment was found with a bump and discoloration on the back of the head, but staff did not report the injury of unknown origin to CDPH within the required two-hour timeframe. The delay in reporting was confirmed through staff interviews and record review, resulting in a delayed investigation and potential risk to all residents.
A resident with multiple complex diagnoses, including atrial fibrillation and dementia, was administered heparin injections without a comprehensive care plan in place to address the medication and its associated risks. Despite physician orders and facility policy requiring such a plan, the care team did not initiate or document interventions or monitoring for potential complications, as confirmed by the DON.
Expired food items, including baking soda, colander seeds, red food coloring, and breadcrumbs, were found in the facility's dry storage room. The Dietary Procurement Personnel and Dietary Manager acknowledged the importance of labeling and discarding expired items to prevent potential illness among residents. The facility's policy requires proper storage and labeling, but these procedures were not followed.
The facility failed to follow infection control practices by washing laundry at incorrect temperatures, storing resident cold packs with staff food, and improperly disinfecting a cloth gait belt. Staff were unaware of the correct laundry temperature policy, and resident equipment was stored with staff food, risking contamination. A cloth gait belt was inadequately disinfected with wipes, contrary to facility policy requiring proper cleaning of reusable items.
The facility did not post the results of complaint investigations by the CDPH in accessible areas, violating residents' rights. The DON acknowledged the survey binder was incomplete, and the ADM confirmed the responsibility to post these results. Facility policies stated residents' rights to access survey results, but the facility failed to comply.
The facility failed to conduct annual competency assessments for an LVN and three CNAs, as required by policy. The DON, recently hired, had not completed these assessments, which are necessary to ensure staff can safely perform their duties. This oversight was confirmed through record reviews and interviews.
The facility failed to label opened medications with the date in two medication carts, risking the administration of expired drugs to residents with conditions like epilepsy and diabetes. LVNs acknowledged the risk, and the DON stressed the importance of proper labeling per policy.
A resident with severe cognitive impairment was not dressed daily, remaining in a hospital gown over several days, contrary to their care plan and the facility's dignity policy. Staff interviews confirmed the resident was only dressed when taken out of bed, highlighting a failure to promote the resident's dignity and self-esteem.
A resident with multiple medical conditions, including a fractured femur and dementia, was found with the call light out of reach, potentially delaying necessary care. A CNA confirmed the oversight and corrected it, while the DON acknowledged the importance of call light accessibility as per facility policy.
The facility failed to notify the physician of significant changes in two residents' conditions. One resident experienced an 18-pound weight loss over three months without physician notification, despite facility policy requiring it. Another resident had swollen ankles, a new finding, but the physician was not informed. These oversights placed the residents at risk for further complications.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect data being sent to CMS. One resident's schizophrenia diagnosis was not reflected in the MDS, and another resident's MDS was not updated quarterly. The MDS Nurse and DON acknowledged these deficiencies, emphasizing the importance of timely and accurate assessments for resident care and facility reimbursement.
A facility failed to accurately complete the PASRR Level 1 screening for a resident with schizophrenia, leading to the omission of a necessary Level 2 evaluation. The resident, who had a history of schizophrenia and dementia, was incorrectly documented as having no serious mental illness, resulting in the case being closed without further evaluation. This oversight was identified during a review of the resident's records, where it was noted that the facility did not adhere to its policy of completing a new PASRR when a new mental health disorder was diagnosed.
The facility failed to create individualized care plans for three residents, leading to unmet care needs. A resident with a history of falls lacked a care plan for a one-to-one sitter. Another resident experienced significant weight loss without a care plan for nutritional interventions. A third resident had swollen ankles without a care plan to address the condition. The facility's policy requires comprehensive care plans, but this was not followed.
A resident with severe cognitive impairment and specific preferences for outdoor activities was not taken outside for garden strolls, despite it being important for their well-being. Facility staff confirmed the lack of a schedule for such activities, and the Director of Nursing acknowledged the oversight, which contradicted the facility's policy on individualized care and meaningful engagement.
A resident with a pacemaker was not monitored according to professional standards, as their pacemaker had not been checked for four years. Despite the care plan requiring regular evaluations, a scheduled check was canceled and not rescheduled. The facility's policy required checks every three months or yearly, depending on the model, to prevent potential malfunctions.
The facility failed to conduct timely joint mobility assessments for three residents with limited ROM, as required by their care plans. Residents with conditions such as dementia, cerebral infarction, and osteoarthritis did not receive quarterly assessments on time, potentially affecting their physical capabilities. The ADOR and DON acknowledged the importance of timely assessments to monitor and address any decline in ROM.
A facility failed to provide floor mats for a resident at high risk of falls, despite the care plan indicating their necessity. The resident, with severe cognitive impairment and multiple diagnoses, was observed without floor mats on two occasions. Additionally, the facility did not replace sharps containers in several rooms when they were over 75% full, contrary to policy, posing a risk of needlestick injuries. Staff interviews confirmed these deficiencies.
A facility failed to follow its policy for maintaining oxygen therapy equipment for a resident, leading to undated and unlabeled oxygen tubing and humidifier. The resident, with acute respiratory failure and obstructive sleep apnea, had an order for BIPAP therapy. An LVN confirmed the oversight, acknowledging the risk of bacterial growth and infection. The DON highlighted the importance of weekly changes for infection control and proper oxygen delivery.
A facility failed to obtain a physician's order for a 1:1 sitter for a resident with a history of falls and cognitive impairment. Despite the resident's need for close supervision due to muscle weakness, lack of coordination, and dementia, the required order was not found in the medical chart, contrary to the facility's policy.
A resident with severe cognitive impairment and functional limitations did not receive physical therapy (PT) services despite an active physician's order. The order for PT evaluation and treatment was not executed, and no documentation explained the omission. The Assistant Director of Rehabilitation and the Director of Nursing confirmed the oversight, noting that the rehabilitation department should have acted on the order within 24 hours.
A facility failed to maintain timely medical records for a resident when their Joint Mobility Assessment (JMA) was not documented until nearly a year after the effective date. The resident, with diagnoses including Parkinson's Disease and cerebral infarction, was assessed as cognitively intact with functional limitations. The delay was confirmed by the Assistant Director of Rehabilitation, who noted the JMA was signed late, not meeting professional standards. The Director of Nursing highlighted the importance of timely documentation for continuity of care.
A resident's representative signed an arbitration agreement without understanding its implications due to a lack of explanation from the facility. The Admissions Coordinator did not discuss the agreement with the representative, and the facility lacked a specific arbitration policy, leading to the deficiency.
A facility failed to ensure hospice services met professional standards for a resident with Alzheimer's and hypertension. The hospice representative did not participate in care conferences, and the facility lacked a hospice calendar and updated physician certification, leading to a lapse in hospice care coordination.
The facility did not update and post daily staffing information as required. Observations revealed that the Direct Care Service Hours Per Patient Day (DHPPD) forms at the front desk and a nursing station were outdated by several days. A CNA confirmed the lack of updates, and the DSD acknowledged the oversight, noting that updates should occur daily, including weekends and holidays, as per facility policy.
A facility failed to elevate a resident's head of bed to the required 30 to 45 degrees during gastrostomy tube feeding, as ordered by the physician. The resident, with a history of dysphagia and respiratory failure, was observed with the bed elevated only to 20 degrees, contrary to the care plan and facility policy, increasing the risk of aspiration.
A facility failed to inform a resident's responsible party about skin discoloration, an x-ray order, and its results, violating their policy. The resident had severe cognitive impairment and required extensive assistance. The oversight was acknowledged by an LVN during an interview.
A resident in an LTC facility, with conditions including acute kidney failure and depression, reported being roughly handled by a CNA during nighttime assistance to the restroom. The resident, who was cognitively intact, felt humiliated and disrespected. The CNA admitted to the rough handling and apologized. The incident was reported by the resident's daughter, and the facility's policies emphasize protection from abuse.
A resident with a history of acute kidney failure and other conditions reported being handled roughly by a CNA during the night, which was a violation of the facility's abuse prevention policy. The resident was cognitively intact and required assistance with toileting. The DON acknowledged that rough handling could be considered abuse, highlighting a failure to adhere to the facility's policy against abuse and neglect.
A resident at high risk for falls experienced multiple falls due to the facility's failure to implement a physician's order for a soft belt restraint while in a wheelchair. Despite the resident's cognitive impairment and dependency on staff for mobility, the care plan was not updated after initial falls, and the soft belt was not applied as required. This oversight resulted in the resident sustaining a nasal fracture and requiring hospitalization.
A resident with a history of dementia and other conditions experienced multiple falls, but the facility failed to initiate a new 72-hour neuro check after each incident as required by their policy. This resulted in a delay in starting the neuro check after the second fall, potentially delaying necessary interventions.
The facility failed to implement a communication care plan for a resident whose primary language was Spanish, leading to refusals of care due to concerns about miscommunication with non-Spanish-speaking staff. Interviews revealed that the facility did not regularly include residents' preferred languages or communication methods in care plans, despite policies emphasizing the importance of accommodating residents' needs and preferences.
The facility failed to report an injury of unknown origin to CDPH within the required two-hour timeframe. A resident with dementia and other conditions was found with a knee fracture, and the injury was not reported promptly, resulting in a delay in the investigation by CDPH. The DON acknowledged the reporting failure, which violated the facility's policy and state regulations.
Failure to Obtain Informed Consent Prior to Initiation of Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident representative prior to initiating a psychotropic medication. A resident with diagnoses including depression, knee surgery, and congestive heart failure was initially admitted and later readmitted to the facility. A History and Physical dated 9/12/2025 documented that the resident had the capacity to understand and make decisions, and a Minimum Data Set dated 1/7/2026 indicated the resident was independent in cognitive skills for daily decision making, though requiring moderate assistance with some activities of daily living. On 2/2/2026, a physician placed a telephone order for Cymbalta 30 mg by mouth in the morning for depression, and the Medication Administration Record showed the resident received this medication daily from 2/4/2026 to 2/24/2026. During an interview and concurrent record review on 2/24/2026, the ADON confirmed there was no documentation in the clinical record indicating that informed consent for Cymbalta had been obtained from the resident’s representative, despite the admission record identifying that the resident had a representative. The ADON stated that facility staff cannot initiate any psychotropic drug until the physician obtains informed consent from the resident’s representative and acknowledged that no such consent was present in the chart. The DON stated that not obtaining informed consent prior to initiating any psychotropic drug is a violation of resident rights and that residents or their representatives have the right to make an informed decision to accept or decline psychotropic medications. Review of the facility’s policy on Psychotropic Medication Use, dated 3/2025, showed that prior to initiating, increasing, or switching psychotropic medications, staff and the physician are required to review non-pharmacological interventions, indications and rationale, potential risks and benefits, and the right to accept or decline treatment with the resident or representative before obtaining documented consent or refusal.
Inaccurate MDS Coding for Daily Use of Alarms
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, resulting in the transmission of inaccurate clinical data to CMS. The resident had dementia, a history of falls, and severe cognitive impairment, and required partial to moderate staff assistance for transfers. A physician order dated 4/30/2024 directed staff to apply both a wheelchair and bed alarm to alert staff when the resident attempted to get up without assistance. The Medication Administration Record for the entire month of December 2025 documented daily use of both a wheelchair and bed alarm for this resident. Despite this, the MDS dated [DATE] did not indicate the resident’s daily use of a bed or wheelchair alarm. During interview, the MDS Assistant stated that MDS coding for alarms is based on the previous seven days of alarm use and confirmed that the resident had used alarms daily during that seven-day lookback period. The MDS Assistant acknowledged that the MDS dated [DATE] was not accurate and stated that the MDS should accurately reflect the resident’s clinical condition and the care they received or required, and that alarms were considered a restraint whose use should be routinely reviewed. The facility’s MDS Coordinator Lead job description required that resident assessments present an accurate reflection of the resident, which was not met in this case.
Failure to Care Plan and Implement Ordered Floor Mats for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan that reflected a physician’s order for floor mats for a resident at high risk for falls. The resident had diagnoses including cognitive impairment and lack of coordination, and assessments documented severe cognitive impairment, inability to make decisions, and a need for substantial to maximal assistance with bed mobility and transfers. Following an unwitnessed fall on 8/11/2025, a Change of Condition assessment and Fall Risk Evaluation identified the resident as high risk for falls. A physician order dated 8/11/2025 directed that floor mats be placed on either side of the resident’s bed, and an IDT review on 8/12/2025 recommended floor mats at the bedside to reduce injury risk. Subsequent Change of Condition assessments on 8/18/2025 and 12/17/2025 documented two additional unwitnessed falls at the bedside. On observation on 1/15/2026, no floor mats were present on either side of the resident’s bed. A CNA reported that the resident was at risk for falls due to a history of falls and frequent attempts to get out of bed unassisted, and stated she usually removed the floor mat during the day shift and was unsure if staff replaced it in the evening. One LVN stated the resident had a history of falls and attempts to get out of bed unassisted, could not recall recent use of floor mats, and was not aware of any floor mat orders, adding that floor mats should be care planned so all staff would know they were needed. Another LVN confirmed the resident had orders for floor mats on either side of the bed and that he was responsible for ensuring physician orders were carried out, but he did not recall checking for floor mats that morning and acknowledged there was no care plan for floor mat use. The facility’s care plan policy stated that the care plan was to be used in developing the resident’s daily care routines and be available to staff responsible for providing care or services.
Failure to Implement Ordered Fall-Prevention Measures and Complete Post-Fall Risk Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain ordered fall-prevention interventions and to complete required fall risk evaluations for residents identified as being at high risk for falls. One resident with severe cognitive impairment, poor safety awareness, and a documented history of unwitnessed falls had physician orders and IDT recommendations for floor mats to be placed on both sides of the bed following a fall. Despite these orders and the facility’s fall management policy, surveyors observed that no floor mats were at the bedside; instead, a single fall mat was stored behind the room door. A CNA reported that only one mat was used and that she typically removed it during the day shift, and an LVN stated he was unaware of any floor mat orders and had not ensured their implementation, even though the LVN job description required carrying out physician orders. The same resident had additional physician orders for a bed alarm and wheelchair alarm after another unwitnessed fall, and the care plan directed staff to monitor, document, and report changes in the effectiveness of these alarms. Multiple subsequent assessments, including a change of condition assessment and a rehab post-fall screen, documented that alarms and floor mats were not in place at the time of later falls and that the resident continued to exhibit confusion, impulsiveness, forgetfulness, and poor safety awareness. Staff interviews revealed that CNAs and LVNs had not observed the resident using bed or wheelchair alarms, and one LVN acknowledged that the resident had a known pattern of removing and dismantling alarms, but this behavior had not been documented or reported to the physician until months later. The ADON stated that the physician should be notified when a resident refuses ordered alarms so that the plan of care can be reviewed and other interventions considered, and the facility’s fall protocol required staff to monitor and document resident responses to fall interventions. A second resident, also with severe cognitive impairment and requiring supervision or touch assistance for bed mobility and transfers, experienced an unwitnessed fall in the dining room, after which she complained of right knee pain. Although the facility’s fall clinical protocol required staff to re-evaluate the situation and reconsider fall interventions after any fall, and the ADON stated that a Fall Risk Evaluation should be completed immediately or within 24 hours following any fall, no Fall Risk Evaluation was completed for this resident after the incident. The ADON confirmed that the assessment was not done and acknowledged that it should have been completed to promptly identify interventions to prevent further falls.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) in a timely manner for one resident. The resident, who had severe cognitive impairment and required moderate assistance with activities of daily living, was observed by staff with a bump and discoloration on the back of her head. The initial observation of the injury was made by a Certified Nurse Assistant (CNA) during the evening shift, who reported it to the Registered Nurse Supervisor. The CNA later inquired if the injury had been reported to the Director of Nursing (DON), the Administrator, and CDPH, and was told by the RN Supervisor that it had been taken care of. However, subsequent staff interviews and record reviews revealed that the injury was not reported to the appropriate authorities until the following day, after being observed again by another CNA and reported up the chain of command. The facility's policy required that injuries of unknown origin or suspected abuse be reported within two hours to the appropriate agencies. Interviews with the DON and Administrator confirmed that the injury should have been reported the previous day, in accordance with policy and regulatory requirements. The delay in reporting resulted in a delay of an onsite investigation by CDPH and had the potential to place all residents at risk for abuse.
Failure to Develop Comprehensive Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was receiving heparin injections for deep vein thrombosis prophylaxis. The resident had multiple diagnoses, including atrial fibrillation, subdural hemorrhage, repeated falls, and dementia, and required substantial to maximal assistance with activities of daily living. Despite a physician's order to administer heparin subcutaneously every 12 hours, there was no care plan in place to address the administration of this medication or to monitor for potential side effects and complications, such as bleeding. The deficiency was identified through a review of the resident's admission record, Minimum Data Set, physician's orders, and medication administration record, as well as an interview with the Director of Nursing. The DON confirmed that a care plan should have been initiated when the heparin order was received, in accordance with the facility's policy and procedure for developing comprehensive, person-centered care plans. The absence of a care plan meant that necessary interventions and monitoring for the resident's safety were not documented or implemented.
Expired Food Items Found in Storage
Penalty
Summary
The facility failed to ensure that food items were discarded after their use-by dates, as observed during a survey. In the dry storage room, several expired food items were found, including baking soda powder, colander seeds, red food coloring, and breadcrumbs. The Dietary Procurement Personnel (DP 1) acknowledged that these items should have been labeled with an opened date and a use-by date, and discarded once expired. DP 1 emphasized the importance of tracking these dates for safety reasons, as serving expired food could pose a risk of illness to residents. The Dietary Manager confirmed the facility's process of labeling food items with opened and use-by dates and stated that expired items should be discarded to prevent them from being served to residents. The facility's policy and procedure on food storage, although undated, indicated that the Nutrition Services Manager is responsible for ensuring proper storage and labeling of food items. The presence of expired food items in storage suggests a lapse in adherence to these procedures, potentially compromising resident safety.
Infection Control Deficiencies in Laundry, Rehabilitation, and Equipment Use
Penalty
Summary
The facility failed to implement appropriate infection control practices in several areas. Firstly, the laundry was not washed at the correct temperature as per the facility's policy and procedure. The laundry staff, including the Laundry Aide and Maintenance Supervisor, were following a signage on the washing machine that indicated a temperature range of 140-145 degrees Fahrenheit. However, the facility's policy required soiled linen to be washed at a temperature range of 158-176 degrees Fahrenheit. This discrepancy was not known to the staff, indicating a lack of awareness and adherence to the facility's infection control policies. In the rehabilitation office, reusable cold modality packs used for residents were stored in the same combination freezer/refrigerator as staff food containers. The Assistant Director of Rehabilitation confirmed this practice, which was against infection control protocols. The Infection Preventionist and Director of Nursing both stated that resident equipment should not be stored with staff food due to the risk of contamination. The facility's policy emphasized the need for a safe and sanitary environment to prevent disease transmission, which was not followed in this instance. Additionally, a Restorative Nursing Aide used a cloth gait belt with a resident and attempted to disinfect it with wipes, which was inadequate for porous materials. The Infection Preventionist and Director of Nursing confirmed that cloth gait belts must be washed to be properly disinfected, and that disinfecting wipes are only effective on non-porous materials like plastic gait belts. The facility's policy required reusable items to be cleaned and disinfected between residents, which was not adhered to in this case.
Failure to Post Complaint Investigation Results
Penalty
Summary
The facility failed to post the results of complaint investigations conducted by the California Department of Public Health (CDPH) over the past three years in areas that are prominent and accessible to residents, family members, and visitors. During an observation and interview, the Director of Nursing (DON) acknowledged that the survey binder available at nursing station 2 was incomplete and did not include these results. Instead, the complaint investigation results were kept in a separate binder in the DON's office, which was not accessible to residents and their families. The DON admitted that this practice violated residents' rights by not making the information readily available. The Administrator (ADM) confirmed that it was his responsibility to ensure the survey binder and complaint investigation results were posted as required. The facility's policy and procedure on Resident's Rights, as well as the admission packet, clearly stated that residents have the right to examine the results of the most recent surveys and any plans of correction. However, the facility did not comply with these requirements, thereby placing residents, family members, and visitors at risk of not being informed about the facility's compliance status and past performance.
Failure to Conduct Annual Competency Assessments for Nursing Staff
Penalty
Summary
The facility failed to ensure that annual competency assessments were conducted for four out of five randomly selected staff members, which is a requirement to ensure that nursing staff have the necessary skills to provide safe and effective care to residents. During a review of employee records, it was found that a Licensed Vocational Nurse (LVN) and three Certified Nurse Assistants (CNAs) did not have the required annual competency assessments on file. This oversight was confirmed during an interview with LVN 7, who indicated that the Director of Nursing (DON) was responsible for completing these assessments. The DON acknowledged that competency assessments must be conducted upon hire and annually, and that staff cannot work on the floor without completing and passing these assessments. However, the DON stated that she had been recently hired and had not yet completed the assessments for the identified staff members. The facility's policy, dated March 2024, mandates that competency evaluations be conducted upon hire, annually, and as necessary based on the facility assessment, highlighting the importance of these evaluations in maintaining compliance with state licensing requirements.
Failure to Label Opened Medications in Medication Carts
Penalty
Summary
The facility failed to label medications with the opened date on the label for drugs stored in two of four sampled medication carts. This oversight was identified during observations and interviews with Licensed Vocational Nurses (LVNs) and a review of residents' records. The medications involved were intended for residents with various medical conditions, including epilepsy, diabetes mellitus, and end-stage renal disease, among others. The absence of an opened date on these medications raised concerns about the potential administration of expired drugs, which could lead to ineffective treatment and possible harm to the residents. During the survey, it was observed that Medication Cart 1 contained an open vial of testosterone cypionate for a resident with epilepsy and an open box of ipratropium-albuterol inhalation solution for a resident with diabetes mellitus, neither of which were labeled with an opened date. LVN 7 acknowledged that without the opened date, there is a risk of administering expired medication. Similarly, Medication Cart 2 had an opened bottle of Phenergan/codeine oral syrup, an opened tube of Nitro-Bid transdermal ointment, and an opened tube of estradiol vaginal cream, all lacking an opened date. LVN 6 confirmed the risk of administering expired medications under these circumstances. The Director of Nursing (DON) emphasized the importance of labeling medications with the opened date to prevent residents from receiving expired medications, which could lead to adverse effects. The facility's policy and procedure on medication labeling, which aligns with state and federal guidelines, was reviewed and indicated that all medications should be properly labeled. However, the failure to adhere to this policy resulted in the identified deficiency.
Failure to Dress Resident Daily
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 47, was properly dressed daily, which is a violation of the resident's right to be treated with respect and dignity. Resident 47, who has severe cognitive impairment and is dependent on staff for personal hygiene, showering, and dressing, was observed wearing a hospital gown over several days. The resident's care plan indicated that staff should assist the resident in selecting clothes and ensure that clothing is clean, age-appropriate, and in good repair. However, observations over three consecutive days showed that the resident remained in a hospital gown, indicating a failure to adhere to the care plan. Interviews with staff, including an LVN, two CNAs, and the DON, revealed that the resident was not dressed unless taken out of bed, which was not consistent with the facility's policy on dignity. The staff acknowledged the importance of dressing the resident daily to promote a sense of dignity and respect. The facility's policy emphasized that residents should be cared for in a manner that enhances their well-being and self-esteem, including being dressed in their preferred clothing. Despite this policy, the resident was not dressed in regular clothing, which could impact their sense of self-worth and dignity.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one resident, identified as Resident 14, which could potentially delay necessary care and services. Resident 14 was admitted with several medical conditions, including a displaced fracture of the left femur, cerebral infarction with hemiplegia and hemiparesis, and unspecified dementia. The resident was dependent on staff for various activities of daily living, such as toileting, eating, dressing, showering, and personal hygiene. During an observation, it was noted that the call light was placed on a dresser behind the bed, out of the resident's reach, which was confirmed by a Certified Nursing Assistant (CNA) who then moved the call light within reach. The Director of Nursing (DON) acknowledged that call lights should be within residents' reach to enable them to call for help when needed. The facility's policy, dated April 2024, also indicated that the purpose of the call light policy was to ensure residents have the necessary means of communication with nursing staff by keeping the call light within reach. This oversight in adhering to the policy resulted in a deficiency as it compromised the resident's ability to communicate their need for assistance.
Failure to Notify Physician of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to notify the physician of a significant weight loss in Resident 24, who experienced an 18-pound weight loss, equating to 11.8% over three months. Resident 24 was admitted with diagnoses including failure to thrive, urinary tract infection, and cerebral infarction with left hemiplegia and dysphagia. Despite the significant weight loss documented in the resident's Weights and Vitals Summary, there was no documentation indicating that the physician was notified, as confirmed by the Director of Nursing (DON). The facility's policy required physician notification for weight changes, but this was not adhered to, leading to a potential risk for further weight loss. Additionally, the facility failed to notify the physician about the swollen ankles of Resident 39, who was admitted with conditions such as gastrostomy, Parkinson's disease, and atherosclerotic heart disease. During an observation, Resident 39 was noted to have swollen and red ankles while sitting in a wheelchair. Licensed Vocational Nurse (LVN) 5 acknowledged the swelling as a new finding and stated that the physician should have been notified. However, the DON confirmed that there were no records of the physician being informed about this change in condition. The facility's policy on notifying physicians of changes in a resident's condition was not followed in both cases. The policy required notification of the physician and responsible parties when there was a significant change in a resident's condition, such as weight loss or swelling. The failure to notify the physician in these instances placed the residents at risk for further complications, as the necessary medical interventions were not implemented in a timely manner.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, leading to incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS). For one resident, the MDS assessment did not reflect a diagnosis of schizophrenia under Section A, which is crucial for determining mental illness conditions. This oversight was acknowledged by the MDS Nurse during a review, who confirmed that the diagnosis was not checked in the MDS assessment, despite the resident having a history of schizophrenia and dementia. The nurse emphasized the importance of accuracy in the MDS for both resident care and facility reimbursement. For another resident, the facility failed to update the MDS quarterly as required. The MDS Nurse admitted that the resident's MDS was not updated on time due to other responsibilities such as meetings and document updates. The Director of Nursing (DON) also confirmed that the MDS should be updated quarterly to ensure the staff can continue the resident's plan of care and monitor for any improvements or declines. The facility's policy and procedure on the accuracy of assessments highlighted the need for comprehensive assessments to be conducted quarterly, which was not adhered to in this case.
Failure to Accurately Complete PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident diagnosed with schizophrenia. The resident, who was initially admitted and later readmitted to the facility, had a history of schizophrenia and dementia, which impaired their cognitive abilities and decision-making capacity. Despite these diagnoses, the PASRR Level 1 screening incorrectly indicated that the resident had no serious mental illness and was not receiving psychotropic medications, leading to the case being closed without a Level 2 evaluation. During a review of the resident's records, it was found that the PASRR Level 1 screening was not completed accurately, as confirmed by the MDS nurse. The facility's policy required a new PASRR to be completed when a new mental health disorder was diagnosed, but this was not done. The failure to refer the resident for a Level 2 evaluation potentially resulted in the resident not receiving appropriate treatment recommendations for their schizophrenia.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized person-centered care plans with measurable objectives, timeframes, and interventions for three residents. For Resident 19, the facility did not address the need for a one-to-one sitter despite the resident's history of falls and cognitive impairment. During an interview, a Licensed Vocational Nurse (LVN) confirmed that there was no care plan or physician order for the use of a sitter, which is necessary for staff to ensure the resident's care goals are met. Resident 24 experienced significant weight loss over a three-month period, dropping from 153 pounds to 135 pounds. Despite this, the facility did not create a care plan to address the weight loss, which is crucial for implementing nutritional interventions. The Director of Nursing (DON) acknowledged the lack of a care plan and emphasized the importance of care planning as a guide for staff to meet the resident's specific needs. For Resident 39, who had swollen ankles and redness, the facility did not develop a care plan with interventions to address this condition. Observations confirmed the swelling, and an LVN stated that a care plan should have been developed to prevent the condition from worsening. The DON noted that interventions should be put in place once a condition is identified, and follow-ups are necessary to ensure the resident's condition improves. The facility's policy requires comprehensive, person-centered care plans to meet residents' needs, but this was not adhered to in these cases.
Failure to Provide Garden Strolls for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 47, was taken outside for a garden stroll, which was an activity important to the resident's mental and emotional well-being. Resident 47, who was admitted to the facility with diagnoses including epilepsy, chronic kidney disease, and benign prostatic hyperplasia, was noted to have severely impaired cognition and was dependent on staff for personal care. The Minimum Data Set (MDS) indicated that it was very important for Resident 47 to go outside for fresh air when the weather was good, and the Activities Review Record showed a preference for sensory stimulation and garden strolls. Despite these documented preferences, the Activity Attendance Record for September 2024 showed no documentation of Resident 47 being taken outside for a garden stroll. Interviews with facility staff, including an Activity Assistant and a Licensed Vocational Nurse, confirmed that there was no set schedule for taking Resident 47 outside, and they had not observed the resident being taken for garden strolls. The Director of Nursing acknowledged that staff should offer and take Resident 47 outside daily when the weather was favorable, using nonverbal cues to assess the resident's interest. The facility's policy emphasized the importance of individualized care and engagement in meaningful activities, which was not adhered to in this case.
Failure to Monitor Pacemaker in Resident
Penalty
Summary
The facility failed to ensure that a resident with a pacemaker received treatment and care in accordance with professional standards of practice. The resident, who was admitted with diagnoses including acute on chronic congestive heart failure and hypertensive heart disease, had a Boston Scientific pacemaker implanted in 2017. Despite the care plan indicating the need for regular pacemaker evaluations, the resident reported that their pacemaker had not been checked since admission to the facility. The Director of Nursing confirmed that a scheduled pacemaker evaluation was canceled and not rescheduled, resulting in the pacemaker not being checked for four years. The facility's policy required pacemaker checks every three months or yearly, depending on the model, to prevent potential malfunctions. The failure to adhere to this policy posed a risk of pacemaker failure, which could lead to serious medical complications.
Failure to Conduct Timely Joint Mobility Assessments
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for three residents who had limited ROM or were assessed at risk for decline in joint ROM. The facility did not ensure that Residents 64, 14, and 15 received timely quarterly rehabilitation joint mobility screens to monitor changes in joint ROM, as indicated in their care plans. This deficiency was identified through observation, interview, and record review. Resident 64, who was admitted with diagnoses including dementia and cerebral infarction, was observed with functional limitations in both upper and lower extremities. The resident's care plan required quarterly assessments of joint mobility, but the Joint Mobility Assessments (JMA) were not completed on time. The last assessment was conducted on 5/21/2024, and the subsequent assessment was overdue by the end of August 2024. The Assistant Director of Rehabilitation (ADOR) confirmed the delay and emphasized the importance of timely assessments to monitor and address any decline in ROM. Similarly, Resident 14, with a history of severe cognitive impairment and hemiplegia following a cerebral infarction, did not receive a timely JMA after the last one on 6/17/2024. The assessment was due by the end of September 2024. Resident 15, diagnosed with dementia and osteoarthritis, also experienced a delay in their JMA, which was completed late on 8/28/2024. The Director of Nursing (DON) acknowledged the responsibility of rehabilitation staff to complete JMAs timely to prevent deterioration in residents' physical capabilities, which could affect their balance, ability to feed themselves, and mobility.
Failure to Implement Fall Prevention and Sharps Disposal Protocols
Penalty
Summary
The facility failed to ensure that Resident 81 had floor mats at the bedside to prevent injury from a fall. Resident 81, who was diagnosed with dementia, COPD, and anxiety, was identified as having severely impaired cognition and was dependent on staff for personal care. The resident was assessed as high risk for falls, and the care plan included the use of floor mats as a preventive measure. However, during observations on two separate occasions, no floor mats were present at the bedside. Interviews with LVN 5 and the DON confirmed the absence of floor mats and acknowledged the increased risk of injury to Resident 81 without them. Additionally, the facility did not replace sharps containers in rooms 221, 321, and 333 when they were at least 75% full, as required by the facility's policy. Observations revealed that the containers were overfilled, with one container having a razor protruding from it. LVN 8 and RN 1 confirmed the importance of replacing sharps containers to prevent needlestick injuries and stated that it was the responsibility of all nurses to ensure containers were changed when full. The facility's policy indicated that containers should be sealed and replaced when they are 75% to 80% full.
Failure to Maintain Oxygen Therapy Equipment
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the maintenance of oxygen therapy equipment for a resident, identified as Resident 23. The deficiency was observed when the oxygen tubing and humidifier in Resident 23's room were found to be undated and unlabeled, contrary to the facility's policy that requires these items to be dated and changed every seven days. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the responsibility of licensed nurses to label and date the equipment upon opening. The LVN also noted that failing to change the oxygen tubing within the specified timeframe could lead to bacterial growth and potential respiratory infections. Resident 23, who was initially admitted to the facility with acute respiratory failure with hypoxia and obstructive sleep apnea, had an active order for Bilevel Positive Airway Pressure (BIPAP) therapy at 2 liters per nasal cannula every night. The Director of Nursing (DON) emphasized the importance of dating the humidifier and changing the oxygen tubing weekly for infection control and ensuring the patency of the tubing to deliver the correct oxygen concentration. The facility's policy, dated February 2024, clearly states the requirement to change the oxygen cannula and tubing every seven days and to mark the humidifier bottle with the date and initials upon opening.
Physician Order Missing for 1:1 Sitter
Penalty
Summary
The facility failed to ensure that a physician signed an order for a one-to-one (1:1) sitter for a resident, identified as Resident 19, who was under close supervision due to a history of falls. During an observation and interview, a staff member was noted to be sitting within arm's reach of Resident 19, serving as the 1:1 sitter. The staff member confirmed her role was to prevent falls due to the resident's history. However, upon reviewing Resident 19's medical chart, it was discovered that there was no physician's order for the sitter, which is a requirement according to the facility's policy. Resident 19 was readmitted to the facility with diagnoses including muscle weakness, lack of coordination, and dementia, which affected cognitive abilities. The Minimum Data Set (MDS) assessment indicated that Resident 19 was not cognitively intact. Despite these conditions, the necessary physician's order for the sitter was missing, as confirmed by a Licensed Vocational Nurse (LVN) during a record review. The facility's policy, dated March 2024, clearly states that the use of sitters must be approved by the resident's attending physician, highlighting the oversight in this case.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide physical therapy (PT) services to a resident, despite an active physician's order for PT evaluation and treatment. The order was dated 4/5/2024, but no PT services were provided to the resident, who was part of a sample of 12 residents. This oversight was identified during an observation and interview on 10/2/2024, where the resident was seen sitting in a wheelchair and able to drink with assistance. The resident had been admitted with diagnoses including dementia and cerebral infarction, and the Minimum Data Set (MDS) indicated severe cognitive impairment and functional limitations in both upper and lower extremities. The Assistant Director of Rehabilitation (ADOR) confirmed that there was no PT evaluation or documentation explaining the lack of PT services for the order dated 4/5/2024. The ADOR stated that the rehabilitation department should have seen the resident within 24 hours to complete an evaluation. The Director of Nursing (DON) also confirmed that the order should have been carried out and that the nurse receiving the order should have communicated it to the rehabilitation department. The facility's policy indicated that rehabilitative services should be provided upon the written order of the resident's attending physician.
Failure to Maintain Timely Medical Records
Penalty
Summary
The facility failed to maintain timely medical records for a resident, identified as Resident 63, when their Joint Mobility Assessment (JMA) dated November 20, 2023, was not documented until October 3, 2024. This delay in documentation was discovered during a record review, where it was noted that the JMA was blank and marked as not completed. The Assistant Director of Rehabilitation (ADOR) confirmed that the JMA was signed almost a year after the effective date, which did not meet professional standards for timely documentation. The ADOR was unsure of the reason for the delay, as the therapist responsible was not present at the facility on the day of the review. Resident 63 was admitted with diagnoses including Parkinson's Disease and cerebral infarction, and was assessed as cognitively intact with functional limitations in the range of motion on one side of the upper extremity. The Director of Nursing (DON) emphasized the importance of timely and accurate documentation to ensure continuity of care and proper follow-up. The facility's policy on charting and documentation, dated March 2024, required that all services provided to residents be documented objectively, completely, and accurately. The failure to document the JMA in a timely manner had the potential to result in inaccurate medical documentation and delay appropriate interventions for Resident 63.
Failure to Ensure Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the representative of a resident understood the arbitration agreement they were signing. The resident, who was not cognitively intact, was admitted with diagnoses including hypertension and a history of falling. The representative, referred to as FM 1, signed the arbitration agreement without a full understanding of its implications. During interviews, FM 1 stated that no one from the facility explained the form, and she had to seek information online to understand what she was signing. The Admissions Coordinator (AC) confirmed that the arbitration agreement was part of the admissions packet and stated that she would answer any questions if asked. However, she admitted that she did not speak with FM 1 about the agreement. Additionally, the facility lacked a specific policy on arbitration, only having a policy on arbitration mediation, which outlines the process once arbitration is initiated. This lack of communication and policy clarity led to the representative entering into an agreement without proper understanding.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for a resident by not involving a hospice representative in the interdisciplinary team care conference meeting. The resident, who was diagnosed with Alzheimer's Disease and hypertension, was admitted to hospice care but lacked the capacity to understand and make decisions. The facility's records did not show participation of a hospice representative in the care conference, which was crucial for coordinating the resident's care and ensuring continuity. Additionally, the facility did not maintain a hospice calendar with scheduled visits for the hospice team, and the physician's certification for hospice benefit was not updated or available in the resident's medical record. This oversight resulted in the resident no longer being under hospice care, as the last certification had expired. The facility's policy required a coordinated care plan between the facility, hospice agency, and resident/family, which was not adequately implemented, potentially leading to a lack of coordination in hospice care delivery.
Failure to Update and Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was updated and posted daily in a visible and prominent place. During an observation at the front desk in the main lobby, the Direct Care Service Hours Per Patient Day (DHPPD) form was found to be dated three days prior. Similarly, at the second-floor northeastern nursing station, the DHPPD was also outdated by four days. A Certified Nursing Assistant confirmed that the DHPPD had not been updated for at least three days. The Director of Staff Development acknowledged that the DHPPD at the front desk was not updated over the weekend and emphasized that it should be updated daily, including weekends and holidays. The facility's policy requires that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel responsible for resident care be posted in a prominent location in a clear and readable format.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
The facility failed to ensure that the head of the bed (HOB) was elevated to the physician-ordered angle of 30 to 45 degrees for a resident receiving gastrostomy tube (GT) feeding. During an observation and interview, it was noted that the resident's HOB was only elevated to 20 degrees while receiving Jevity 1.5 cal at 65 cc per hour. The treatment nurse acknowledged that the HOB should be elevated to 30 degrees to prevent aspiration. The resident involved had a medical history of dysphagia, respiratory failure, and toxic encephalopathy, and was dependent on staff for various activities of daily living. The resident's care plan and physician's orders both specified the need for the HOB to be elevated to 30 to 45 degrees during and after feeding to mitigate the risk of aspiration. The facility's policy on enteral feedings also required the HOB to be elevated to at least 30 degrees during and after feeding.
Failure to Notify Responsible Party of Medical Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident about a change in the resident's condition and the subsequent medical interventions. Specifically, the responsible party was not informed about the skin discoloration observed on the resident's right wrist and elbow, the physician's order for an x-ray, and the results of the x-ray, which showed no fracture. This oversight was confirmed during an interview with the resident's family member, who stated they were unaware of the x-ray and its results. The resident in question was admitted with diagnoses including hemiplegia and hemiparesis affecting the right side, aphasia, and rheumatoid arthritis. The resident's cognitive skills were severely impaired, requiring extensive assistance with daily activities. The facility's policy mandates notifying the responsible party of any changes in the resident's medical condition, which was not adhered to in this case. An interview with a Licensed Vocational Nurse revealed an acknowledgment of the failure to notify the responsible party as required.
Resident Abuse by CNA
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when a Certified Nurse Assistant (CNA) grabbed the resident's wrist roughly. The incident occurred when the resident, who was admitted with diagnoses including acute kidney failure, difficulty in walking, encephalopathy, and depression, requested assistance to the restroom during the night. The resident, who was cognitively intact and required moderate to maximal assistance with daily activities, reported that the CNA appeared angry and handled her roughly, causing her to feel humiliated and disrespected. Interviews conducted with the resident, the CNA involved, and other staff members corroborated the resident's account of the incident. The CNA admitted to being rough and apologized to the resident. The Social Services Director confirmed that the incident was reported by the resident's daughter and that the resident's wristband fell off due to the rough handling. The Director of Nursing stated that no injuries were observed, and the facility's policies emphasized the protection of residents from abuse and neglect.
Failure to Prevent Rough Handling of Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program,' which was revised in March 2024. This policy clearly states that the facility does not condone any form of resident abuse or neglect. However, an incident involving a resident, a female with a history of acute kidney failure, difficulty in walking, encephalopathy, and depression, highlighted a breach of this policy. The resident, who was cognitively intact and required moderate to maximal assistance with toileting, reported being handled roughly by a Certified Nurse Assistant (CNA) during the night. During a telephone interview, the CNA admitted that the resident had complained about being handled too roughly, to which the CNA apologized. The Director of Nursing (DON) confirmed that any form of abuse, including rough handling, is not tolerated in the facility. The facility's policy emphasizes the protection of residents from abuse, neglect, exploitation, or misappropriation of property by anyone, including facility staff. This incident demonstrated a failure to protect the resident from potential abuse, as outlined in the facility's own policies.
Failure to Implement Safety Measures Leads to Resident Falls
Penalty
Summary
The facility failed to ensure the safety of a resident who was at risk for falls, resulting in the resident experiencing multiple falls and sustaining injuries. The resident, who had cognitive impairment and was dependent on staff for mobility, was assessed as having a high risk for falls. Despite this, the staff did not implement the physician's order to apply a soft belt restraint when the resident was in a wheelchair, as indicated in the care plan and facility policy. This failure to apply the soft belt was a significant factor in the resident's fall incidents. The resident experienced three falls within an eight-day period, with the third fall resulting in a fracture of the nasal bridge, requiring hospitalization. The care plan for the resident included interventions such as frequent monitoring, use of alarms, and application of a soft belt for safety. However, the care plan was not updated after the first two falls, and the staff did not follow the prescribed interventions, including the use of the soft belt, which was not documented in the Medication Administration Record (MAR). Interviews with the Director of Nursing (DON) and a Certified Nursing Assistant (CNA) revealed that the staff was not aware of the physician's order for the soft belt, and the MAR did not reflect its use. The facility's policies on fall reduction and the use of soft/self-release belts were not adhered to, contributing to the resident's repeated falls and subsequent injury. The lack of adherence to the care plan and physician's orders highlights the facility's failure to provide adequate supervision and implement necessary safety measures for the resident.
Failure to Conduct Timely Neuro Checks After Resident Falls
Penalty
Summary
The facility failed to adhere to its policy and procedure for conducting 72-hour neuro checks following a fall incident involving a resident. The resident, who had a history of muscle weakness, dementia, cerebral infarction, and urinary tract infection, experienced multiple falls within a short period. Despite the facility's policy requiring a new 72-hour neuro check to be initiated after each fall, the staff continued the neuro check from a previous incident, resulting in a delay of three and a half hours in starting the neuro check after the second fall. The Director of Nursing acknowledged during an interview that a new 72-hour neuro check form should have been started following the second fall incident. The facility's policy, dated 2012 and 2013, clearly outlined the requirement for neurological assessments to be conducted for 72 hours following a fall to assess for any neurological deficits. The failure to complete the neuro checks as per the facility's protocol had the potential to delay necessary interventions if the resident's neurological status changed.
Failure to Implement Resident-Specific Communication Care Plans
Penalty
Summary
The facility staff failed to implement or develop resident-specific communication care plans for a resident whose primary spoken language was Spanish. The resident, who had no cognitive impairments and required supervision or assistance for daily activities, expressed concerns about miscommunication with non-Spanish-speaking staff, leading to refusals of care such as bathing or showering. Despite the resident's clear preference for Spanish-speaking staff, this preference was not documented in the care plan, and no methods or interventions for ensuring effective communication were in place. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, revealed that the facility did not regularly include residents' preferred languages or communication methods in care plans. The facility's policies and procedures emphasized the importance of accommodating residents' needs and preferences, promoting communication, and maintaining dignity, but these were not followed in this case. The lack of a communication care plan for the resident created the potential for miscommunication and negatively impacted the resident's care and well-being.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not reporting an injury of unknown origin to the California Department of Public Health (CDPH) within the required two-hour timeframe. This deficiency involved a resident who was admitted with diagnoses including dementia, hypothyroidism, and legal blindness. The resident was dependent on staff for activities of daily living and was always incontinent of bowel and bladder. On 3/11/2024, the resident complained of right knee pain, and an unnamed CNA found the resident with both legs dangling and slight swelling to the right knee. A radiology report on 3/12/2024 revealed an acute medial supracondylar fracture of the distal femur, and the resident was transferred to a general acute care hospital. The Director of Nursing (DON) acknowledged that the injury should have been reported to CDPH immediately or within two hours but was not done, resulting in a delay in the investigation by CDPH. The facility's policy and procedure titled 'Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating' dated 4/2021, mandates that all reports of abuse, neglect, exploitation, or injuries of unknown origin must be reported to local, state, and federal agencies immediately. The DON confirmed that the fracture was considered an injury of unknown origin and should have been reported to CDPH promptly to ensure the incident was investigated and the resident's safety was maintained. The failure to report the injury in a timely manner led to a delay in the investigation by CDPH, which is a violation of the facility's policy and state regulations.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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