Stillwater Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in El Cajon, California.
- Location
- 510 E. Washington Avenue, El Cajon, California 92020
- CMS Provider Number
- 555076
- Inspections on file
- 67
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Stillwater Post-acute during CMS and state inspections, most recent first.
A resident with Parkinson’s disease and an anxiety disorder, known by staff to tightly hold and rub her hands when upset, was observed by nursing staff with a quarter-sized purplish discoloration on the top of her hand after she complained about a CNA. Interviews with an LN, the ADON, and the DON confirmed that this hand-squeezing and rubbing behavior was recognized but not documented or incorporated into a comprehensive, person-centered care plan, despite facility policy requiring the IDT to develop such plans to address residents’ physical, mental, and psychosocial needs.
Several residents did not receive care in accordance with their needs due to failures in care planning and implementation. One resident with diabetes had repeated high blood sugar readings without physician notification or documentation. Another resident using a palm guard splint lacked a care plan and staff awareness regarding its use. A resident at risk for aspiration was left unsupervised during meals, leading to a choking incident, and another resident did not receive scheduled podiatry care, resulting in neglected foot conditions.
The facility did not maintain adequate nursing staff, especially on weekends and nights, leading to long waits for assistance, delayed incontinence care, late meal delivery, and falls due to lack of help. Multiple residents and CNAs reported that staff shortages resulted in unmet care needs, with registry staff sometimes unavailable or late, and the DON confirmed that these shortages led to increased complaints and delays in care.
Surveyors found that the facility did not ensure meals were palatable, attractive, or served at appropriate temperatures, with residents reporting dissatisfaction due to lack of variety, poor seasoning, and cold or unappetizing food. Staff failed to follow standardized recipes for both regular and pureed meals, and did not consistently consider residents' food preferences, leading to concerns about meal quality and nutritional value.
Frozen biscuits, hash browns, and chicken breast were found in unsealed, unlabeled, and undated bags in the kitchen freezer, contrary to facility policy. Additionally, a food services worker wore a beard restraint that did not fully cover his beard and mustache during tray line service, exposing food to potential contamination.
A resident who was bedbound, dependent for toileting, and cognitively intact was instructed by night staff to have a bowel movement in her brief instead of being offered a bedpan, despite her requests and facility policy requiring staff to promote dignity and respond promptly to toileting needs. Interviews with staff and review of facility policy confirmed that alert residents should be offered a bedpan to maintain dignity.
A resident with heart failure and an absent right ankle was left lying on his bed in only a disposable brief and without linens after a shower, resulting in him feeling cold. The resident requested a blanket from a CNA, who was delayed in providing it for over an hour due to being busy, contrary to facility policy requiring a comfortable and homelike environment.
A resident with a diagnosis of bipolar disorder was not accurately screened for mental health needs, as the PASRR Level 1 screening failed to trigger a required Level 2 evaluation and a follow-up screening was not completed within the specified timeframe. Both the MDSN and DON confirmed the screening was inaccurate and did not follow facility policy.
A resident with a history of depression and severe cognitive impairment was admitted and did not receive an initial activities care plan within the required 48 hours. The resident, who was non-verbal and withdrawn, was not evaluated by the activities staff until several days after admission, resulting in a lack of engagement in activities. Staff interviews confirmed the delay and acknowledged that the resident's immediate psychosocial needs were not addressed as per facility policy.
A resident with a history of stroke and metabolic encephalopathy was admitted and placed on a medication regimen, but the facility did not create a comprehensive care plan for antibiotic monitoring. Both the DON and IP confirmed that the care plan lacked specificity regarding the medication, contrary to facility policy requiring individualized, person-centered care plans.
A resident with dementia and a history of failure to thrive did not receive individualized therapeutic or social activities as outlined in their care plan, with documentation and staff interviews confirming inconsistent provision of required one-on-one activities. The resident was frequently observed alone in bed, and facility policy for regular review of activity participation was not followed.
A resident with diabetes, neuropathy, and peripheral vascular disease did not receive podiatry care as ordered, resulting in long, thick toenails and untreated fungal foot conditions. Staff interviews revealed that CNAs reported foot issues to nurses, but the resident was not placed on the podiatry schedule due to a lack of communication and awareness of the physician's order.
A resident with left-sided paralysis and contractures was provided a palm guard splint without a physician order, individualized care plan, or proper documentation. Staff were unaware of care requirements, and the device was applied and monitored inconsistently, contrary to facility policy and professional standards.
A resident with Parkinson's Disease, dysphagia, and a history of stroke was left unsupervised during a meal despite being identified as at risk for aspiration. The resident experienced a choking episode while eating breakfast alone, after a CNA failed to follow instructions to supervise. Facility records and staff interviews confirmed the need for supervision, but the requirement was not communicated or followed, leading to the incident.
Two residents with orders for tube feeding did not receive nutrition as prescribed: one resident's feeding was not started on time, and another's feeding was administered at a lower rate than ordered. Licensed nurses and the DON confirmed these deviations from physician orders, which were not in line with facility policy on enteral nutrition.
A resident with ALS had a peripheral IV in place for a week without a label or documented monitoring or scheduled changes. The IV was observed to be unlabeled, and the nurse confirmed it needed to be changed. There were no orders for IV monitoring or changes, and facility policy lacked guidance on labeling or frequency of IV changes.
Three residents experienced medication administration and documentation failures, including a medication left at bedside for self-administration without an order, improper administration of an inhaled steroid without following manufacturer instructions, and missing documentation for controlled medication doses. Nursing staff and the DON confirmed that these actions did not follow professional standards or facility protocols.
A resident with a history of metabolic encephalopathy was prescribed Rifaximin, but the facility did not conduct monthly medication regimen reviews for several months. The ICPN did not track or monitor the antibiotic use since it was not for an active infection, and there was no documentation of side effect monitoring or assessment of continued need. The DON confirmed that all antibiotics should be reviewed monthly, but this was not done, resulting in a failure to ensure the resident’s drug regimen was free from unnecessary drugs.
Two residents had medications that were not properly labeled or securely stored. One resident's IV antibiotic was labeled with handwritten tape instead of a pharmacy label, and another resident kept hydrocortisone gel sachets at the bedside without a self-administration order. Both the DON and nursing staff confirmed these practices were not in line with facility policy.
A resident with a history of metabolic encephalopathy was prescribed long-term Rifaximin, but the facility failed to conduct monthly medication regimen reviews or monitor for side effects as required by its antibiotic stewardship policy. The Infection Control Prevention Nurse did not track the resident's antibiotic use because it was not for an infection, and the Director of Nursing confirmed that all antibiotics should have been reviewed and tracked for appropriateness.
The facility did not ensure that call lights were working in three rooms, resulting in residents being unable to reliably signal for help from their bedrooms and restrooms. Observations showed that when call lights were activated, the visual indicators above the doors did not illuminate, and staff did not always check restrooms when the lights were on. Maintenance did not routinely check bathroom call lights, and issues were not promptly reported or addressed, contrary to facility policy.
Licensed nurses did not assess a resident with COPD and CHF before transferring the resident to a hospital at the request of the responsible party. Despite facility policy requiring assessment and physician notification for changes in condition or status, no assessment or documentation was completed prior to the transfer. The resident was later diagnosed at the hospital with pneumonia and acute respiratory failure.
A resident with schizophrenia eloped from a facility without staff knowledge. Initially placed in a secured unit due to a history of elopement, the resident was later moved to a non-secured unit as he showed no exit-seeking behavior. On the day of the incident, staff did not notice the resident's absence until hours later, despite routine checks being part of facility policy. The resident was assessed as low risk for elopement, which may have contributed to the lack of preventive measures.
The facility failed to maintain a safe hallway floor, with holes and cracks observed leading to station 3. During the survey, two residents were using walkers, one was wheeling himself, and another was in a wheelchair pushed by staff. The Maintenance Director acknowledged the issue and planned to order temporary flooring for safety. The DON confirmed the need for safe flooring. The facility's policy did not address indoor floor maintenance.
A resident with end-stage renal disease experienced a fall before a dialysis session, but the incident was not documented on the dialysis communication form, leaving the dialysis staff unaware of the fall. Facility staff interviews confirmed the importance of documenting such incidents for continuity of care, as per facility policy.
A resident with a colostomy and on bladder training experienced no urine output for over 24 hours and no bowel movement for several days. Facility staff failed to document these outputs consistently and did not notify the attending physician as required by policy, potentially risking the resident's health.
A resident with paraplegia and osteoarthritis experienced a fall due to the facility's failure to follow a physician's order for side rails, which were intended to aid in bed mobility. The order was issued months before the fall, but the side rails were only installed afterward. Staff acknowledged the oversight, which was contrary to the facility's care plan policy.
The facility failed to ensure kitchen staff competently performed food and nutrition services. Two Diet Aides did not correctly test the sanitizer in the dish machine, and one Diet Aide could not properly calibrate a food thermometer. The Dietary Department Kitchen Staff In-Services Binder lacked training on these procedures, leading to potential food contamination risks.
The facility failed to ensure food safety and sanitation methods in the kitchen were followed according to standards of practice and facility policy. The ice machine had debris and was not cleaned properly, the ice machine did not have an appropriate air gap, and expired food items were found in storage. Additionally, the facility failed to maintain proper temperature monitoring in refrigerators and did not ensure that food-contact surfaces and utensils were properly cleaned and sanitized.
The facility failed to ensure call lights were within reach for 11 residents and did not provide a bariatric bed as ordered for a resident with morbid obesity. Observations revealed call lights on the floor or wrapped around bed rails, making them inaccessible. Staff interviews confirmed the importance of call light accessibility and following physician orders, but these were not adhered to, leading to the noted deficiencies.
The facility failed to develop and implement individualized care plans for residents with PTSD, nail care needs, and smoking risks. Staff were unaware of PTSD triggers, nail care was neglected, and a smoking risk plan was not followed, leading to inconsistent and inadequate care.
The facility failed to provide timely incontinence and nail care for four residents, leading to deficiencies in their ADLs. Residents with paraplegia, stroke, severe cognitive impairment, and Alzheimer's Disease were found with wet sheets, blankets, and long fingernails, indicating a lack of proper care. Staff interviews confirmed that procedures were not followed, and the facility's policy on ADLs was not adhered to.
The facility failed to administer oxygen and CPAP therapy as ordered for two residents, leading to potential hindrance in their recovery. One resident received oxygen during the day against orders, and another received an incorrect oxygen rate and inconsistent CPAP use. Additionally, a third resident's BIPAP machine had an empty humidifier chamber, causing discomfort.
The facility failed to provide trauma-informed care for three residents with PTSD. Care plans lacked specific triggers and interventions, and staff were unaware of how to handle episodes of acting out from triggers. The DON and SSD acknowledged the importance of knowing triggers but did not implement this in practice.
The facility failed to follow the approved menus by the RD, as the Week 4 Spring Menu did not list a soup for any meal, despite soup being served. The RDS confirmed that soups are made daily and served to nearly twenty residents, but they were not listed on the printed menu, leading to a deficiency in meeting the nutritional needs of the residents.
The facility failed to ensure food was served at an acceptable temperature and palatability. Observations revealed that pureed meals had different tastes and textures compared to regular meals, and the facility's thermometer was not calibrated correctly. Residents reported that food often tasted bad and was served cold. Additionally, kitchen staff did not follow approved recipes accurately, contributing to the deficiencies observed.
The facility failed to demonstrate proper infection control practices, including improper storage of a CPAP mouthpiece, undated oxygen humidifiers, a urinary catheter bag in contact with the floor, and inadequate cleaning of a BIPAP machine. Interviews with staff confirmed these practices were against the facility's policies and could lead to infections.
The facility failed to report an injury of unknown origin for a resident with severe cognitive impairment, delaying the investigation and placing the resident at risk for further injury. Despite visible bruises and the resident's inability to provide details, the incident was not promptly reported to CDPH as required by the facility's policy.
The facility failed to follow up on a resident's broken eyeglasses, despite a referral being made for repair. The resident, diagnosed with ectropion, was observed using eyeglasses held together with scotch tape. Staff responsible for the resident did not report the issue to social services, and no follow-up was documented.
The facility failed to ensure resident safety by not addressing a hazardous condition in a resident's room and not completing a safe smoking assessment for another resident. Staff did not document or promptly repair peeling paint and exposed drywall in one room, and did not ensure the use of a required smoking apron for a resident with nicotine dependence.
A resident with significant weight loss did not consistently receive prescribed Glucerna supplements, leading to continued weight loss. Despite recommendations and orders, the supplement was often missing from meal trays, and the resident's weight was not effectively monitored. The facility's RD and DON were unaware of the inconsistency, and the facility's weight change protocol was not followed.
The facility failed to manage a resident's pain before dressing changes, despite the resident's chronic pain syndrome and complaints of pain. Staff acknowledged the oversight, and the resident's care plan did not include pre-procedure pain medication, contrary to the facility's pain management policy.
The facility failed to complete pre-dialysis assessments for a resident with end-stage renal disease, leading to potential undetected complications. Despite policies requiring the completion of dialysis communication forms, multiple forms were found incomplete over several months.
The facility failed to honor a resident's vegetarian diet preference, leading to the resident frequently ordering food from outside vendors and consuming only portions of the meals provided. Staff interviews revealed a lack of awareness and understanding of the resident's dietary needs, and the facility's policy on dietary preferences was not effectively implemented.
The facility failed to ensure accurate clinical record documentation for a resident with prostate cancer and an indwelling urinary catheter. Observations and interviews revealed missing entries in the treatment administration record (TAR) for catheter care and monitoring on multiple dates. The director of nurses confirmed that the TAR should reflect the care provided.
The facility failed to follow proper infection control practices, including not elevating medical supplies above the floor, storing water-damaged supplies, and an employee entering an isolation room without appropriate PPE. These actions placed residents at risk for infections.
Failure to Develop Person-Centered Care Plan for Resident Hand-Rubbing Behavior
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop a comprehensive, person-centered care plan addressing a resident’s known behavior of tightly holding and rubbing her hands when upset. The resident was admitted with Parkinson’s disease and an anxiety disorder, and staff interviews revealed that she had a tendency to tightly hold and rub her hands when distressed or when spoken to. The DON demonstrated this behavior and acknowledged that there was no documentation or care plan reflecting it. The facility’s own policy on comprehensive, person-centered care plans requires the IDT, in conjunction with the resident and/or representative, to develop a care plan that describes services to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being. The deficiency came to light after the resident complained about a CNA and was observed with a quarter-sized, dark purplish discoloration on the top of her right hand between the forefinger and thumb. LN 1 and the ADON both observed this discoloration and confirmed the resident had reported the issue to the ADON. Despite these observations and the known behavior of the resident squeezing and rubbing her hands when upset, there was no corresponding care plan or documentation to guide staff in monitoring or managing this behavior. In a subsequent interview, the DON stated there should have been a care plan regarding the resident squeezing her hand when upset or when spoken to and that it was important to have a care plan to observe and monitor the resident, confirming that the required person-centered care planning had not been completed for this need.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Four residents experienced deficiencies in care planning and implementation. For one resident with Type 2 Diabetes Mellitus, multiple blood sugar readings above 350 mg/dl were recorded over several days, but there was no documentation that the physician was notified as required by the facility's policy. Licensed nurses admitted to not always documenting physician notifications, and the Director of Nursing confirmed that if notification was not documented, it was considered not to have occurred. Another resident with a history of hemiplegia and contractures was using a palm guard splint on the left hand. Staff, including CNAs and licensed nurses, were unaware of the care requirements for the splint, and there was no care plan in place for its use or monitoring. The care plan was only updated after the issue was identified, and staff interviews revealed that the splint had been used for months without proper orders or documentation, potentially leading to improper care. A third resident with Parkinson's Disease, dysphagia, and a history of stroke required supervision during meals due to aspiration risk. Observations showed the resident eating alone and experiencing choking episodes without staff present. Although staff recognized the need for supervision, there was no care plan addressing aspiration precautions or meal supervision. Additionally, a fourth resident with peripheral vascular disease and diabetes had a care plan for podiatry care that was not followed, as the resident had not received podiatry services as scheduled, resulting in long, thick toenails and dry, cracked feet.
Failure to Provide Adequate Nursing Staff Results in Delayed and Missed Resident Care
Penalty
Summary
The facility failed to provide the minimum required nursing staff to meet the needs of all 248 residents, resulting in unmet care needs and delays in assistance. Payroll Based Journal records indicated excessively low weekend staffing, particularly during holidays and the months of January and February, with frequent staff call-offs due to sickness. Surveyor observations and resident interviews revealed long waits for assistance, delayed incontinence care, and late meal delivery. Residents reported waiting hours to be changed, experiencing pain management delays, and not having call lights answered for extended periods. Some residents described falling due to lack of staff assistance, including one who required two-person assistance for transfers and another who was not changed all night. Staff interviews confirmed that shortages were more pronounced on weekends and night shifts, with CNAs reporting increased workloads and reliance on registry staff, who were sometimes late or absent. The Staffing Coordinator and DON acknowledged that short-staffing led to increased resident complaints and delays in care. Facility policy required staffing levels to be based on resident needs, but the observed and reported staffing levels were insufficient to meet those needs, directly impacting resident care and well-being.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that food and drink served to residents was palatable, attractive, and maintained at a safe and appetizing temperature. Multiple residents expressed dissatisfaction with the meals, citing issues such as lack of variety, poor seasoning, repeated menu items, and food being served cold or in unappetizing forms. During a Resident Council meeting, all participants voiced complaints about the food, including concerns about cold breakfasts, mushy and overcooked vegetables, lack of menu adherence, and insufficient snack and dessert options. Observations of meal service confirmed that some food items were bland, lacked flavor, or were not visually appealing, particularly the pureed options. Further investigation revealed that staff did not consistently follow standardized recipes for meal preparation. For the pureed garden meatloaf, staff cooked ingredients in a tilt skillet rather than baking as directed by the recipe, and for the regular garden meatloaf, breadcrumbs were added without measuring, and the recipe book was not consulted during preparation. Staff members declined to confirm whether recipes were being followed when questioned. These deviations from established recipes compromised the nutritional value and consistency of the meals served. Facility policies required adherence to residents' food preferences and the use of approved, standardized recipes to ensure meal quality and nutritional adequacy. However, the observed practices did not align with these policies, as residents' preferences were not consistently considered, and recipes were not properly followed. These failures had the potential to decrease residents' meal intake and contribute to weight loss, as noted by the surveyors.
Improper Food Storage and Incomplete Beard Restraint Use in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage and staff hygiene practices in the kitchen. During an observation of the walk-in freezer, frozen biscuits, hash brown potatoes, and chicken breast were found in unsealed, unlabeled, and undated plastic bags. The Registered Dietician confirmed that these practices were unacceptable and acknowledged that food in the freezer should be sealed, labeled, and dated to maintain food quality and prevent contamination. Facility policy also required frozen foods to be stored in airtight, moisture-resistant wrappers and to be labeled and dated. Additionally, during a tray line service observation, a food services worker was seen wearing a beard restraint that did not fully cover his beard and mustache while preparing to plate food. The beard restraint only covered his chin, leaving the upper beard and mustache exposed. The Dietary Supervisor and Registered Dietician both stated that all facial hair should be completely covered to prevent contamination of food, in accordance with facility policy. These lapses in food storage and staff hygiene had the potential to compromise food safety.
Failure to Offer Bedpan Compromises Resident Dignity
Penalty
Summary
Staff failed to maintain the dignity of a resident who was bedbound and dependent for self-care and toileting hygiene, but cognitively intact. The resident reported being constipated and stated that night staff instructed her to have a bowel movement in her brief, rather than offering a bedpan. The resident indicated that she was not offered a bedpan by night staff, despite her alertness and ability to communicate her needs. Subsequent interviews with the resident confirmed that this practice continued, with night shift staff not providing a bedpan and instead asking her to use her brief. Interviews with a CNA, a licensed nurse, the charge nurse, and the DON all confirmed that the expectation for alert residents who cannot use the commode or bathroom is to be offered a bedpan to maintain dignity and allow for resident choice. Facility policies reviewed also emphasized the importance of promoting dignity, promptly responding to toileting requests, and prohibiting demeaning practices. The failure to offer a bedpan as requested compromised the resident's dignity and did not align with facility policy or staff expectations.
Resident Left Uncovered and Cold After Shower
Penalty
Summary
A deficiency occurred when a resident, admitted with heart failure and an absent right ankle, was left uncovered after a shower. The resident was observed lying on his bed wearing only a disposable brief and without any linens, and reported feeling cold. The resident stated that after being returned to his bed by a CNA following a shower, he requested a blanket, but the CNA said she would return with one and did not do so for over an hour. The CNA later confirmed she was delayed in bringing the blanket due to being busy. The Director of Nursing acknowledged that blankets should have been ready for the resident upon return from the shower, in accordance with the facility's policy to provide a safe, clean, and comfortable environment, including clean bed and bath linens and comfortable temperatures.
Failure to Complete Accurate PASRR Mental Health Screening
Penalty
Summary
The facility failed to accurately complete a mental health screening for one resident who was admitted with a diagnosis of bipolar disorder. According to the admission record, the resident's Preadmission Screening and Resident Review (PASRR) Level 1 screening was completed and indicated a negative result, not triggering a Level 2 mental health evaluation, despite the presence of a qualifying mental health diagnosis. The PASRR documentation also instructed the facility to resubmit a new Level 1 screening within 31 days, which was not done. Interviews with the Minimum Data Set Nurse (MDSN) and the Director of Nursing (DON) confirmed that the PASRR was inaccurate and should have led to a Level 2 evaluation, and that a new screening should have been completed within the required timeframe. The facility's policy also states that individuals meeting certain criteria should be referred for a Level 2 PASRR evaluation, which did not occur in this case.
Failure to Initiate Timely Activities Care Plan for New Admission
Penalty
Summary
The facility failed to initiate an initial activities care plan within 48 hours for a newly admitted resident with a history of depression and severe cognitive deficits. The resident was admitted with significant communication challenges, being non-verbal and only oriented to person, and was observed to be withdrawn, frowning, and teary-eyed during multiple visits. Staff interviews revealed that the activities care plan was not started until three days after admission, despite facility policy requiring a baseline care plan within 48 hours. The Activities Assistant responsible for the care plan acknowledged the delay and stated that the resident was not evaluated until after the required timeframe, resulting in the resident remaining in bed without engagement in activities. Further interviews with the Activities Director and DON confirmed that the baseline care plan should have included communication and activity preferences to support the resident's psychosocial well-being. The Activities Director noted that if the resident was unable to verbalize preferences, the team should have communicated with the family to update the care plan accordingly. The delay in initiating the activities care plan meant that the resident's immediate needs for engagement and emotional support were not met as required by facility policy.
Failure to Develop Comprehensive Care Plan for Medication Monitoring
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident following a comprehensive assessment, specifically omitting a care plan for antibiotic monitoring. The resident in question was admitted with a history of stroke and metabolic encephalopathy and had been on a specific medication since admission. During interviews and record reviews, both the DON and Infection Preventionist acknowledged that the care plan was not specific to the resident's medication and that such a plan should have been in place. The facility's own policy requires comprehensive, person-centered care plans to prevent or reduce decline in residents' functional status, but this was not followed for the resident's antibiotic monitoring.
Failure to Provide Individualized Activities per Care Plan
Penalty
Summary
The facility failed to provide individualized therapeutic and/or social activities according to the plan of care for one of seven reviewed residents. The resident, who had a history of adult failure to thrive and dementia, was observed multiple times over several days resting in bed, nonverbal, and staring blankly at the ceiling. Record reviews showed that the resident's care plan required one-on-one room visit activities three times per week to reduce behavioral and psychological symptoms of dementia. However, documentation revealed that these activities were not consistently provided, with several weeks showing only one or two activities, and some periods with no activities at all. Interviews with the Activities Director and the DON confirmed that the resident was not receiving the planned frequency of activities, particularly when the Activities Director was unavailable. The Activities Director acknowledged the lapse in activity provision and noted the resident's previous enjoyment of music and other activities. The DON stated that dependent residents should have regular activity visits per their care plan. Facility policy required regular review of activity participation records, but this was not followed, resulting in the resident not receiving activities as planned.
Failure to Provide Physician-Ordered Foot Care
Penalty
Summary
A resident with diagnoses including peripheral vascular disease, neuropathy, and diabetes mellitus was not provided with foot care and treatment as ordered by the physician. The resident had a physician's order for podiatry visits every two months and as needed for fungal and hypertrophic nails, corns, and calluses. Despite this, the resident reported having long, thick toenails and a fungal condition, and had not seen the podiatrist for several months. Observation confirmed the resident had long, thick toenails and dry, cracked feet. The last documented podiatry visit was several months prior to the observation. Interviews with CNAs revealed that they were not permitted to cut or file toenails and were instructed to report long toenails to a nurse. The Assistant Director of Nursing confirmed that the process required the nurse to notify the social worker to add the resident to the podiatry list. However, the social worker was unaware of the resident's specific order for podiatry every two months and had not included the resident on the rolling schedule for podiatry visits. The facility's policy required referral to qualified professionals for residents with foot disorders or related medical conditions, but this was not followed for the resident in question.
Failure to Evaluate and Manage Palm Guard Splint Use per Professional Standards
Penalty
Summary
A resident with a history of left-sided hemiplegia and hemiparesis following a cerebral infarction was observed wearing a palm guard splint on the left hand. The resident reported being unable to move the left hand and stated that the splint was worn continuously for extended periods, with no set schedule for removal. Certified Nursing Assistants and nursing staff were unaware of the specific care required for the palm guard splint, including when it should be removed or how to monitor for potential complications. Record review and staff interviews revealed that there was no physician order in place for the use of the palm guard splint, and the device was applied by a Restorative Nurse Assistant without proper authorization. Documentation regarding the application, removal, and monitoring of the splint was lacking, and there was no individualized care plan addressing the use and care of the device. Multiple staff members, including licensed nurses and the Assistant Director of Nursing, confirmed the absence of necessary orders and care planning, and acknowledged the importance of such measures for safe and effective use of the splint. The facility's policy required screening by the rehabilitation team and a physician order for devices other than simple hand rolls, as well as staff in-servicing and documentation in the care plan and daily notes. These procedures were not followed for the resident in question, resulting in a failure to evaluate and manage the use of the palm guard splint according to professional standards of practice.
Failure to Provide Required Mealtime Supervision Resulting in Choking Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a choking incident for a resident with significant risk factors, including Parkinson's Disease, dysphagia, and a history of stroke with left-sided weakness. The resident was identified as requiring supervision during meals due to aspiration risk, as evidenced by coughing with food and drinks and a tendency to inhale food and gulp liquids. Despite this, the resident was left unsupervised during breakfast, resulting in a choking episode where the resident was found coughing, with a red face, and unable to speak, requiring immediate intervention by nursing staff. Interviews and observations revealed that although the Assistant Director of Nursing (ADON) had instructed a Certified Nursing Assistant (CNA) to supervise the resident during breakfast, the CNA was unaware of the supervision requirement and did not remain with the resident. The facility's whiteboard indicated the need for supervision, and both the ADON and Director of Nursing (DON) confirmed the importance of following such instructions for residents at risk of aspiration. The facility's policies reviewed did not provide specific guidance on supervision to prevent aspiration or choking, contributing to the deficient practice.
Failure to Follow Tube Feeding Orders for Two Residents
Penalty
Summary
The facility failed to follow prescribed nutrition orders for two residents receiving tube feedings. For one resident with a history of protein calorie malnutrition and severe cognitive deficits, the tube feeding was not started at the ordered time. Observations showed that the tube feeding bag, which should have been replaced and restarted at 2 P.M., remained hung with formula from the previous day and was not turned on as ordered. Interviews with licensed nurses confirmed that the feeding was not administered according to the physician's orders, and the resident, who was NPO and dependent on tube feeding for nutrition, did not receive the required intake in a timely manner. For another resident diagnosed with malnutrition, dementia, and dysphagia, the tube feeding was observed to be running at a rate lower than the physician's order. The feeding was set at 50 ml/hr instead of the ordered 65 ml/hr. The responsible nurse acknowledged the error, and the Director of Nursing confirmed that staff should have ensured the feeding was administered at the correct rate. Both incidents were contrary to the facility's policy on enteral feeding safety precautions, which requires adherence to best practices in enteral nutrition.
Failure to Label and Change Peripheral IV Line According to Standards
Penalty
Summary
A deficiency occurred when a resident with Amyotrophic Lateral Sclerosis was found to have a peripheral intravenous (IV) line in place for one week without a label and without documentation of monitoring or scheduled changes. During an observation and interview, the IV in the resident's right hand was noted to be unlabeled, and the resident confirmed it had been in place for a week. The licensed nurse acknowledged that the IV should have been changed. Review of the medical record revealed no orders to monitor or change the IV prior to the observation, despite an order for IV gentamycin being present. The facility's policy did not specify requirements for labeling or changing IVs at a set frequency.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for three residents. One resident was prescribed pantoprazole to be administered before breakfast at 6:30 A.M., but the medication was left at the bedside, allowing the resident to self-administer it at the wrong time and without supervision. The resident did not have an order to self-administer medications, and the nurse on duty confirmed that the medication was not given as ordered. The Director of Nursing (DON) acknowledged that medications should not be left at the bedside and that staff are expected to remain with residents until medications are taken. Another resident was administered Advair Diskus, an inhaled steroid, without following the manufacturer's instructions. The nurse failed to instruct the resident to rinse and spit out water after inhalation, as required to prevent oral thrush. The DON confirmed that the manufacturer's instructions were not followed during administration and that this step is necessary to reduce the risk of developing a fungal infection in the mouth or throat. For a third resident, the facility could not account for two doses of a controlled medication, hydrocodone-APAP, which were removed from the locked supply but not documented on the medication administration record (MAR). The nurse and DON both stated that controlled medications must be signed out and documented when administered, but this was not done. Additionally, the DON reported that required weekly audits of controlled medications were not being conducted as per facility protocol.
Failure to Complete Monthly Medication Review for Antibiotic Use
Penalty
Summary
The facility failed to complete a monthly medication regimen review (MRR) for a resident who was receiving Rifaximin, an antibiotic prescribed for encephalopathy. The resident was admitted with a history of metabolic encephalopathy and had been on Rifaximin since the previous year. A review of the resident’s records showed that no MRR was conducted for the months of January through March, despite the ongoing use of the antibiotic. The Infection Control Prevention Nurse (ICPN) confirmed that the resident’s Rifaximin use was not tracked or reviewed as part of the antibiotic stewardship log, as the focus was only on residents with infections. The ICPN also acknowledged that there was no documentation of side effect monitoring or routine assessment of the medication’s appropriateness in the resident’s clinical chart. Further interviews revealed that the DON expected all antibiotics, both short-term and long-term, to be tracked and reviewed monthly for indication of use and inclusion in the care plan. The facility’s policy required thorough MRRs to prevent, identify, and resolve medication-related problems, but this was not followed for the resident in question. The lack of monthly review and monitoring for the continued use of Rifaximin resulted in a failure to ensure the resident’s drug regimen was free from unnecessary drugs, as required by facility policy and federal regulations.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that medications were properly labeled and stored for two residents. For one resident with cellulitis, an intravenous antibiotic (vancomycin) was found at the bedside with an incorrect label consisting of handwritten tape, rather than a pharmacy-issued label. The Director of Nursing confirmed that the IV should have had a proper pharmacy label and not a handwritten one. This improper labeling was directly observed during a survey. For another resident, several sachets of hydrocortisone 1% external gel were found in a bowl at the bedside, despite the absence of a physician's order for self-administration. The resident confirmed using the medication for a rash, and both a licensed nurse and the Director of Nursing stated that the ointment should have been stored in a locked treatment cart, not at the bedside. Facility policy also required all medications to be stored securely in locked compartments, accessible only to authorized personnel.
Failure to Monitor Long-Term Antibiotic Use per Stewardship Policy
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship policy and procedures by not evaluating and monitoring the ongoing use of a long-term antibiotic for one of twenty sampled residents. Specifically, a resident with a history of metabolic encephalopathy was prescribed Rifaximin for encephalopathy, but there was no evidence of monthly medication regimen reviews (MRR) for this antibiotic from January to March. The Infection Control Prevention Nurse (ICPN) did not include this resident in the antibiotic tracking log, as the log was limited to residents with infections, despite the resident's ongoing use of an antibiotic. The ICPN acknowledged that routine monitoring for medication use and appropriateness should have been conducted monthly, and that there was no documentation of side effect monitoring or a stop date for the medication in the clinical chart. Interviews with the ICPN and the Director of Nursing (DON) confirmed that the expectation was for all antibiotics, both short-term and long-term, to be tracked and reviewed for indication of use, and to be included in the care plan. The DON stated that the ICPN should have followed up with the MRR and pharmacy recommendations regarding antibiotic appropriateness and continued use on a monthly basis. The facility's policy on antibiotic stewardship, revised in May 2001, indicated that the purpose of the program was to monitor the use of antibiotics in residents, which was not followed in this case.
Failure to Maintain Functional Call Light System in Resident Rooms and Restrooms
Penalty
Summary
The facility failed to ensure that call lights were functioning in three residents' rooms, specifically in both the bedrooms and restrooms. Multiple observations revealed that when the call lights were activated in these rooms, the visual indicators above the doors did not illuminate, making it impossible for staff in the hallway to know when assistance was needed. Interviews with residents and staff confirmed that residents experienced significant delays in receiving help, with one resident reporting waiting over an hour after activating the call light. Staff, including CNAs and the Assistant Director of Nursing, were observed not checking restrooms when call lights were activated, even when the restroom doors were closed, and the malfunctioning lights were not visible in the hallway. Further review showed that the maintenance director did not routinely check the functionality of bathroom call lights, only inspecting them if notified of an issue. The maintenance log used to check room temperature did not include checks for call light functionality, and the maintenance director was unaware of the malfunctioning call lights until informed by staff. The facility's policy required the call system to remain functional at all times, but this was not adhered to, as evidenced by the lack of regular checks and delayed reporting of issues by staff, including agency CNAs.
Failure to Assess Resident Prior to Hospital Transfer
Penalty
Summary
Licensed nurses failed to assess a resident prior to transferring the resident to a general acute care hospital (GACH) at the request of the resident's responsible party. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), was known to have respiratory issues and received breathing treatments. On the day in question, the responsible party requested that the resident be sent to the hospital, but the licensed nurses did not perform or document an assessment before the transfer. One nurse stated that since there was no doctor's order and the resident did not appear to be in distress, no documentation was made. The Director of Nursing confirmed that the nurses did not assess the resident as required by facility policy when a change in condition or transfer is requested. The facility's policy requires prompt assessment and notification of the attending physician and responsible party when there is a significant change in a resident's condition or status. In this case, the lack of assessment prior to transfer meant that the resident's clinical status was not evaluated or documented before being sent to the hospital, despite the resident later being diagnosed at the hospital with pneumonia and acute respiratory failure with hypoxia. This omission was identified during a complaint investigation and confirmed through interviews and record review.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident diagnosed with schizophrenia, who eloped from the facility without staff knowledge. The resident, who had a history of leaving a previous facility, was initially placed in a secured unit but later moved to a non-secured unit as he had not exhibited exit-seeking behavior. Despite this, the resident successfully left the facility on 1/28/25 and was not found as of 1/30/25. The staff did not know the resident's exit point or current whereabouts. Interviews with facility staff revealed that the resident was ambulatory, independent, and known to socialize with other residents across different stations. On the day of the elopement, the resident was not seen in his room during meal and medication passes, and staff did not find his absence unusual due to his social habits. The resident did not have a wander guard, as he was assessed as low risk for elopement, and staff did not observe any exit-seeking behavior. The facility's policy on routine resident checks, revised in July 2013, mandates regular checks to maintain resident safety and well-being. However, the staff failed to notice the resident's absence until several hours later, prompting a missing person alert. The facility's interdisciplinary notes and elopement assessments showed a change in the resident's risk status over time, from high risk to low risk, which may have contributed to the lack of preventive measures in place at the time of the incident.
Unsafe Hallway Flooring Poses Risk
Penalty
Summary
The facility failed to ensure the safety of the hallway floor, which posed a risk to residents, staff, and visitors. During an unannounced visit, surveyors observed holes and cracks in the hallway floor leading to station 3, from the kitchen to the nurses' station. At the time of observation, two residents were ambulating with walkers, one resident was wheeling himself, and another was in a wheelchair being pushed by a staff member. The Maintenance Director acknowledged the issue and mentioned plans to order and replace the flooring temporarily for safety. The Director of Nursing also confirmed that the flooring should be safe for everyone. The facility's policy on grounds maintenance did not specifically address maintaining the floor inside the building.
Failure to Document Resident Fall on Dialysis Communication Form
Penalty
Summary
The facility failed to document a witnessed fall of a resident on the dialysis communication form, which is used to inform the dialysis staff of any changes in the resident's condition prior to treatment. The resident, who was readmitted to the facility with end-stage renal disease, experienced a fall during a transfer from bed to wheelchair before a scheduled dialysis session. Although the fall was documented in the facility's SBAR-Fall note and the physician and responsible party were notified, this critical information was not communicated to the dialysis staff. Interviews with facility staff, including licensed nurses and the Director of Nursing, revealed that it is standard practice to document such incidents on the dialysis communication form to ensure continuity of care. The dialysis licensed nurse confirmed that the form for the date in question lacked any mention of the fall, which could have left the dialysis staff unaware of potential injuries or complications. The facility's policy on the care of residents with end-stage renal disease emphasizes the importance of exchanging information between the facility and the dialysis center, highlighting a lapse in protocol adherence.
Failure to Monitor and Document Bowel and Urine Output
Penalty
Summary
The facility staff failed to properly monitor and document the bowel and urine output of a resident who had a colostomy and was on bladder training. The resident, who had an intact cognition and was admitted with diagnoses including stroke, pressure ulcer, and rectal cancer, experienced no urine output for more than 24 hours and no bowel movement from the colostomy bag for several days. Despite the facility's policy requiring notification of the attending physician when there is no urine output for eight hours or no bowel movement for 2-3 days, the staff did not assess the resident or notify the physician, leading to a potential risk of urinary tract infection and other complications. The documentation of the resident's bowel movements and urine output was inconsistent and incomplete. Certified Nursing Assistants (CNAs) failed to document the resident's bowel movements and urine output accurately, with several shifts showing no documentation or incorrect entries. The Director of Nursing acknowledged the lack of proper documentation and the failure to follow the facility's policy for monitoring and managing urinary and bowel output. This oversight in care and documentation had the potential to result in serious health issues for the resident.
Failure to Implement Physician-Ordered Side Rails
Penalty
Summary
The facility failed to implement a comprehensive resident-centered care plan by not following a physician's order to install side rails on a resident's bed. The resident, who was admitted with paraplegia and osteoarthritis of the hip, experienced a fall on 6/14/24. The interdisciplinary team recommended side rails as an intervention to promote mobility after the fall. However, the physician had already ordered the installation of half side rails on both sides of the bed on 2/24/24, which was not executed by the facility. During interviews and record reviews, it was confirmed that the side rails were only installed after the resident's fall, despite the existing physician's order. The licensed nurse and the assistant director of nursing acknowledged that the side rails should have been installed when initially ordered. The facility's policy on comprehensive person-centered care plans, revised in March 2022, was not adhered to, as the care plan was not developed and implemented in accordance with the physician's directive.
Deficiencies in Kitchen Staff Competency
Penalty
Summary
The facility failed to ensure the kitchen staff competently performed and carried out the functions of the food and nutrition services department. Two Diet Aides (DAs) did not correctly test the sanitizer in the low-temperature dish machine. DA 1 incorrectly identified the sanitizer level as 100 ppm when it was actually dark gray, and DA 5 provided incorrect information about the minimum wash temperature and sanitizer levels. The dish machine manufacturer's data plate indicated the minimum wash temperature was 120 degrees F, and the minimum chlorine sanitizer level was 50 ppm, with a range of 50-100 ppm. The facility's policy and procedure for dishwashing also specified these requirements, but the staff failed to adhere to them. Additionally, the Dietary Department Kitchen Staff In-Services Binder did not have in-services reviewing proper thermometer calibration or dish machine sanitizer testing for kitchen staff from May 2023 to April 2024. Another deficiency was observed when DA 4 could not properly calibrate a food thermometer. During an observation, DA 4 used a thermometer to take the temperature of roasted turkey, which indicated 120 degrees F, while the surveyor's thermometer showed 164 degrees F. DA 4 admitted to not calibrating the thermometer and demonstrated a lack of knowledge on how to do so correctly. The facility's policy on thermometer use and calibration required food thermometers to be calibrated each week, but DA 4 failed to follow this procedure. The Registered Dietitian Supervisor (RDS) acknowledged that the kitchen staff should know how to correctly test the dish machine sanitizer level and calibrate thermometers, indicating a lapse in staff training and competency in these critical areas.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure food safety and sanitation methods in the kitchen were followed according to standards of practice and facility policy. The ice machine had dark black and dark gray debris around the chute opening and inside the ice-making evaporator, and was not cleaned according to the manufacturer's guidelines. The ice machine did not have an appropriate air gap, as the pvc piping extended from the machine into a floor drain, which is against regulations. Additionally, two bags of hoagie rolls were found to be outdated and expired in the dry food storage room, and several other food items were not labeled with an opened date or use-by date as required by facility policy. The facility also failed to maintain proper temperature monitoring in the walk-in and reach-in refrigerators. The internal thermometer in the walk-in refrigerator was not working properly, making it difficult to determine the temperature. The thermometer in the reach-in refrigerator read 58 degrees Fahrenheit, while the temperature of the milk inside the refrigerator was 48 degrees Fahrenheit, indicating that the refrigerator was not maintaining the required temperature of 41 degrees Fahrenheit or lower. Furthermore, the facility did not ensure that food-contact surfaces and utensils were properly cleaned and sanitized. Four food scoopers were found with brown, crusted debris, and 12 scoopers were found with water in them. Seven sharp butcher cutting knives were found with greasy grime and food particles crusted on them. These deficiencies had the potential to expose residents to contaminants that could cause foodborne illness.
Failure to Ensure Call Lights Within Reach and Provide Bariatric Bed
Penalty
Summary
The facility failed to ensure that call lights were positioned within reach for 11 of 58 residents, which had the potential to endanger the health, safety, and recovery of the residents. Multiple observations were conducted over several days, revealing that call lights were consistently out of reach for residents, either lying on the floor or wrapped around bed rails. This was observed in residents with various diagnoses, including anxiety disorder, schizophrenia, dementia, stroke, and metabolic encephalopathy. The care plans for these residents specifically included interventions to keep call lights within reach, but these were not followed, as evidenced by the repeated observations of call lights being inaccessible. For instance, Resident 3, who was admitted with anxiety disorder and schizophrenia, was observed multiple times with the call light on the floor, out of sight and reach. Similarly, Resident 23, who had dementia, was found with the call light cord wrapped around the bed rail, making it inaccessible. Resident 33, who had suffered a stroke, could not locate his call light, which was found hanging behind the head of the bed. These observations were consistent across other residents, including those with severe cognitive impairments and those requiring maximum assistance for daily activities. Additionally, the facility failed to provide a bariatric bed as ordered by the physician for Resident 401, who was admitted with morbid obesity. Despite the physician's order for a bariatric mattress, the resident was observed with a regular mattress, which could have caused discomfort and a sense of confinement. Interviews with staff, including CNAs, LNs, and the DON, confirmed that the call lights should always be within reach and that physician orders should be followed. However, these expectations were not met, leading to the deficiencies noted in the report.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for residents with PTSD, nail care needs, and smoking risks. For three residents diagnosed with PTSD, the care plans did not include specific triggers or interventions to manage their condition. Observations and interviews revealed that staff were unaware of the residents' triggers and how to handle episodes, leading to inconsistent care. For example, one resident with severe cognitive impairment exhibited behaviors such as refusing care and hoarding items, but her care plan lacked details on her PTSD triggers and appropriate interventions. Another resident's care plan mentioned emotional distress as a trigger but did not specify what caused the distress or how to address it. Staff interviews confirmed the lack of detailed information in the care plans, which hindered their ability to provide consistent and effective care for these residents. The facility also failed to implement a care plan for a resident's nail care. An observation revealed that the resident had long fingernails with a dark brown substance underneath, and the resident stated that no one had offered to cut his nails. The resident's care plan indicated that assistance with grooming and trimming of fingernails was required, but this intervention was not carried out. The DON acknowledged the importance of implementing the care plan and assisting residents with nail care but admitted that it was not done in this case. Additionally, the facility did not implement a care plan related to smoking risk for a resident with Parkinson's disease, dementia, and nicotine dependence. The care plan required the resident to wear a non-flammable apron during smoking activities, but an observation showed that the resident was not wearing the apron while smoking. The activity director acknowledged that the resident should have been offered the apron before smoking, and the DON confirmed that the care plan was not implemented as required. This failure to follow the care plan put the resident at risk of injury from cigarette burns.
Failure to Provide Timely Incontinence and Nail Care
Penalty
Summary
The facility failed to provide timely incontinence care and nail care for four residents, leading to deficiencies in their activities of daily living (ADL). Resident 67, who has paraplegia and moderate cognitive impairment, was found lying in bed with a wet sheet and stated that he had been waiting for assistance to change his briefs. Similarly, Resident 86, who has a stroke and reduced mobility, was observed with a wet blanket and long fingernails, indicating a lack of timely incontinence and nail care. Both residents reported that their call lights were turned off without receiving the necessary care, and staff interviews confirmed that proper procedures were not followed when the assigned CNA was on a break. Resident 185, who has severe cognitive impairment and reduced mobility, was found with long fingernails and a dark brown substance underneath them. The resident stated that no one had offered to cut his fingernails, and staff interviews revealed that there was confusion about who was responsible for nail care. Similarly, Resident 167, who has Alzheimer's Disease, was observed with long fingernails and black debris under them. The resident expressed a desire to have his nails trimmed, but staff had not reported the need for nail care to the licensed nurse. The facility's policy on ADLs, which includes maintaining good nutrition, grooming, and personal hygiene, was not followed. Interviews with the Director of Nursing (DON) and other staff members confirmed that the residents' needs were not adequately addressed, leading to potential risks of skin breakdown and infection. The facility's failure to provide timely incontinence and nail care for these residents highlights significant deficiencies in their care practices.
Failure to Administer Oxygen and CPAP Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen and CPAP therapy as ordered by the physician for two residents, leading to potential hindrance or worsening of their recovery process. Resident 89, diagnosed with COPD, was observed receiving oxygen during the day despite the physician's order specifying oxygen only at night. The humidifier bottle attached to the oxygen condenser was also found empty. The clinical record and care plan indicated that oxygen should be administered only at night, and the resident's oxygen saturation levels were within acceptable limits without daytime oxygen. LN 33 confirmed that the physician's orders were not followed, which could lead to a build-up of carbon dioxide and increased dependency on oxygen for Resident 89. Resident 401, also diagnosed with COPD and sleep apnea, was observed receiving 5 liters of oxygen per minute, contrary to the physician's order of 2 liters per minute. Additionally, the CPAP machine, which was supposed to be applied every night, was not being used consistently due to a missing order on the Medication Administration Record (MAR). LN 33 acknowledged the oversight and stated that the CPAP order was not listed on the MAR, leading to staff being unaware of the requirement. The DON and DSD both emphasized the importance of following physician's orders to prevent respiratory distress and ensure proper sleep for Resident 401. Another resident, Resident 138, with a diagnosis of obstructive sleep apnea, was found using a BIPAP machine with an empty humidifier chamber. The resident expressed discomfort with the BIPAP machine, and LN 12 confirmed that the humidifier chamber should be filled with sterile water by the licensed nurses. The RT also stated that the humidifier chamber should not be empty to ensure moist air delivery. The facility's policy did not provide specific guidance on when to refill the humidifier chamber, leading to the observed deficiency.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility did not ensure residents with past traumas received trauma-informed care in accordance with professional standards of practice. This deficiency was observed in three residents who had diagnoses of PTSD. For Resident 10, there was no documented evidence of her PTSD event or triggers within the clinical record. The care plan for PTSD did not provide specific triggers or interventions, and staff were unaware of how to handle episodes of acting out from triggers. The DON acknowledged the lack of information and suggested that property should be listed as a possible trigger, but no concrete steps were taken to identify or document specific triggers for Resident 10. Resident 164's care plan indicated that the resident was triggered by emotional distress but did not specify what the triggers were or how to address them. The unit manager admitted to not delving into the resident's history due to its sensitive nature and stated that staff walked on eggshells around the resident. The CNA and LN interviewed were unaware of the specific triggers, and the social services director emphasized the importance of knowing the triggers to provide appropriate care. Resident 176's care plan also lacked specific information about PTSD triggers. The SSD acknowledged that the care plan should have been updated to include the resident's triggers, which were identified as flashes and noises. Staff members, including CNAs, were unaware of the resident's PTSD diagnosis and triggers. The DON stated that staff should know the residents' PTSD triggers to effectively care for them and prevent re-traumatization. The facility's policy on trauma-informed care emphasized the need to identify and decrease exposure to triggers, but this was not implemented in practice for the residents reviewed.
Failure to Follow Approved Menus
Penalty
Summary
The facility failed to ensure that the approved menus by the Registered Dietitian (RD) were followed as printed. Specifically, the Week 4 Spring Menu for April 22-28, 2024, did not list a soup for breakfast, lunch, or dinner, despite the presence of soup on the trayline during an observation on April 23, 2024. The Registered Dietitian Supervisor (RDS) confirmed that the cooks make a different soup every day using vegetables and add thickener and butter for residents on fortified diets. The RDS acknowledged that the regular soup was not on the printed menu but stated it should be listed as it was part of the daily nutritional analysis. This discrepancy between the printed menu and the actual food served had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the residents' nutritional status. During interviews, it was revealed that nearly twenty residents receive the regular or fortified soup, which was not listed on the printed menu. The facility's policy and procedure titled Menu Planning, dated 2020, indicated that menus are planned to meet the nutritional needs of residents in accordance with established national guidelines and are to be approved by the facility RD prior to the beginning of each quarterly menu cycle. The failure to follow the approved menus as printed was a clear deviation from the facility's established policies and procedures, leading to a deficiency in meeting the nutritional needs of the residents.
Failure to Ensure Food Quality and Safety
Penalty
Summary
The facility failed to ensure that food was served at an acceptable temperature and palatability according to the facility policy and the resident council. During observations and interviews, it was noted that the pureed meals were prepared using ground meat and thickener, which resulted in a different taste and texture compared to the regular meals. Additionally, the facility's thermometer was not calibrated correctly, leading to inaccurate temperature readings. Residents reported that the food often tasted bad and was served cold, requiring reheating by nursing staff. A test tray observation confirmed that the pureed BBQ ground beef was served at an incorrect temperature and had a grimy taste. Further observations revealed that kitchen staff did not follow approved recipes accurately. For example, the preparation of egg salad sandwiches was done by eyeballing ingredient amounts rather than measuring them as per the recipe. The sandwiches were then stored without ensuring they were cooled to the required temperature. The facility's policies on pureed food preparation and meal service were not adhered to, contributing to the deficiencies observed. The Resident Dietitian Specialist (RDS) acknowledged these issues and the importance of using calibrated thermometers and following recipes to ensure food quality and safety.
Infection Control Deficiencies
Penalty
Summary
The facility failed to demonstrate proper infection control practices in several instances. For Resident 401, the CPAP machine's mouthpiece was not stored properly. It was observed uncovered and resting in an open drawer with personal items and later on a bedside table exposed to the environment. Interviews with the Licensed Nurse (LN), Director of Staff Development (DSD), Infection Control Nurse (ICN), and Director of Nursing (DON) confirmed that the mouthpiece should have been stored in a clear plastic bag to prevent contamination and infection. The facility's policy did not provide guidance on the storage of the facemask, contributing to this deficiency. For Resident 187, the oxygen humidifier attached to the oxygen condenser was not dated when it was initiated. Observations over two days confirmed that the humidifier remained undated. Interviews with LN, DSD, ICN, and DON revealed that the humidifiers should be changed weekly and dated to prevent the growth of pathogens in the distilled water, which could lead to infections. The facility's policy on oxygen administration did not include guidance on infection prevention practices or the labeling and dating of oxygen equipment. Resident 216's urinary catheter bag was found lying on the floor, covered with a blue dignity bag. Interviews with the Certified Nursing Assistant (CNA), LN, ICN, and DON confirmed that the catheter bag should not be in contact with the floor to prevent cross-contamination and infection. The facility's policy on catheter care explicitly stated that catheter tubing and drainage bags should be kept off the floor. Additionally, for Resident 138, the BIPAP machine was not cleaned according to the facility's policy. The respiratory therapist (RT) confirmed that there was no documentation of the cleaning in the treatment administration record (TAR), and the DON emphasized the importance of cleaning the BIPAP machine to prevent bacterial infections. The facility's policy required daily cleaning of the mask, nasal pillows, and tubing, but did not provide guidance on storage.
Failure to 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) for Resident 220, which delayed the investigation and placed the resident at risk for further injury. Resident 220, who was readmitted to the facility with diagnoses including metabolic encephalopathy, violent behavior, and dementia, was observed with greenish-purple bruises on the face and neck. Despite the visible injuries and the resident's severe cognitive impairment, the facility did not promptly report the incident to CDPH as required by their policy. Interviews with staff and the resident's family member revealed that the facility assumed the bruises were from a fall, but no one witnessed the fall, and the resident was unable to provide details due to confusion. The facility's policy on abuse investigation and reporting, which mandates prompt reporting of injuries of unknown origin to local, state, and federal agencies, was not followed. The administrator and Director of Nursing (DON) acknowledged that the source of Resident 220's injury was still uncertain and that the injuries had not been reported to CDPH. This failure to implement the facility's abuse investigation and reporting policies resulted in a delayed investigation into the resident's injuries.
Failure to Follow Up on Broken Eyeglasses
Penalty
Summary
The facility failed to follow up on Resident 124's broken eyeglasses, which were observed to be held together with scotch tape. Despite a referral being made to repair the eyeglasses, no further follow-up was documented. Resident 124, who has a diagnosis of ectropion, was seen using the broken eyeglasses during lunch and while coloring in bed. Both LN 11 and CNA 11, who were responsible for Resident 124, did not report the broken eyeglasses to social services. The social service director confirmed that a referral had been made but acknowledged that there should have been a follow-up. A review of the facility's policies indicated that residents who have lost or damaged their visual devices should be assisted in obtaining replacements. However, the facility did not adhere to this policy, as evidenced by the lack of follow-up on the referral made for Resident 124's eyeglasses repair.
Failure to Address Room Hazards and Complete Safe Smoking Assessments
Penalty
Summary
The facility failed to ensure the safety of residents by not identifying and addressing potential hazards in resident rooms and not completing safe smoking assessments. In the case of Resident 221, who was admitted with dementia and required supervision for personal care, the staff did not address a hazardous condition in the resident's room. The room had peeling paint, exposed drywall, and a sharp plastic border strip, which posed a risk of injury or ingestion. Despite observations and acknowledgments from various staff members, including the Activities Director, Licensed Nurse, and Director of Maintenance, the hazard was not documented or promptly repaired as per the facility's policy on hazardous areas and equipment. For Resident 35, who had diagnoses including Parkinson's disease, dementia, schizophrenia, and nicotine dependence, the facility failed to complete a safe smoking assessment. The resident was observed smoking without a flame-retardant smoking apron, which was required by his care plan. Staff members, including the Activity Assistant and Activity Director, were aware of the resident's smoking habits and the need for a smoking apron but did not ensure its use. The Director of Nursing confirmed that the smoking apron should have been provided to protect the resident from burns. These deficiencies highlight the facility's failure to adhere to its policies on hazard identification and safe smoking practices, putting residents at risk of injury. The staff's inaction and lack of proper documentation and follow-up contributed to the unsafe conditions observed during the survey.
Failure to Provide Consistent Nutritional Supplements
Penalty
Summary
The facility failed to ensure the nutritional needs of a resident with significant weight loss were met. Resident 41, who had diagnoses including dysphagia, metabolic encephalopathy, and chronic kidney disease, experienced a 10.31% weight loss over six months. Despite a recommendation and order for Glucerna supplements three times a day, the resident did not consistently receive the supplement. Interviews with staff and the resident confirmed that the Glucerna was often missing from meal trays, and the resident expressed willingness to consume it if provided. The resident's weight history showed fluctuations and a notable decrease, indicating the supplement was not effectively administered as part of the care plan. The facility's registered dietitian (RD) and Director of Nursing (DON) were unaware of the inconsistency in providing the Glucerna supplement. The RD's assessments and recommendations were not effectively communicated or implemented, leading to the resident's continued weight loss. The facility's policy on weight change protocol was not followed, as the RD did not monitor and evaluate the success of the interventions. The DON stated that weight loss management was the RD's responsibility, but the RD did not communicate with the medical staff regarding the resident's significant weight changes. This lack of coordination and oversight contributed to the resident's unintentional weight loss and inadequate nutritional intake.
Failure to Provide Pain Management Before Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 155, who was admitted with chronic pain syndrome. Despite the resident's complaints of pain and the ineffectiveness of the current pain medication, the facility did not have any additional orders for pain medication. Observations and interviews revealed that the resident experienced significant pain during dressing changes on her feet, and no pain medication was administered prior to these procedures. The resident explicitly communicated the pain experienced during dressing changes, but this was not addressed by the staff. The unit manager and a licensed nurse both acknowledged that pain medication was not given before the dressing changes, despite recognizing it as a good idea. The resident's pain care plan did not include instructions to administer pain medication before dressing changes. The Director of Nursing confirmed the importance of managing pain prior to such procedures to prevent suffering. The facility's policy on pain assessment and management emphasized the need to identify and address pain, particularly during treatments like wound care, but this was not followed in Resident 155's case.
Incomplete Pre-Dialysis Assessments for Resident with ESRD
Penalty
Summary
The facility failed to ensure that assessments were completed before a resident's dialysis treatment, which was necessary to monitor for complications such as infection, bleeding, and abnormal vital signs. Resident 219, who had end-stage renal disease and attended dialysis treatments three times per week, was affected by this deficiency. During interviews and record reviews, it was found that the pre-dialysis communication forms for Resident 219 were incomplete on multiple occasions, including specific dates in February, March, and April 2024. Licensed nurses acknowledged the incomplete forms and could not provide a reason for the oversight. The Director of Nursing confirmed that it was the facility's policy to complete dialysis communication forms to inform the dialysis center of any changes in the resident's condition. The facility's policy and procedure, as well as the dialysis agreement, emphasized the importance of maintaining records and exchanging information between the facility and the dialysis center. Despite these guidelines, the facility did not adhere to its own policies, resulting in the potential for undetected complications in Resident 219's care.
Failure to Honor Vegetarian Diet Preference
Penalty
Summary
The facility failed to honor a vegetarian diet preference for Resident 48, who was readmitted with diagnoses including diabetes and hypertension. Despite the resident's clear dietary preferences and dislikes, the facility provided meals that did not align with her vegetarian diet. Observations revealed that Resident 48 often had to order food from outside vendors to meet her dietary needs, leading to significant personal expense. The resident's dissatisfaction with the facility's food options was evident, as she consumed only portions of the meals provided and expressed a desire for simple vegetarian options like cooked brown rice and steamed vegetables. Interviews with staff, including a CNA and the Registered Dietitian (RD), indicated a lack of awareness and understanding of the resident's vegetarian diet needs. The RD admitted to offering inappropriate food options and was unaware of the facility's vegetarian diet guidelines. The Director of Nursing (DON) also confirmed that the facility should honor residents' food preferences but was unaware of the specific issues faced by Resident 48. The facility's policy on dietary preferences was not effectively implemented, leading to the resident's nutritional needs not being met.
Incomplete Clinical Record Documentation
Penalty
Summary
The facility failed to ensure a clinical record was completed accurately for a resident with a diagnosis of malignant neoplasm of the prostate. During an observation, the resident was found with an indwelling urinary catheter, and the urine was darker than normal. Interviews with licensed nurses revealed that the treatment administration record (TAR) for the resident was incomplete, with missing check marks indicating that urinary catheter care and monitoring were not consistently documented on multiple dates. The director of nurses confirmed that the TAR should reflect the care provided to the resident. A review of the facility's policy and procedure on charting and documentation indicated that all services provided to the resident should be documented in the medical record, including treatments and services performed. The policy also specified that documentation should include care-specific details and the name and title of the individual who provided the care. The failure to complete the clinical record accurately did not provide an accurate representation of the care provided to the resident and had the potential to cause confusion among care providers.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow proper infection control practices in several instances. Medical supplies, including personal protective equipment (PPE) such as face masks, disposable gloves, and gowns, were observed not being elevated above the floor, which could lead to contamination. Additionally, a storage area outside the facility building had water leaks, resulting in water-damaged medical supplies. The ceiling of this storage area had darkened water circles and black spots indicative of previous leaks, and a plastic bin was used to collect dripping water. The central supply personnel acknowledged the disarray and water damage, and the Maintenance Director confirmed awareness of the need to elevate medical supplies to prevent cross-contamination, noting that some gloves had become soggy and were discarded as a result of the leaks. An employee was also observed entering an isolation room without wearing the appropriate PPE, specifically an isolation gown, despite a posted sign indicating the need for such precautions. The certified nurse assistant admitted to not following the required protocol while passing a meal tray. The Director of Nursing confirmed that the employee should have worn a gown as per the facility's policy on contact precautions for residents with Carbapenem-Resistant Organisms and the policy on transmission-based precautions. These failures in infection control practices had the potential to spread germs and placed residents at risk for infections.
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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