Sunny Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in La Mirada, California.
- Location
- 12200 La Mirada Blvd., La Mirada, California 90638
- CMS Provider Number
- 055737
- Inspections on file
- 60
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Sunny Hills Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, malnutrition, and a recent UTI had STAT labs ordered, which returned an elevated WBC count significantly above the normal range. Documentation showed that the physician and family were notified only of the resident’s weight loss, with no evidence that the abnormal WBC result was reported or that a COC was completed. In interviews, an LVN, an RN, and the DON all confirmed that abnormal labs should be reported to the physician and responsible party and documented as a COC, and the facility’s policy required notification of significant changes in condition, but this did not occur for the elevated WBC.
A resident with a stage 4 sacrococcygeal pressure injury and osteomyelitis, who was cognitively intact but dependent on staff for ADLs, received wound care from an LVN while wearing a soiled incontinence brief containing feces. The LVN removed the old dressing, cleansed and redressed the wound per physician orders, then replaced the same soiled brief instead of cleaning the resident and applying a clean brief, despite facility care plan and policy requirements to keep skin clean, minimize moisture, and prevent fecal contamination of pressure injuries.
A resident with anemia, muscle weakness, severe cognitive impairment, and oropharyngeal dysphagia, who had physician orders and a nutritional care plan for 1:1 feeding assistance, was left with an open meal tray and no CNA present to help despite verbally stating a need for assistance. The tray remained unattended for about 20 minutes before a CNA not assigned to the resident briefly assisted, left to get water, and then returned to resume feeding. The assigned CNA later admitted she opened the tray, left to pass other trays, and did not return as planned, while staff interviews and facility policy confirmed that residents requiring 1:1 feeding should not have trays served until an attendant is ready to assist.
Two residents who required significant assistance with ADLs experienced a lack of clean linens, incontinent pads, towels, and blankets due to repeated shortages in linen storage and carts. Staff confirmed that these shortages led to delays in providing clean bedding and personal care, resulting in residents remaining in soiled or uncomfortable conditions until more linens were delivered. Facility policies required clean linens, but these were not consistently available, affecting resident comfort and care.
A resident with diabetes, anxiety disorder, and impaired cognition was not assessed or treated for scabies after exposure from a roommate who tested positive. Despite reporting persistent itching and rash to staff, no skin assessment was documented, and the resident was not isolated or tested. Staff interviews confirmed that required monitoring and infection control procedures were not followed, contrary to facility policy.
A resident with osteoporosis was administered Alendronate Sodium daily instead of the recommended weekly dose due to an incorrectly entered physician order. Nursing staff did not identify or clarify the error despite medication alerts and packaging instructions, resulting in the resident receiving the medication more frequently than intended.
A resident with Alzheimer's disease and dementia, identified as an elopement risk, was left unsupervised after being assisted to the restroom. The resident exited through an unmonitored, open front door while the receptionist was away from her post, and staff did not respond promptly to the door alarm. The resident was later found outside after falling from her wheelchair, sustaining multiple fractures and injuries. The facility did not follow its own policies for supervision and elopement prevention, leading to the incident.
The facility failed to provide a safe, clean, and homelike environment for residents, with observations of dusty vents, peeling paint, and broken fixtures in several rooms. Staff interviews confirmed that maintenance and cleaning issues were not addressed promptly, despite the facility's policies emphasizing the importance of a sanitary and safe environment.
A resident with moderate cognitive impairment and multiple diagnoses did not swallow scheduled stool softener medications, as observed when pills were left on the bedside table. An LVN confirmed the oversight, and the DON stated that nurses should ensure residents ingest all medications. Facility policy required observation of medication consumption.
A resident with a history of falls was admitted without a baseline care plan indicating fall risk or preventive interventions. The resident later experienced an unwitnessed fall, resulting in injuries and a hospital transfer. Facility staff confirmed the absence of a timely care plan increased fall risk, contrary to policy requiring a plan within 48 hours.
The facility failed to maintain safe food storage practices, as refrigerator temperatures were not logged for two days, a container of grated cheese was unlabeled, and an open bag of tortillas was improperly stored. These actions violated the facility's policies, risking food spoilage and contamination.
The facility failed to implement proper infection control practices, including not wearing appropriate PPE during G-tube handling, allowing medical tubing to touch the floor, and not labeling oxygen humidifier bottles. These actions put residents at risk of infection, as confirmed by staff interviews and observations.
The facility failed to follow gastrostomy tube (GT) orders and protocols for four residents, leading to incorrect feeding formula administration and improper medication flushing. A resident received the wrong GT feeding formula, while others did not have their GT flushed as prescribed, risking medication errors and tube clogging. LVNs admitted to not following procedures due to insufficient training, and the facility's policies were not adhered to, posing risks to residents' health.
Two residents experienced medication administration errors due to improper GT flushing and inadequate training of nursing staff. The errors resulted in a medication error rate of 25.81%, significantly above the acceptable threshold.
Two residents in the facility experienced significant medication errors related to insulin administration. One resident received Humulin R insulin without the required coordination with meal times, while another was given Insulin Aspart significantly earlier than their meal. The facility failed to notify physicians or clarify orders, and there was a lack of insulin training for staff.
The facility failed to properly store and label medications for five residents, including unrefrigerated Insulin Lispro, expired Humulin R, and improperly stored Lorazepam Oral Solution. An oral inhaler was also not labeled with an open date. Additionally, the destruction of non-controlled medications was not witnessed as required, leading to potential health risks.
Two residents with specific dietary needs and preferences were not offered alternative food choices, despite expressing dissatisfaction with their meals. Staff interviews revealed a lack of communication and action regarding the residents' meal preferences, contrary to the facility's policies.
The facility failed to ensure safe oxygen administration for three residents by not dating nasal cannulas, allowing tubing to touch the floor, and not posting precautionary signs outside rooms. These deficiencies posed risks of respiratory infection and fire hazards, contrary to facility policies.
A facility failed to properly assess and monitor the use of bedrails for a resident with severe cognitive impairment and multiple health conditions. The resident was observed with bilateral bedrails without a proper assessment or physician's order, contrary to the facility's policy. Interviews revealed that the necessary assessments and monitoring were not conducted, placing the resident at risk for entrapment and other safety issues.
A resident with obstructive sleep apnea and COPD did not receive prescribed BIPAP therapy due to the facility's failure to train nurses on the equipment's use. Interviews revealed that nurses were unaware of how to operate the BIPAP machine and falsely documented its use. The facility's policies required adherence to physician orders, but the lack of training led to the resident not receiving necessary respiratory support.
A resident with severe cognitive impairment was administered Seroquel without informed consent. Despite facility policy requiring consent for psychotropic medications, staff failed to obtain it before administration. Interviews confirmed the oversight, highlighting the need for informed consent in such cases.
A resident with severe cognitive impairment was observed with bedrails in use without a physician's order or informed consent from the responsible party (RP). The facility's policy required informed consent before using bedrails, but the RP was not informed of the risks and benefits, violating their right to make an informed decision.
A resident with severe cognitive impairment and multiple health issues was found with her call light out of reach, preventing her from communicating with staff. Despite care plan interventions requiring the call light to be accessible, it was positioned above her head, leading to distress as she was unable to request assistance. An LVN confirmed the importance of the call light being within reach to prevent frustration.
A facility failed to protect a resident's confidential information by not removing identifiable health information from an IV medication bag before disposal. An RN confirmed that RNs were responsible for managing IV therapy and should blacken out resident information before disposal. The facility's policy emphasized the importance of maintaining confidentiality.
Three residents in a shared room experienced dissatisfaction due to old, yellow stains on the ceiling and an unfinished painted wall. Despite a previous water leak being repaired, the staining was not addressed, leading to an unappealing living space. The residents, with various medical conditions and cognitive impairments, expressed their unhappiness with the room's appearance.
The facility failed to conduct timely background criminal checks for four employees, as required by its policy. Interviews and record reviews revealed that checks were either delayed or not conducted at all, contrary to the facility's procedures. This lapse in protocol was acknowledged by the Director of Staff Development.
Two residents in an LTC facility were found to lack person-centered care plans addressing their specific needs. One resident, with severe cognitive impairment and using bedrails, had no care plan for monitoring safety and effectiveness. Another resident, whose primary language was Korean, had no care plan for overcoming language barriers, hindering effective communication. These deficiencies were contrary to the facility's policies on care planning and communication.
A facility failed to meet professional standards of care for three residents. A resident with sleep apnea and COPD did not receive BIPAP therapy as ordered, with nurses falsifying MAR entries. Another resident with multiple health issues did not receive medications and monitoring as prescribed, with missing documentation indicating non-compliance. A third resident's blood sugar was not checked as ordered, with no documentation to confirm the task was completed.
The facility failed to provide communication aids for two residents who did not speak English, impacting their ability to communicate needs. A resident who spoke Korean and another who spoke Spanish were not given communication boards, despite their medical conditions and care plans indicating the need for such aids. Staff interviews confirmed the absence of these aids, contrary to the facility's policy on effective communication.
A resident with a history of breast cancer reported a new bump under her breast and requested a mammogram, but the LTC facility failed to schedule the appointment despite a physician's order. The resident, who had chronic kidney disease, type 2 diabetes, and major depressive disorder, was frustrated by the lack of follow-up. The nursing department was responsible for scheduling the mammogram based on the resident's insurance, but this was not done, violating the facility's policy on assisting residents with follow-up appointments.
A long-term care facility failed to properly manage pressure ulcer prevention and care for three residents. One resident with a Stage IV pressure ulcer did not receive adequate interventions, as necessary padding was often missing, and the care plan lacked specific measures to prevent further skin breakdown. Additionally, two residents had their low air loss mattresses set incorrectly, making them too firm and increasing the risk of pressure ulcers. These deficiencies highlight a failure to adhere to the facility's pressure injury prevention policy.
A resident with prostate cancer and radiation proctitis did not receive prescribed Sucralfate enemas due to incorrect medication reconciliation and administration errors. The MAR showed discrepancies, and the medication was held despite physician orders. The facility's policies for medication orders and documentation were not followed, leading to potential worsening of the resident's condition.
A resident with severe cognitive impairment was verbally abused by a contracted X-ray provider, who used profanity and made threats during an X-ray procedure. The facility staff failed to protect the resident from this abuse, as confirmed by interviews with the DON, ADON, an LVN, and a CNA.
The facility failed to implement proper infection control practices, including timely placement of a resident on Novel Respiratory Precautions after COVID-19 exposure, lack of fit testing for CNAs, and inadequate training in PPE use. These deficiencies increased the risk of virus transmission within the facility.
Failure to Notify Physician and Responsible Party of Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician and the responsible party of a change of condition related to abnormal lab results for one of five sampled residents. The resident had diagnoses including mild protein-calorie malnutrition and a urinary tract infection, and was documented as lacking capacity to make medical decisions, with severe cognitive impairment and dependence on staff for ADLs. A physician’s order directed that STAT labs, including a CBC, CMP, and urine culture and sensitivity, be obtained. The lab report from that testing showed an elevated WBC count of 15,200 cells/µL, above the normal reference range of 4,000–10,000 cells/µL. Review of the SBAR communication form for that date showed that the physician and family were informed of the resident’s weight loss, but there was no documentation that the physician or responsible party were notified of the elevated WBC or that a change of condition (COC) was completed. During interviews, an LVN acknowledged that the WBC was elevated, that no COC was completed, and that the physician and responsible party should have been notified. An RN stated that any abnormal lab results should be reported to the physician and documented as a COC, and that the resident had a change from baseline labs warranting such action. The DON stated that nurses must complete a COC when labs are abnormal and notify the physician and responsible party so all are aware of the abnormal results. The facility’s “Notice of Changes” policy indicated the facility must inform the physician and/or family or legal representative when there is a significant change in the resident’s condition, such as deterioration in health, mental, or psychosocial status, which did not occur in this case regarding the elevated WBC.
Failure to Maintain Cleanliness During Stage 4 Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves a failure to follow proper infection control practices during pressure injury wound care for Resident 2, who was admitted with a stage 4 pressure injury to the sacrococcygeal area and osteomyelitis of the vertebra, sacral, and sacrococcygeal region. During an observed wound care procedure, the LVN performed a dressing change while the resident was wearing a soiled incontinence brief containing a small amount of brown feces. The LVN removed the old dressing, cleansed the wound with normal saline, completed the wound care, and then replaced the same soiled brief on the resident, stating that the brief was dirty with stool but that she would wait for a CNA to change it later. Resident 2’s records showed that the resident had decision-making capacity, no cognitive impairment, and was dependent on staff for ADLs including toileting and personal hygiene. The care plan directed staff to keep the resident’s skin clean and provide skin care per facility guidelines, and the physician’s order specified daily cleansing and dressing of the stage 4 pressure injury. Facility staff, including the LVN, RN, and DON, acknowledged that residents should be cleaned of stool and urine and provided with a clean brief before wound care to prevent contamination of the pressure injury. The facility’s pressure injury prevention and management policy stated that treatment and services are to be provided to heal pressure injuries and prevent infection, including minimizing exposure to moisture and keeping skin clean, especially from fecal contamination.
Failure to Provide Timely 1:1 Feeding Assistance and Meal Supervision
Penalty
Summary
The deficiency involves the facility’s failure to provide required 1:1 feeding assistance and timely meal support to a resident identified as being at risk for malnutrition. During a noon meal observation in the resident’s room, the resident was positioned in high Fowler’s with a towel placed around the chest and an open meal tray set on the bedside table. When asked, the resident opened his eyes, nodded that he wanted to eat, and verbally stated he needed help eating, but no CNA was present to assist. The tray remained open and unattended in front of the resident for approximately 16 minutes before any staff entered the room to help. When CNA 1, who stated the resident was not on her assignment, entered the room, she indicated she could assist and provided one spoonful of food before leaving to get water, then returned several minutes later to resume feeding. CNA 1 acknowledged that the resident required 1:1 feeding assistance and that leaving a tray open for a long time could cause the food to become cold, which she stated was not acceptable. Review of the resident’s records showed diagnoses including anemia, muscle weakness, and oropharyngeal dysphagia, with a history and physical indicating capacity to understand and make decisions, and an MDS documenting severe cognitive impairment and dependence on staff for ADLs, with partial/moderate assistance needed for eating. Physician’s orders and the nutritional care plan both specified that the resident was a 1:1 feeder and required 1:1 feeding assistance. CNA 3, who was assigned to the resident on the day of the observation, reported that her practice was to pass trays to other residents first and then bring trays to residents needing 1:1 feeding. She stated that she placed a towel on the resident, opened the meal tray in front of him, observed him open his eyes, and then left the room to pass other trays, intending to return in about 10 minutes but did not check back or return to see if he was eating. CNA 3 acknowledged that leaving the tray open could cause the food to get cold and that it was not acceptable to leave a tray unattended for 20 minutes in front of a resident who could not eat independently. RN 1 and the DON both stated that residents requiring 1:1 feeding should not have trays left in front of them without assistance, and the facility’s “Meal Supervision and Assistance” policy specified that meals should not be served until the attendant is ready to assist the resident.
Failure to Provide Adequate Linens and Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two of six sampled residents by not ensuring the availability of sufficient linens, incontinent pads, towels, and blankets. Multiple observations revealed that linen storage stations and carts were repeatedly found without essential items such as blankets, incontinent pads, towels, and sheets at various times of the day and night. Staff interviews confirmed that linen shortages occurred, particularly at the start of shifts and during nighttime hours, resulting in residents having to wait for clean linens to be delivered from the laundry department. One resident, with diagnoses including gait disturbance, spondylosis, and COPD, required substantial to maximum assistance with activities of daily living (ADLs) and reported that only their diaper was changed during nighttime care, not the sheets or blankets. The resident expressed a desire for fresh and clean blankets. Another resident, with hemiplegia, metabolic encephalopathy, and diabetes, was dependent on staff for ADLs and reported that nurses ran out of sheets and towels during the night, leading to situations where only the diaper was changed and not the sheets, resulting in discomfort from sweaty sheets. Staff interviews corroborated the residents' accounts, with laundry and nursing staff acknowledging the importance of having adequate linens available for resident care and comfort. The facility's policies required the provision and maintenance of clean bed and bath linens, but the observed and reported shortages indicated a failure to meet these standards, directly impacting the residents' environment and care.
Failure to Assess and Treat Resident After Scabies Exposure
Penalty
Summary
The facility failed to assess and treat a resident after exposure to scabies, following the positive diagnosis of the resident's roommate. Despite the resident's history of diabetes mellitus and anxiety disorder, as well as impaired cognitive skills and dependence on staff for personal care, there was no documented skin assessment in the medical record. The resident reported persistent itching and a rash, which she identified as scabies, and stated that staff did not assess her skin or address her symptoms. Observation confirmed the presence of a red rash, and the resident indicated she had informed staff of her condition. Interviews with staff revealed that the treatment nurse was not aware of the resident's skin issues and had not been notified of the rash, despite acknowledging that monitoring should have begun after the roommate's positive scabies result. The infection preventionist nurse admitted to not assessing or isolating the exposed resident, and the DON confirmed that exposed residents should be isolated and assessed. The facility's policy required assessment and isolation of residents exposed to scabies, but these procedures were not followed, resulting in the resident experiencing ongoing discomfort and an increased risk of transmission.
Medication Administration Exceeds Recommended Dose
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes mellitus, osteoporosis, and muscle weakness, was administered Alendronate Sodium at a dosage exceeding the manufacturer's recommended frequency. The physician's order was incorrectly entered as a daily administration of 70 mg, rather than the intended weekly dose. This error was not identified by the nursing staff, despite medication alerts and packaging instructions indicating the correct weekly dosing schedule. The resident received the medication on three separate days within a week, as documented in the Medication Administration Record. The error was further confirmed through interviews with the resident, who reported receiving the medication more frequently than prescribed, and with the pharmacist, who stated that the pharmacy only supplied four tablets and the packaging clearly indicated weekly dosing. The pharmacist also noted that exceeding the recommended dose could result in adverse effects. Interviews with the DON and a registered nurse revealed that the medication alert indicating the excessive dosage was overlooked, and the order was not clarified with the nurse practitioner or physician until after the error was discovered. The facility's policy required medications to be administered according to physician orders and manufacturer specifications, but this protocol was not followed in this instance.
Plan Of Correction
Determines that the disputed findings are relied upon in a manner adverse to the interests of the provider either by the governmental agencies or third party. Corrective action for residents found to have been affected by this deficiency: - The Physician and/or NP of resident #1 was notified of the medication administration error on May 18, 2025, and the order was clarified. - The Physician was contacted on May 18, 2025, and labs were ordered for resident #1 to rule out any abnormality. Resident's Calcium level was normal, and no other abnormalities were noted. - An order was also obtained for monitoring of Dysphagia. - DON provided 1:1 education with the licensed nurse on May 19, 2025. Identification of others at risk: - DON and/or Designee audited residents with Alendronate 70 mg on May 20, 2025, and no other resident was affected by this practice. Measures that will be put into place to ensure that this deficiency does not recur: - Starting on May 19, 2025, the Director of Nursing initiated in-service with Licensed Nurses on the facility's policy titled "Medication Errors" and "Medication Administration." - Med Pass competency was initiated by the DON/Designee on May 29, 2025, and will be continued by the DSD/Designee on med pass observation to at least one (1) licensed nurse per month for three (3) months. Findings will be reported to the Director of Nursing for follow-up. - Pharmacy Nurse Consultant will perform med pass observation during their monthly scheduled visit. Findings will be reported to the Director of Nursing for follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: - The Director of Nursing will review all new residents with Alendronate orders to ensure orders are transcribed accurately for three (3) months. - The Director of Nursing will provide a summary trend analysis of the facility's compliance on a monthly basis for three months to the QA committee for further evaluation and recommendations until substantial compliance is sustained.
Failure to Prevent Elopement and Provide Supervision Results in Resident Injury
Penalty
Summary
A facility failed to provide adequate supervision and accident prevention for a resident identified as an elopement risk. The resident, who had diagnoses of Alzheimer's disease and dementia and was assessed as lacking capacity for decision-making, had a documented history of wandering and previous attempts to leave the facility without informing staff. The resident's care plan specifically identified the risk for elopement and included interventions such as anticipating needs, encouraging activity participation, and frequent visual checks for safety. Despite these documented risks and interventions, the resident was left unsupervised in a wheelchair in the hallway after being assisted to the restroom, and staff did not maintain the required level of monitoring. On the day of the incident, the resident was observed propelling herself down the hallway and was later seen in the front lobby. The facility's front exit door was left wide open and unmonitored when the receptionist left her post unattended to use the restroom. No staff were present to observe or redirect the resident, and the door alarm was not responded to in a timely manner. The resident exited the facility unsupervised, traveled to an adjacent property, and fell from her wheelchair onto the street. The incident was not immediately noticed by staff, and the resident was found by a passerby who called emergency services. As a result of the elopement and fall, the resident sustained multiple injuries, including fractures to the nose, jaw, and ribs, a laceration to the lip, a hematoma, and damage to dental implants. Interviews with staff and review of records confirmed that the facility did not follow its own policies and procedures regarding supervision, elopement prevention, and door monitoring. The lack of supervision and failure to ensure the function and monitoring of exit doors directly led to the resident's elopement and subsequent injuries.
Removal Plan
- Resident 1 was placed on 1:1 supervision with staff educated on supervision until a safe plan is determined by the IDT.
- In-service education was provided to the weekend and evening receptionist regarding not leaving their post unattended.
- In-service education regarding monitoring/supervision, wandering, and elopement policy was provided to the receptionist and facility staff on shift, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel.
- Facility doors were checked for appropriate function by the Maintenance Director.
- A head count of all in-house residents was initiated and all residents were accounted for.
- Elopement assessments were completed on all residents by the DON/designee.
- Two residents identified at risk for elopement were reviewed by the DON/designee for appropriate care plan interventions.
- In-service education regarding wandering and elopement was provided to facility staff, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel. Staff on leave or PRN will be in-serviced on their next scheduled shift.
- An IDT meeting was conducted for the two residents identified as at risk for elopement.
- The DON or designee will audit new admissions with elopement risks and ensure appropriate interventions are in place.
- The SSD or designee will review all new admissions to ensure an elopement risk assessment has been completed, and those residents identified at risk are updated in the Elopement binder. Audits will be conducted until substantial compliance is achieved.
- New hires will receive education on wandering, elopement, and resident safety by the DON, SSD, or designee(s) upon hire and annually thereafter. Ongoing in-service trainings regarding wandering, elopement, resident safety, and resident monitoring/supervision will be performed.
- Elopement risk binders were reviewed and updated by the DON and Administrator. Binders are available at each nursing station and reception area, updated by the SSD with oversight by the DON.
- Elopement code drills were initiated on all shifts and will continue by Administrator/DON and/or DSD.
- A check of facility doors and alarms was performed by the Maintenance Department to ensure function and securement. Frequency increased.
- A check of facility doors and alarms will be performed by the Maintenance Department until substantial compliance is achieved. Any findings will be corrected immediately and trends reported to the QA/QAPI Committee.
- The QAPI Committee will review and discuss elopement and supervision for all residents during QAPI meetings to determine effectiveness and provide feedback and program modification until compliance is maintained.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for 8 out of 9 residents in the affected rooms. Observations revealed that the activity room had ceiling vents covered in dust, with strands hanging over them, and walls with dried food spots. In several residents' rooms, paint was peeling off the walls behind headboards, and one room had a plastic baseboard sticking out from the wall. These conditions were confirmed by interviews with housekeeping and maintenance staff, who acknowledged the importance of cleanliness and maintenance for resident safety and hygiene. Interviews with staff revealed that deep cleaning was conducted monthly, but issues such as dirty walls and broken fixtures were not addressed promptly. The housekeeping staff stated that they informed the supervisor about maintenance issues, but these were not resolved in a timely manner. The maintenance supervisor and director of nursing both emphasized the need for a clean and safe environment, as outlined in the facility's policies and procedures. However, the facility's failure to adhere to these policies resulted in unsanitary conditions and potential safety hazards for the residents.
Failure to Ensure Resident Swallowed Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 3, swallowed scheduled stool softener medications during medication administration. This oversight was observed when two small, white, circular pills were found inside a plastic cup on Resident 3's bedside table. Resident 3, who was admitted with diagnoses including primary generalized osteoarthritis and chronic obstructive pulmonary disease, had moderate cognitive impairment and required substantial assistance with activities of daily living. The physician's orders for Resident 3 included taking Docusate Sodium Oral Tablet 100 mg, two tablets by mouth twice a day for bowel management. During an interview, a Licensed Vocational Nurse (LVN) confirmed that Resident 3 did not take the pills and acknowledged that the facility did not ensure the resident took all her medications. Another LVN stated that it was inappropriate to leave medication at a resident's bedside, as it could lead to missed doses or other residents taking medication not prescribed to them. The Director of Nursing (DON) confirmed that nurses should ensure residents ingest or swallow all medications during administration and that it was not acceptable to leave pills at a resident's bedside. The facility's policy on medication administration required licensed nurses to observe residents consuming their medication.
Failure to Initiate Baseline Care Plan for Resident with Fall Risk
Penalty
Summary
The facility failed to initiate a baseline care plan for a resident with a history of falls, which is a requirement to be completed within 48 hours of admission. The resident, who was admitted with diagnoses including contusion, laceration, hemorrhage of the brainstem, and repeated falls, did not have a baseline care plan indicating a high risk for falls or interventions to prevent further incidents. This omission was identified during a review of the resident's records, which showed that the baseline care plan dated several days after admission lacked necessary fall prevention measures. The deficiency was further highlighted when the resident experienced an unwitnessed fall in the bathroom, resulting in skin tears and a hospital transfer for evaluation. Interviews with facility staff, including an LVN and the DON, confirmed that the absence of a baseline care plan for a resident with a history of falls placed the resident at risk for repeated falls. The facility's policy mandates the development of a resident-centered baseline care plan within 48 hours of admission, which was not adhered to in this case.
Deficient Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as observed during a survey. The temperature for Refrigerator 1 was not logged for two consecutive days, which was confirmed by the Dietary Supervisor (DS) during an interview. The DS acknowledged that refrigerator temperatures were supposed to be checked daily to ensure they were functioning correctly and to prevent food spoilage. The absence of temperature records for those days meant that any potential issues with the refrigerator's temperature could go unnoticed, risking the spoilage of produce stored inside. Additionally, a container of grated cheese inside Refrigerator 2 was found without a label indicating the product name, open date, and use by date. The DS admitted that the cheese had been transferred into the container without proper labeling, which could lead to confusion and the use of expired products. Furthermore, an open bag of tortillas was observed to be ripped and not stored in a tight-lidded container, as required. The DS stated that such items should be placed in sealable containers to prevent contamination. These practices were in violation of the facility's policies and procedures, which require daily temperature logging and proper labeling and storage of food items.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices for several residents, leading to potential risks of infection. Licensed nurses did not adhere to Enhanced Barrier Precautions when handling a gastrostomy tube for a resident. Despite signage indicating the need for gowns and gloves, a nurse only wore gloves and failed to don a gown while administering medication through the G-tube. This oversight was confirmed through interviews with various staff members, including the Infection Preventionist Nurse and the Director of Staff Development, who emphasized the necessity of wearing gowns during such procedures to prevent infection transmission. In another instance, the facility did not maintain proper hygiene standards for medical equipment. The nasal cannula tubing for a resident was repeatedly observed touching the floor over several days, posing a risk of contamination. Similarly, the indwelling urinary catheter tubing for two residents was also found touching the floor, which could lead to infections. Staff interviews highlighted the importance of ensuring that such tubing does not contact the floor as part of infection prevention practices. Additional deficiencies included an unlabeled oxygen humidifier bottle for a resident, which should have been dated to ensure timely changes for infection control. Furthermore, a resident's bed linens were placed back on the bed after falling to the floor, contrary to the facility's policy on handling soiled linens. These practices were inconsistent with the facility's infection prevention and control program, which mandates proper handling and separation of clean and soiled linens, as well as adherence to enhanced barrier precautions for high-contact resident care activities.
Failure to Implement Gastrostomy Tube Orders and Protocols
Penalty
Summary
The facility failed to implement gastrostomy tube (GT) orders in accordance with its policy for four residents. Resident 56 received the incorrect GT feeding formula, Glucerna 1.2 instead of the prescribed Glucerna 1.5, which was intended to manage their diabetes and nutritional needs. This error was identified during an observation and confirmed by a Licensed Vocational Nurse (LVN) who acknowledged the mistake and the potential impact on the resident's blood sugar and nutritional status. For Residents 81, 41, and 35, the facility did not adhere to the prescribed protocol for flushing the GT before and after medication administration. Observations revealed that medications were administered without the required flushing, which could lead to medication errors and potential clogging of the GT. LVNs involved in the administration process admitted to not following the correct procedures, citing insufficient training as a reason for the oversight. The facility's policies and procedures were not followed, as evidenced by the discrepancies between the prescribed orders and the actual practices observed. The Director of Staff Development and the Regional Nurse Consultant confirmed that the standard practice was not adhered to, and there was a lack of proper training documentation for some of the LVNs involved. This failure to follow established protocols and ensure staff competency in GT management posed significant risks to the residents' health and safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 25.81% error rate during medication administration for two residents. Resident 81 and Resident 41 were both affected by improper medication administration through their gastrostomy tubes (GT). The errors were identified during observations and interviews with the nursing staff responsible for administering the medications. Resident 81, who has a history of hemiplegia, hemiparesis, and dysphagia, was not administered medications as per the physician's orders. The Licensed Vocational Nurse (LVN) responsible for Resident 81's care did not flush the GT before and after each medication, as required. Additionally, the medications were not mixed adequately, leading to residual medication remaining in the cups. The LVN admitted to insufficient training in GT medication administration, which contributed to the errors. Similarly, Resident 41, diagnosed with epilepsy and dysphagia, also experienced medication administration errors. The LVN did not flush the GT before or after administering medications, contrary to the facility's policy and physician's orders. The LVN acknowledged the oversight and the need for additional water to ensure proper medication delivery. The Regional Nurse Consultant confirmed that the standard practice was not followed, which could lead to clogged GTs and incomplete medication delivery.
Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 36 and Resident 55, were free from significant medication errors, specifically concerning the administration of insulin. Resident 36, who has Type II diabetes mellitus and hypertension, was administered Humulin R insulin at 11:30 AM daily, despite the resident's enteral feeding being turned off from 9 AM to 1 PM. This administration was not in accordance with the physician's order to administer the insulin before meals, nor was it aligned with the manufacturer's specifications. The facility did not document any notification to the physician regarding this discrepancy, nor was there any clarification of the order, leading to repeated administration errors over a period of time. Resident 55, also diagnosed with Type II diabetes mellitus, was administered Insulin Aspart before meals as per a sliding scale. However, the insulin was given significantly earlier than the meal was provided, with an observed instance where the insulin was administered over an hour before the resident received lunch. This was contrary to the manufacturer's instructions to administer Insulin Aspart within 5-10 minutes before a meal. The facility's failure to coordinate insulin administration with meal times was not documented or addressed, and there was no evidence of physician notification or order clarification. The facility's policy on the timely administration of insulin was not adhered to, as evidenced by the lack of coordination between insulin administration and meal times for both residents. Interviews with staff, including the Director of Staff Development and the Regional Nurse Consultant, highlighted the importance of administering fast-acting insulins like Humulin R and Insulin Aspart in conjunction with meals to prevent hypoglycemia. The absence of insulin training on the facility's checklist for licensed nurses further contributed to the medication errors observed.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals for five residents, leading to potential health risks. An unopened vial of Insulin Lispro for Resident 2 was found unrefrigerated in a medication cart, contrary to the manufacturer's requirement to refrigerate until opened. Additionally, a vial of Humulin R for Resident 17 was stored past its expiration date, which should have been discarded according to the manufacturer's guidelines. Controlled medications requiring refrigeration, such as Lorazepam Oral Solution for Residents 15 and 42, were improperly stored at room temperature instead of being refrigerated as per the manufacturer's instructions. Furthermore, an oral inhaler, Trelegy Ellipta, for Resident 92 was opened without being labeled with an open date, which is necessary to track its shortened expiration period once opened. The facility also failed to follow its policy for the destruction of discontinued and expired non-controlled medications. The process was not witnessed by a second nurse, as required, and documentation was incomplete, with only one nurse's initials recorded. This lack of adherence to proper procedures for medication storage and disposal increased the risk of residents receiving ineffective or potentially harmful medications.
Failure to Provide Alternative Food Choices
Penalty
Summary
The facility failed to provide alternative food choices and an alternative menu for two residents, impacting their nutritional status and quality of life. Resident 77, who has diabetes mellitus, dysphagia, Parkinson's disease, and hyperlipidemia, was observed to have a meal tray that did not align with her preferences. Despite having a care plan that required honoring her food preferences and offering substitutes if meals were less than 50% consumed, Resident 77 was not offered an alternative meal when she expressed dissatisfaction with her food. She reported not being aware of the alternative menu available in the hallway. Similarly, Resident 24, who has congestive heart failure, hyperlipidemia, hypertension, gastroesophageal reflux disease, and dysphagia, also expressed dissatisfaction with the meals provided. Despite having a care plan that required offering substitutes if meals were less than 50% consumed, Resident 24 was not offered an alternative meal. She was observed eating from a container of cashews instead of the meal provided, indicating a lack of awareness of the alternative menu. Interviews with staff, including CNAs and LVNs, revealed a lack of communication and action regarding the residents' dissatisfaction with their meals. Staff members acknowledged that residents should be offered alternative options if they do not like the food provided, but this was not done for Residents 24 and 77. The facility's policies and procedures require staff to offer suitable nourishing alternatives when meals are refused, but these were not followed, leading to the deficiency.
Deficient Oxygen Administration Practices
Penalty
Summary
The facility failed to implement safe oxygen administration practices for three residents, leading to several deficiencies. Resident 14's nasal cannula was not dated with an open date, and the tubing was observed touching the floor on multiple occasions. Additionally, there was no precautionary sign indicating oxygen use outside Resident 14's room. These practices were not in line with the facility's policy, which requires oxygen equipment to be dated and changed weekly, and for precautionary signs to be posted. Resident 54's nasal cannula was also observed touching the floor on several occasions, and there was no sign indicating oxygen use outside their room. Resident 54 had a history of chronic kidney disease and cardiomegaly and was dependent on staff for various activities of daily living. The lack of precautionary signage and improper handling of oxygen equipment posed a risk of respiratory infection and fire hazards. Similarly, Resident 99's room lacked a precautionary sign despite the presence of an oxygen concentrator at the bedside. Resident 99 had a history of respiratory failure, COPD, pulmonary edema, and dementia, and required continuous oxygen for shortness of breath. The absence of a no-smoking sign was acknowledged by a registered nurse as a potential fire risk. The facility's policy mandates that oxygen warning signs be placed on the doors of rooms where oxygen is in use, which was not adhered to in these cases.
Failure to Properly Assess and Monitor Bedrail Use
Penalty
Summary
The facility failed to ensure the proper use of bedrails for a resident, identified as Resident 331, as per the facility's policy and procedure. The deficiency was identified through observation, interview, and record review. The facility did not assess Resident 331's risk for entrapment or the need for bedrails, nor did it conduct monitoring specific to the resident's use of bedrails. This oversight had the potential to result in accidents such as entrapment or falls. Resident 331 was initially admitted to the facility with diagnoses including sepsis, dementia, and chronic obstructive pulmonary disease. The Minimum Data Set indicated that the resident's cognition was severely impaired, and they were dependent on staff for various activities of daily living. The History and Physical report noted that Resident 331 lacked the capacity to understand and make decisions. Despite these conditions, the resident was observed with bilateral bedrails up, without a proper assessment or physician's order. Interviews with RN 1 and the Director of Nursing revealed that the facility did not follow its process for assessing the need for bedrails, the risk of entrapment, and performing close monitoring. The facility's policy required an evaluation of alternatives before installing bedrails and documentation of monitoring during their use. However, these steps were not followed for Resident 331, placing them at risk for entrapment and other safety issues.
Failure to Provide BIPAP Therapy Due to Lack of Staff Training
Penalty
Summary
The facility failed to ensure that licensed nurses were trained on the use of a BIPAP machine, which is essential for providing respiratory support to residents with conditions such as obstructive sleep apnea and COPD. This deficiency was identified for one resident, who had a physician's order for BIPAP therapy at bedtime. Despite the order, the resident did not receive the BIPAP therapy due to the nurses' lack of training and familiarity with the equipment. Interviews with the resident revealed that she was aware of her need for the BIPAP machine and expressed concern about not receiving it. The resident reported that the nurses did not provide the machine because they did not know how to operate it. Further interviews with two licensed vocational nurses confirmed that they had not been trained on the BIPAP machine and had falsely documented its use. One nurse mentioned a missing piece of the equipment but did not report it or notify the physician. The facility's policies and procedures required the provision of physician-ordered services, including noninvasive ventilation, according to professional standards. However, the lack of in-service training for the nurses on the BIPAP machine led to the resident not receiving the necessary therapy, as documented in the facility's policy and procedure reviews.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering Seroquel, a psychotropic medication, to a resident. The resident, who was admitted with diagnoses including sepsis, dysphagia, depression, and dementia, lacked the capacity to understand and make decisions, as indicated in their History and Physical and Minimum Data Set. Despite this, Seroquel was ordered and administered without informed consent, as confirmed by a review of the resident's Medication Administration Record and an interview with a registered nurse. Interviews with nursing staff revealed that informed consent is required before administering antipsychotic medications, and the absence of such consent should prompt the nurse to contact the resident's family or responsible party. The facility's policy mandates obtaining informed consent for complex decisions, including the administration of psychotherapeutic medication. The failure to secure informed consent for Seroquel administration was acknowledged by the nursing staff, who stated that the medication should not have been given without it.
Failure to Obtain Informed Consent for Bedrail Use
Penalty
Summary
The facility failed to ensure that the responsible party (RP) of a resident was informed in advance about the risks and benefits of using bedrails. The resident, who was severely cognitively impaired and dependent on staff for various activities, was observed with bilateral bedrails up. However, there was no physician's order for the use of bedrails, nor was there any documentation indicating that the RP had consented to their use. This lack of informed consent violated the RP's right to make an informed decision regarding the resident's care. Interviews with the registered nurse (RN) and the Director of Nursing (DON) revealed that the facility's policy required informed consent from the resident or their RP before bedrails could be used. The RN acknowledged that the bedrails should not have been applied without a physician's order and the RP's consent. The DON confirmed that an assessment for the need and risk of bedrails should have been completed, and the RP should have been informed of the associated risks. The facility's policy on the proper use of bedrails also emphasized the necessity of obtaining informed consent prior to their installation and use.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which prevented the resident from effectively communicating with staff. The resident, who had multiple diagnoses including muscle weakness, anxiety disorder, dementia, and functional quadriplegia, was observed lying in bed with the call light positioned above her head, out of reach. The resident expressed distress by yelling that she was cold and needed to be covered up, indicating her inability to use the call light to request assistance. The resident's care plan included interventions to anticipate and meet her needs, including having a call light within reach, but this was not adhered to. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependence on assistance for daily activities. The facility's policy on fall prevention required that call lights and frequently used items be within reach, but this was not followed in the resident's case. An interview with an LVN confirmed the importance of having the call light within reach to prevent the resident from becoming frustrated and angry when her needs were unmet. The failure to ensure the call light was accessible was a deficiency in the facility's care for the resident.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information by not removing identifiable health information from an intravenous (IV) medication bag before disposing of it in the trash. During an observation, an empty IV medication bag with identifiable health information was found in the trash can in a resident's room. This oversight was noted for a resident who had been admitted with multiple diagnoses, including diabetes mellitus, dysphagia, sepsis, and dementia. The resident's cognitive skills for daily decision-making were severely impaired, as indicated in their Minimum Data Set (MDS). A registered nurse (RN) confirmed that only RNs were responsible for managing IV therapy and were required to blacken out the resident's information on the IV medication bag before disposal. The RN acknowledged that it was unacceptable to find the IV medication bag with identifiable information in the trash and emphasized the importance of protecting the resident's dignity and confidentiality. The facility's policy on confidentiality, revised in December 2022, stated the importance of securing and maintaining the confidentiality of residents' personal and medical records.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for three residents who shared a room with visible old, yellow stains on the ceiling and an unfinished painted wall. During observations, the ceiling near the door had a yellow stain, and the wall had an uneven surface and paint color. Interviews with the residents revealed dissatisfaction with the appearance of their living space, with one resident describing the stain as an 'eye sore' and another expressing dislike for the 'ugly' ceiling and wall. The residents involved had various medical conditions, including chronic kidney disease, depression, type 2 diabetes mellitus, and dementia, with varying levels of cognitive impairment. The Regional Maintenance Director acknowledged that a previous water leak had been repaired, but the staining was not painted over by the former Maintenance Director. The facility's policy on providing a safe and homelike environment was not adhered to, as the necessary repairs were not completed in a timely manner.
Failure to Conduct Timely Background Checks on Employees
Penalty
Summary
The facility failed to conduct background criminal checks for four randomly selected employees prior to hire and upon completion of orientation, as required by the facility's policy. This deficiency was identified during interviews and record reviews conducted with the Director of Staff Development (DSD). The review revealed that a Registered Nurse (RN) hired in 2003 did not have a background check until 2007. Additionally, a Licensed Vocational Nurse (LVN) hired in 2023 had their background check completed after their orientation, and two other LVNs hired in 2024 had no background checks conducted upon hire. The facility's policy, revised in January 2024, mandates that criminal conviction record checks be conducted on all personnel applying for employment, in compliance with state and federal regulations. These checks are to be completed after a contingent offer of employment but before the conclusion of the employee's orientation. The DSD acknowledged that background checks should be done prior to hiring to ensure that individuals with criminal backgrounds are not employed, highlighting a lapse in adherence to the facility's established procedures.
Deficiencies in Care Planning for Residents with Special Needs
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, leading to deficiencies in their care. Resident 331, who was admitted with severe cognitive impairment and multiple diagnoses including sepsis, dementia, and COPD, was observed using bedrails without a corresponding care plan. The absence of a care plan meant there were no documented interventions to monitor the resident's skin, assess the risk of entrapment, or evaluate the effectiveness of the bedrails, potentially compromising the resident's safety and care. Similarly, Resident 66, whose primary language was Korean and who had moderately impaired cognitive skills, did not have a care plan addressing her language barrier. Despite her difficulty in communicating and understanding verbal messages, no communication board or other aids were provided to facilitate effective communication. This oversight could hinder the staff's ability to provide appropriate care and support to the resident, as they might not fully understand her needs or concerns. The facility's policies on the proper use of bedrails and effective communication were not adhered to, as evidenced by the lack of care plans for these residents. The policies required that care plans include measurable objectives and timeframes to meet the residents' needs, which were not implemented in these cases. The failure to develop and implement these care plans could delay the delivery of necessary care and services to the affected residents.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to meet professional standards of quality care for three residents due to the actions and inactions of licensed nurses. For Resident 14, who was diagnosed with obstructive sleep apnea and COPD, the nurses did not follow the physician's order to provide BIPAP therapy at bedtime. Despite the Medication Administration Record (MAR) indicating that the BIPAP machine was used on several dates, interviews with the resident and nurses revealed that the machine was not provided. The nurses admitted to falsifying the MAR entries, citing reasons such as being in a hurry or not knowing how to use the machine. This failure to provide necessary respiratory support could have led to negative outcomes for the resident. For Resident 30, who had multiple diagnoses including diabetes mellitus, dysphagia, and dementia, the facility failed to administer medications and monitor vital signs as ordered. The MAR for October 2024 showed missing documentation for several physician-ordered tasks, such as evaluating pain, monitoring temperature and oxygen saturation, and administering medications like melatonin and atorvastatin. Interviews confirmed that these tasks were not completed, and the lack of documentation indicated non-compliance with physician orders. This inconsistency in care could have delayed necessary treatment and affected the resident's health. Resident 49, who was diagnosed with diabetes mellitus, hypertension, and anemia, also experienced a lapse in care. The facility did not perform a blood sugar check as ordered on a specific date, and there was no documentation to indicate that the task was completed. The facility's policies and procedures emphasized the importance of accurate and timely documentation, yet these were not followed. The failure to monitor blood sugar levels as ordered could have put the resident at risk for complications related to diabetes management.
Failure to Provide Communication Aids for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure effective communication for two residents who did not speak the dominant language, English. Resident 66, whose primary language is Korean, was admitted with several medical conditions including a fracture, dysphagia, and end-stage renal disease. Despite her moderately impaired cognitive skills and difficulty communicating, no communication board or device was provided to assist her in expressing her needs. Observations revealed that Resident 66 struggled to communicate with staff, leading to frustration and unmet needs, such as requesting orange juice instead of cranberry juice. Similarly, Resident 92, who primarily speaks Spanish, was not provided with a Spanish language communication board as indicated in their care plan. Resident 92 has a history of pulmonary mycobacterial infection, COPD, and chronic respiratory failure, and requires an interpreter for effective communication. Despite these needs, staff were observed speaking English to Resident 92, and no communication board was present at the bedside, potentially delaying necessary care. Interviews with facility staff, including CNAs, LVNs, and RNs, confirmed the absence of communication aids for both residents. Staff acknowledged the importance of providing communication boards to facilitate understanding and prevent delays in care. The facility's policy on effective communication emphasizes accommodating residents' communication needs, yet this was not adhered to in the cases of Residents 66 and 92.
Failure to Schedule Mammogram for Resident with Breast Cancer History
Penalty
Summary
The facility failed to follow up on a mammogram appointment for a resident, resulting in a deficiency. The resident, who had a history of breast cancer, noticed a hard bump under her right breast and informed her healthcare team about it. Despite the physician ordering a mammogram screening in August 2024, the nursing department did not set up an appointment, leaving the resident without the necessary diagnostic follow-up. This oversight led to the resident feeling frustrated with her healthcare team. The resident's medical history included chronic kidney disease stage four, type 2 diabetes mellitus, and major depressive disorder. The resident's cognition was intact, and she had the capacity to understand and make decisions. The Director of Nursing confirmed that the nursing department was responsible for scheduling the mammogram based on the resident's insurance. The facility's policy required staff to assist residents in scheduling and attending follow-up appointments as ordered by the physician, which was not adhered to in this case.
Inadequate Pressure Ulcer Management in LTC Facility
Penalty
Summary
The facility failed to adequately implement pressure ulcer interventions for three residents, leading to deficiencies in care. Resident 82, who was at high risk for pressure ulcer development due to quadriplegia and other conditions, had a Stage IV pressure ulcer that was not properly managed. Despite being educated on the importance of repositioning and using padding to protect bony prominences, Resident 82 preferred to remain in a Geri chair for extended periods, which contributed to the pressure ulcer's persistence. Observations revealed that the necessary padding was often not provided, and the care plan lacked specific interventions to prevent further skin breakdown. Resident 331's low air loss mattress (LALM) was not set to the correct weight, which compromised its effectiveness in preventing pressure ulcers. The mattress was observed to be set at a significantly higher weight than the resident's actual weight, making it too firm and increasing the risk of skin breakdown. The treatment nurse acknowledged the incorrect setting and the potential risk it posed to the resident, who was already at high risk for pressure ulcer development. Similarly, Resident 92's LALM was also set incorrectly, with the weight setting far exceeding the resident's actual weight. This error resulted in a mattress that was too hard, potentially contributing to the resident's existing moisture-associated skin damage. The facility's policy on pressure injury prevention was not adequately followed, as evidenced by the failure to ensure that the LALM settings matched the residents' weights, thereby compromising the intended protective measures against pressure ulcers.
Medication Reconciliation and Administration Failure
Penalty
Summary
The facility failed to ensure that the nursing staff correctly reconciled the medication list for a resident upon admission. The resident, who was admitted with diagnoses including malignant neoplasm of the prostate and hemorrhage of the anus and rectum, was supposed to receive Sucralfate enemas twice daily for radiation proctitis. However, the medication was ordered incorrectly for constipation, and the nursing staff did not administer the medication as prescribed. The resident reported not receiving the enemas for about a week, which led to significant rectal bleeding. The Medication Administration Record (MAR) showed discrepancies in the documentation of Sucralfate administration. The MAR indicated that the medication was held on certain days due to bleeding, despite the physician's order to administer it for radiation proctitis. The Director of Nursing confirmed that the medication was ordered with the incorrect indication and that the documentation was inaccurate, with two doses unaccounted for. This discrepancy suggested that the medication was documented as given when it was not. The facility's policies and procedures for medication orders and administration were not followed. The policies required verification of medication orders and accurate documentation in the medical record. The failure to adhere to these procedures resulted in the resident not receiving the necessary treatment, potentially leading to a decline in their condition.
Verbal Abuse by Contracted X-ray Provider
Penalty
Summary
The facility staff failed to protect a resident from verbal abuse by a contracted X-ray provider. The incident involved the X-ray provider using profanity and making threatening remarks towards the resident during an X-ray procedure. Interviews with the Director of Nursing, Assistant Director of Nursing, a Licensed Vocational Nurse, and a Certified Nursing Assistant confirmed that the X-ray provider verbally abused the resident by calling them derogatory names and threatening physical harm. The resident, who was admitted with diagnoses including metabolic encephalopathy and unspecified psychosis, was unable to make their own medical decisions and was dependent on staff for all activities of daily living. The facility's policy on abuse, neglect, and exploitation defines verbal abuse as the use of disparaging and derogatory terms towards residents. The staff's failure to ensure the resident was treated with dignity and respect by the X-ray provider led to the deficiency.
Inadequate Infection Control Practices and PPE Use
Penalty
Summary
The facility failed to implement proper infection control practices as evidenced by several deficiencies. Resident 1, who was exposed to COVID-19, was not placed on Novel Respiratory Precautions promptly on 7/9/2024, despite being reported to the Infection Preventionist Nurse (IPN). It was only after Resident 1 tested positive for COVID-19 on 7/12/2024 that the precautions were initiated. This delay in implementing necessary precautions could have contributed to the potential spread of the virus within the facility. Additionally, the facility did not conduct fit testing for Certified Nursing Assistants (CNAs) 1 and 2, who were in direct contact with Resident 1. Both CNAs were observed entering the room of another COVID-19 positive resident without proper fit-tested N95 masks. CNA 1 had been working at the facility for only two days and was not aware of the requirement for fit testing, while CNA 2 had been employed for six months without being fit tested. This lack of fit testing compromised the effectiveness of the protective equipment, increasing the risk of virus transmission. Furthermore, the CNAs were not adequately trained in the proper donning and doffing of personal protective equipment (PPE). Observations revealed that CNA 1 and CNA 2 were double masking incorrectly and not using goggles or face shields as required. The PPE bin outside the resident's room lacked necessary protective equipment, such as goggles or face shields, further indicating lapses in infection control practices. These deficiencies in training and equipment availability posed a significant risk of a widespread COVID-19 outbreak within the facility.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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