Sunray Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3210 W Pico Blvd, Los Angeles, California 90019
- CMS Provider Number
- 055870
- Inspections on file
- 94
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 24 (2 serious)
Citation history
Health deficiencies cited at Sunray Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including diverticulitis, muscle weakness, dysphagia, depression, and colostomy status, who was cognitively able to make decisions and required moderate to maximum assistance with ADLs, reported that a CNA providing night-shift care handled them roughly, threw towels onto their chest and colostomy site, and made threatening gestures with closed fists while warning the resident not to speak up. The facility suspended the CNA during an investigation but then allowed the CNA to return to work and provide direct care before receiving the required one-on-one in-service on abuse prevention and resident rights. The QA nurse and DSD confirmed that this abuse-related in-service was not completed until after the CNA had already resumed resident care, contrary to facility policy requiring such training prior to direct-care duties.
A resident with depression and chronic anxiety, who had intact cognition and an order for psychology consult and treatment as needed, reported that a CNA interacted with her in a threatening and aggressive manner, after which she experienced increased nocturnal anxiety, fear of falling asleep, and later stated she did not feel safe. Despite these documented emotional and behavioral changes, no behavioral or change-of-condition assessment was completed, no psychologist notes were present, and the care plan was not revised to address the new behavioral health symptoms. Facility staff, including social services and the MDS coordinator, confirmed that required behavioral assessments were not done, and the DON was unaware of the resident’s expressed lack of safety, contrary to facility policies on behavioral assessment, trauma-informed care, and comprehensive person-centered care planning.
A resident with severe cognitive impairment, dysphagia, and a full-code status was given a cookie by a visitor despite being on a pureed diet. Shortly afterward, the resident was found pale, unresponsive, not moving, and with food in the mouth. A CNA, an RNA, and an LVN responded but did not assess responsiveness, did not check for a pulse or breathing, and did not initiate CPR as required by facility policy and CPR guidelines. Instead, they focused on performing the Heimlich maneuver and moving the resident between the bed and a chair. CPR was only started after an RT arrived, found no pulse, and directed staff to return the resident to bed and begin resuscitation, resulting in a delay in basic life support for a full-code resident.
A resident with dementia, severe dysphagia, and a pureed gratification diet was care planned as at risk for aspiration but had no specific nursing interventions for dysphagia or diet management. The facility had a policy requiring visitors to inform nursing staff when bringing food and prohibiting sharing food with other residents, but staff did not educate visitors, did not document checks of outside food, and posted no signage about these requirements. A visitor who routinely brought food for another resident was never counseled about restrictions and, during a visit, gave a regular-texture chocolate chip cookie to the cognitively impaired resident on a pureed diet without consulting staff. Staff later found the resident unresponsive with cookie pieces in the mouth, attempted the Heimlich maneuver and CPR, and the resident was pronounced dead by paramedics, demonstrating a failure to prevent unsafe food from entering the resident environment and to provide adequate supervision for a high-aspiration-risk resident.
Surveyors found that the facility failed to develop individualized, person-centered care plans for dysphagia for four residents with documented swallowing disorders, cognitive impairment, and specialized diet or enteral feeding orders. Although each resident had diagnoses such as dysphagia, dementia, aphasia, or prior pneumonitis and required pureed or fortified diets or GT feedings, their care plan reports either lacked dysphagia care plans entirely or listed aspiration risk without any nursing interventions. The DON, an LVN, and the QAN all confirmed that facility policy requires each diagnosis to have a specific care plan with interventions such as diet orders, aspiration precautions, monitoring for coughing and shortness of breath, swallow evaluations by speech therapy, and education, and acknowledged that these dysphagia care plans were not initiated on admission. Staff stated that without such care plans, nurses would not know the specific treatment and interventions needed, creating a potential increased risk for aspiration and pneumonia.
The facility did not complete required competency evaluations and skills checklists for two CNAs, as mandated by its policies. The DSD confirmed missing documentation for both CNAs, and the DON acknowledged that without these evaluations, the facility could not assess staff knowledge or training needs.
A resident with severe cognitive impairment and total dependence on staff was found in an environment with a strong urine odor and a dirty, wet fall mat near the bed. The CNA acknowledged the odor and unclean conditions, noting that the resident's incontinence brief had not been changed due to being busy with other residents. The facility's policy for a clean and homelike environment was not upheld.
A resident with severe cognitive impairment and multiple medical diagnoses did not receive the ordered amount of enteral nutrition due to a feeding pump being turned off, resulting in only 200 ml being infused over 12 hours instead of the prescribed 960 ml. The discrepancy was confirmed by the DON, and the facility's policy requiring adequate nutritional support was not followed.
The facility failed to ensure timely and accurate medication administration, including late administration of blood pressure medication without physician notification, incomplete documentation of controlled substances, and lack of proper reassessment after PRN medication use. Additionally, two residents received insulin injections in the same sites without proper rotation, contrary to care plans and facility policy.
Staff did not adhere to the RCS diet guidelines by serving garlic bread to residents on a controlled-carbohydrate diet, despite clear instructions in the facility's food portioning and serving guide. Both the dietary aide and supervisory staff confirmed that garlic bread should not have been provided to these residents, as it was not part of the prescribed RCS meal plan.
Dietary staff failed to properly clean and sanitize cups, trays, and dishes, with food residue and tape remaining on items after dishwashing. Clean dishware was stored to air dry while still visibly soiled, and food particles were present on counters where clean items were placed. Staff interviews confirmed that dishes were not adequately scraped or rinsed before washing, resulting in improper cleaning and storage of kitchenware.
Three staff members, including an RN, LVN, and CNA, were found to have started employment without completed background checks, contrary to facility policy. This was discovered during a review following a resident's report of rough handling during care, which led to an abuse investigation. The facility's own policies required background checks before employment, but these were either delayed or missing for the staff involved.
Two residents with significant mobility impairments and pressure injuries did not have their call lights within reach, despite care plans and facility policy requiring accessibility. Staff observations confirmed that the call lights were either placed out of reach or left dangling off the bed, preventing the residents from calling for assistance when needed.
A resident with moderate cognitive impairment and acute kidney failure was discharged from Medicare Part A skilled services without being provided the required Notice of Medicare Non-Coverage (NOMNC). Facility staff and records confirmed the NOMNC was not issued, despite policy requiring advance notification before benefits end.
A resident with multiple advanced pressure ulcers, who was fully dependent on staff and in a persistent vegetative state, was not repositioned every two hours as required by the care plan and facility policy. Observations showed the resident remained on the same side for over three and a half hours, and staff confirmed the lapse in care, despite clear interventions and use of a low air loss therapy mattress.
Two residents requiring ventilator and oxygen support were observed with oxygen tubing resting on the floor, contrary to infection control policies. Both residents had significant respiratory conditions and care plans aimed at preventing infection. Staff, including the RT, IP, and DON, acknowledged that tubing on the floor was an infection control issue.
A resident with multiple medical conditions had a physician's order for 1% hydrocortisone cream without a stop date, allowing indefinite use. The consultant pharmacist identified this during a monthly medication regimen review and recommended adding a stop date or discontinuing the medication. Despite this, staff did not clarify the order with the physician, and the recommendation was not acted upon, contrary to facility policy.
A resident with multiple medical conditions received several scheduled medications late and without required vital sign checks prior to administration. An LVN administered the medications via G-tube hours after the scheduled time, did not notify supervisory staff or the physician about the delay, and failed to assess blood pressure and heart rate immediately before giving antihypertensive medication, as required by physician orders. These actions resulted in a medication error rate of 25%, exceeding the acceptable threshold.
A facility failed to create a person-centered care plan for a resident with major depressive disorder. Despite the resident's diagnosis being noted in the MDS, the care plan did not address depression, and staff confirmed the absence of necessary behavioral monitoring. The facility's policy mandates comprehensive care plans, which were not implemented in this case.
A facility failed to conduct weekly skin assessments for a resident with MASD, as required by their care plan. The resident, with multiple health issues, had their condition worsen to an unstageable pressure injury with necrotic tissue. The facility's policy required a comprehensive care plan, which was not followed.
A mobile linen cart was found uncovered and unattended in a hallway, exposing linens and violating the facility's infection control policies. Staff interviews confirmed the requirement to keep linen carts covered to prevent infection spread. The facility's policies mandate protection of clean linen during transport and storage.
A facility failed to develop a care plan for a resident with a stage four pressure injury on the left trochanter, despite the resident's complex medical conditions and dependency on staff for daily activities. The absence of a care plan was confirmed by the DON and was contrary to the facility's policy requiring comprehensive, person-centered care plans.
The facility failed to conduct background checks for an LVN and a CNA before hiring, as required by their policy to prevent abuse, neglect, and exploitation. This oversight was discovered during a review of employee files, where the checks were missing, and a search with the OIG system found no results. The DON emphasized the importance of these checks to ensure resident safety.
A facility failed to document necessary diagnoses for a resident receiving psychotropic medications. The resident's MDS did not reflect compulsive hoarding disorder or anxiety, despite being prescribed Ativan and Prozac. The MDSN confirmed a miscoding error, and the DON acknowledged the oversight, which could lead to unnecessary treatment.
A resident on oxygen was found smoking in their room, but the facility failed to update the smoking care plan or document smoking education. Despite initial assessments indicating the resident did not smoke, a later assessment confirmed smoking habits. The facility's oversight increased the risk of negative outcomes to the resident's well-being.
Two residents requiring substantial assistance with ADLs were neglected in their care. One resident was left in a soiled incontinence brief for 45 minutes despite calling for help, while another had a dry flaky substance around the eye that was not cleaned overnight. Staff were aware but did not provide timely assistance, citing reasons such as being on break. The facility's policies emphasize the importance of providing necessary care, but these were not followed, leading to neglect.
A resident with major depressive disorder was not provided necessary behavioral health care, as the facility failed to monitor and report symptoms of depression, update care plans, or ensure visits from mental health professionals. Despite known depressive symptoms, the resident was not systematically monitored or receiving medication, leading to unmanaged behavioral health needs.
The facility failed to provide sufficient nursing staff, resulting in delayed care for two residents who required assistance with personal care. CNAs reported being overburdened with assignments, making it difficult to respond promptly to residents' needs. Observations and interviews confirmed that residents experienced delays in receiving help, and family members expressed concerns about staffing levels. Despite claims of stabilized staffing, the facility did not meet required staffing hours, impacting the quality of care.
The facility failed to properly store and label medications, including insulin and inhalation powders, leading to potential risks for residents. Medications were found expired or improperly stored in medication rooms and carts, and timolol eye drops were left unattended during administration.
The facility failed to maintain safe food storage and preparation practices, including improperly labeled and stored thickened milk and juice, unmonitored thaw dates for nutritional supplements, and a dirty, worn can opener blade. These deficiencies posed a risk of foodborne illness to residents.
A facility failed to maintain a functional audible call system, impacting prompt response to resident needs. A resident with significant mobility and health issues reported the system was broken, and staff confirmed the announcement feature had been non-functional for months. Observations showed inconsistency in the system's operation, and temporary measures were in place to address the issue.
A resident's privacy was compromised when an LVN failed to close the bedside curtain during medication administration, violating the resident's right to dignity and privacy. The resident, with intact cognition and requiring assistance for personal hygiene, was observed during this incident. Interviews confirmed the importance of privacy, and the facility's policy emphasized maintaining dignity and respect.
A facility failed to ensure a resident had legal documentation for a representative, potentially delaying care. The resident, with mental disorder and hypertension, had no legal documentation confirming Family Member 2 as their representative after Family Member 1 passed away. The DON stated the admission process should identify a responsible party, but this was not completed, risking delayed care.
A facility failed to implement a care plan for a high-risk resident by not providing floor mats as required, increasing the risk of falls. Despite the care plan's directive, observations showed the absence of floor mats, and staff interviews confirmed the oversight. The resident had severe cognitive impairment and required maximum assistance, highlighting the need for proper fall prevention measures.
A resident with severe cognitive impairment and a high fall risk experienced a fall, but the LTC facility failed to update the fall care plan as required by their policy. Despite the resident's history and recent fall, the care plan was not revised, increasing the risk of further incidents.
The nursing staff failed to provide necessary safety interventions for two residents, one with a history of falls and another with epilepsy, in an LTC facility. Despite care plans and physician's orders, floor mats were not placed for a resident at high fall risk, and padded side rails were not provided for a resident with seizures. Observations and interviews confirmed these deficiencies, highlighting a lack of adherence to facility policies for fall prevention and bed safety.
A resident with multiple health conditions, including ESRD and diabetes, did not receive a required quarterly nutritional assessment, as confirmed by the RD, DS, and DON. The facility's policy mandates such assessments to ensure residents' nutritional needs are met, but the last assessment was conducted shortly after admission, with no follow-up documented.
A resident with a PICC line for Vancomycin administration had their dressing unchanged for nine days, contrary to the facility's policy of changing it every seven days. This oversight was acknowledged by a nurse and confirmed by the DON, highlighting a risk of infection due to non-compliance with the dressing change schedule.
The facility failed to ensure CNAs were competent in identifying fall risks, as evidenced by two CNAs' inability to recognize a yellow star indicating a high fall risk for a resident with severe cognitive impairment. Despite the facility's policy, there was no in-service training on fall prevention, leaving a gap in staff education and competency monitoring.
Two residents in a facility were affected by medication administration deficiencies. One resident with epilepsy did not receive the correct dose of divalproex ER due to a lack of 250 mg tablets, risking potential seizures. Another resident did not receive prescribed pyridoxine (vitamin B6) due to it being out of stock, risking vitamin deficiency. The facility's policy requires medications to be administered as prescribed, but these guidelines were not followed.
A facility failed to limit a PRN order for Lorazepam to 14 days for a resident with generalized anxiety disorder, as required by policy. The resident's physician's order lacked a stop date, leading to potential overmedication. Interviews with the RN and DON confirmed the oversight and acknowledged the risk of adverse effects due to non-compliance with the facility's psychotropic medication policy.
A long-term care facility failed to maintain a medication error rate below 5%, resulting in a 12.9% error rate. Two residents were affected: one did not receive the correct dose of divalproex ER for seizures due to a pharmacy order oversight, and another received metformin late and incorrect doses of other medications due to stock issues and administration errors. These failures were against the facility's medication administration policy.
A resident's food preferences were not updated or honored, leading to decreased meal satisfaction and caloric intake. Despite documented preferences for juice and milk and dislikes for certain foods, the resident received meals that did not align with their preferences. The Dietary Supervisor admitted that preferences were accidentally removed during a menu update, and the facility's policy to identify food preferences upon admission was not followed.
A facility failed to establish a contract and provide orientation for a cosmetologist who provided services to residents, including a resident with Alzheimer's and dementia. The cosmetologist, who was not employed by the facility, entered a resident's room without knocking or ensuring privacy. Interviews revealed no contract or vendor file existed, and it was unclear if the cosmetologist held a valid license. The facility's policy required all vendors to have a contract and undergo a 10-hour orientation, which was not completed.
The facility failed to ensure proper fit testing for staff using Medline N95 respirators, as several CNAs and LVNs were observed wearing these without being fit-tested. The Infection Preventionist confirmed the lack of fit testing, which is required by facility policy when changing respirator models. This deficiency was noted during a COVID-19 outbreak, highlighting the potential risk of exposure to airborne diseases.
A resident with respiratory conditions was not offered flu, pneumonia, and COVID-19 vaccines, despite being cognitively intact and capable of making her own decisions. The facility sought consent from the resident's family member, who refused the vaccines, contrary to the resident's wishes. The facility's policies required offering these vaccines to all residents, but the resident was not directly asked, leading to a deficiency in care.
A resident with dementia entered another resident's room at night and kissed them on the cheek, causing the resident to feel nervous and violated. Despite the incident occurring near the nursing station, no staff observed the event. The facility's policy defines such actions as non-consensual sexual contact.
A resident with dementia wandered into another resident's room and kissed them due to inadequate supervision. Despite having a care plan, the resident was not properly monitored, leading to the incident. Staff interviews revealed lapses in supervision, as the resident's room was near the nursing station, yet no staff observed the resident leaving.
The facility failed to maintain clean and sanitary fall mats in two residents' rooms, potentially exposing them to germs and infection. A resident with severe memory problems and another who was cognitively intact both had soiled fall mats, which were not cleaned by housekeeping. The facility's maintenance logbook lacked records of cleaning the mats, and the facility's cleaning policy was not followed.
The facility failed to ensure that their acting Infection Preventionist (IP) had accessible certification or training records in infection prevention and control. The Director of Staff Development, acting as the IP, could not provide a certificate despite claiming to have one. The facility's policies required specialized training, but the absence of documentation posed a risk to the infection prevention and control program.
Failure to Provide Required Abuse-Prevention In-Service Before CNA Returned to Direct Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy requiring appropriate in‑service training on resident rights and abuse prevention prior to staff having direct-care responsibilities. A resident admitted with diagnoses including diverticulitis, muscle weakness, dysphagia, depression, and colostomy status had documented cognitive capacity to understand and make decisions and required moderate to maximum assistance with ADLs. On a specified date, progress notes documented that this resident reported an allegation of abuse involving a CNA on the night shift. According to the resident’s report in the progress notes, the CNA allegedly woke the resident aggressively, threw two towels on the resident’s chest and another towel on the colostomy site, and turned and pulled the resident while providing incontinence care. The resident further alleged that the CNA made arm gestures with two closed fists and stated that if the resident spoke up about what happened, the resident would be hit, causing the resident to feel afraid of the CNA. The facility initiated an investigation and suspended the CNA pending the outcome, as reflected in the facility’s 5‑day conclusion of the facility‑reported incident. Record review showed that the CNA returned to work and provided resident care on a later date, as indicated by the time sheet. The Quality Assurance Nurse’s in‑service record for the CNA was dated after the CNA had already returned and provided care. In interviews, the Quality Assurance Nurse confirmed that he did not provide an in‑service to the CNA prior to the CNA resuming resident care, and the Director of Staff Development acknowledged she was responsible for providing one‑on‑one in‑service training before the CNA provided care but had not done so. The Administrator confirmed that the CNA was called back to work after the investigation was concluded and that in‑service training was not completed before the CNA’s shift, contrary to the facility’s policy requiring staff training on preventing, recognizing, and reporting abuse, and on resident dignity and respect, prior to having direct-care responsibilities.
Failure to Assess and Address Behavioral Health Needs After Alleged Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with depression and chronic anxiety received necessary behavioral health care and services following an alleged abuse incident. The resident was admitted with diagnoses including HTN, hyperlipidemia, depression, a colostomy, and a gastrostomy, and had intact cognition and decision-making capacity. Physician orders dated 10/23/2025 included a psychology consult and treatment as needed, and the resident’s care plan identified a psychosocial well-being problem related to a language barrier, with interventions including consultations with pastoral care, social services, and psych services. On 1/1/2026, the resident reported an allegation of abuse involving a CNA on the night shift. According to nursing progress notes, the resident stated that the CNA woke her aggressively, threw towels on her chest and colostomy site, pulled and turned her while providing care, and made arm gestures with two closed fists while telling her that if she spoke up about what happened she would be hit. The resident reported feeling afraid of this CNA. Subsequent physician documentation on 1/5/2026 noted that the resident, who had a chronic anxiety disorder per her husband, experienced increased nighttime anxiety and was afraid to fall asleep after this interaction. A progress note on 1/8/2026 documented that the resident stated she did not feel safe. Despite these documented changes in the resident’s emotional and behavioral status, the facility did not complete a behavioral assessment or change-of-condition assessment related to the 1/1/2026 incident. The Social Services Supervisor confirmed that trauma assessments are to be done on admission, quarterly, and at change of condition, and acknowledged that no behavioral assessment was done for the resident’s change in condition on 1/1/2026 and that there were no psychologist progress notes for the resident. The MDS Coordinator also stated there were no behavioral assessments done for the resident for 1/1/2026. The Quality Assurance Nurse described that, in general, an abuse allegation should trigger emotional distress monitoring, psych evaluation, social services consultation, and care plan updates when a resident continues to feel unsafe, but the record showed the resident’s increased anxiety and expressed lack of safety were not identified and addressed through care-planned behavioral health interventions. The facility’s own policies on behavioral assessment, trauma-informed care, and comprehensive person-centered care planning require identification, documentation, and interdisciplinary evaluation of new or changing behavioral symptoms and revision of the care plan when there is a significant change in condition, which did not occur in this case. During interviews, the Social Services Supervisor reported that the resident had made remarks about certain people of different ethnicities being loud, harmful, and unfriendly, and that the resident was not comfortable with certain staff of a different ethnicity, suggesting possible past trauma, but no related behavioral or trauma-focused assessment was documented after the incident. The DON stated she was not aware that the resident had reported not feeling safe on 1/8/2026 and indicated that the nurse should have notified the physician of this statement. Overall, the facility failed to recognize and assess the resident’s increased anxiety and fear following the alleged abuse, failed to initiate required behavioral assessments or a documented change-of-condition process, and failed to implement or document appropriate behavioral health and psychological services as outlined in the resident’s orders and the facility’s policies.
Failure to Promptly Assess and Initiate CPR for an Unresponsive Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff promptly assessed and initiated CPR for a resident who was a documented full code. The resident had severe cognitive impairment, dysphagia, dementia, COPD, a feeding tube, and a POLST and physician order directing that CPR and full treatment be provided to prolong life by all medically effective means. On the day of the incident, a visiting family member of the resident’s roommate brought cookies into the room. After the roommate requested cookies, the visitor fed a cookie to the cognitively impaired resident without consulting staff, despite the resident being on a pureed diet and unable to safely swallow solid foods. Shortly thereafter, the visitor observed the resident shaking, pale, and choking, and called for help. CNA1 responded and found the resident sitting up in bed, pale to bluish, with eyes open and wide, food running from the mouth, no movement, no gasping, no coughing, and no reaction to touch or to a finger sweep of the mouth. CNA1 reported that the resident did not blink, move, push back, or show any rise and fall of the chest. Despite recognizing these signs and being BLS certified (though her prior certificate was expired and her most recent certificate had been issued without her actually taking the class), CNA1 did not check for responsiveness in the prescribed manner, did not check for a pulse, and did not initiate CPR. Instead, she began performing the Heimlich maneuver two to three times and then, with RNA1, transferred the resident from the bed to a chair to continue the Heimlich. RNA1 and LVN1 each entered the room after hearing that a patient was choking. Both acknowledged that they did not assess the resident for responsiveness or check for a pulse before performing or continuing the Heimlich maneuver. RNA1 stated he did not have time to check for a pulse and focused on positioning the resident and performing abdominal thrusts, first in bed and then in a chair. LVN1 stated she was told the resident was choking and immediately performed the Heimlich maneuver without checking for breathing or a pulse, later acknowledging that CPR may have been delayed because the pulse was not checked. Multiple staff, including CNA2 and the DON, observed the resident as unresponsive, pale, not moving, and not alert, yet none of the first responders checked the resident’s pulse or initiated CPR at that time. RT1 arrived to find the resident sitting in a chair, appearing lifeless, not breathing, and without the universal sign of choking. RT1 checked the resident’s pulse, found none, and instructed staff to return the resident to bed and start CPR. Only at that point was CPR initiated. Interviews with the DON and Medical Director confirmed that facility policy and standard CPR protocols required that, upon finding an unresponsive resident, staff should immediately assess responsiveness, check for breathing and pulse, and, if no pulse is found, initiate CPR without delay. The facility’s own CPR policy required assessment of respirations and heartbeat, activation of emergency services, and initiation of CPR in the absence of a palpable pulse. The surveyors determined that CNA1, RNA1, and LVN1 failed to follow these required steps, resulting in a delay in CPR for a full-code resident who was unresponsive, not moving, and without a pulse when first found.
Removal Plan
- Implement a QAPI Performance Improvement Project (PIP) regarding CPR with return demonstrations.
- Educate all nurses on the procedure for initiating CPR and issue CPR certifications.
- Conduct CPR drills.
- Do not permit nurses to work without a CPR card until certification is completed.
- Audit residents' medical charts and identify residents who do not have a POLST.
Failure to Control Visitor Food and Supervise Resident on Pureed Diet Resulting in Choking Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident on a pureed gratification diet received food consistent with the ordered diet and to implement accident-prevention measures related to outside food brought by visitors. The resident had diagnoses including dysphagia oropharyngeal phase, dementia, prior pneumonitis due to inhalation of food and vomit, COPD, and required enteral feeding with only a pureed texture diet ordered for oral gratification. The resident’s care plan identified a risk for aspiration related to dysphagia but contained no nursing interventions addressing dysphagia, aspiration precautions, or the pureed diet. The Director of Nursing stated that each diagnosis required a specific care plan with interventions such as aspiration precautions, diet type, monitoring swallowing, and proper positioning, and acknowledged that this resident’s care plan did not include such interventions. The facility also failed to implement and operationalize its policy on Foods Brought by Family/Visitors. The written policy required family and visitors to inform nursing staff when foods were brought for a resident and prohibited sharing such foods with other residents. The DON stated that staff were supposed to tell family and visitors to check with nurses when bringing food, but there was no documentation of licensed nurses checking outside food, no education given to visitors regarding outside food, and no signs posted for visitors about the policy or about not sharing food with other residents. A family member visitor reported that staff saw her bring food into the facility almost weekly for another resident and never said anything, and that staff did not explain any rules or policies on outside food or what foods were safe or unsafe. On the day of the incident, a visitor brought chocolate chip and oatmeal cookies for the roommate of the resident on a pureed diet. While feeding a cookie to the roommate, the visitor reported that the resident on the pureed diet repeatedly asked for a cookie. The visitor then gave the resident a chocolate chip cookie without asking any staff if it was appropriate. After approximately five to ten minutes, the visitor observed the resident shaking, pale, and appearing to choke, and called for help. A CNA entered and found the resident in bed, unresponsive, pale, with food running from the mouth, and removed pieces of cookie from the mouth with a finger sweep. Additional staff, including a restorative nursing assistant, LVN, and respiratory therapist, responded and attempted the Heimlich maneuver, suctioning, and CPR. The resident was ultimately found to have no pulse and was later pronounced dead by paramedics. The facility’s failure to ensure supervision, environmental safeguards, and enforcement of the outside food policy allowed unsafe, non-pureed food to be provided to a resident with severe cognitive impairment and high aspiration risk, resulting in the resident receiving food inconsistent with the ordered pureed diet and choking. Family interviews further showed that the resident’s responsible party was not informed of any policy for outside food or steps to prevent the resident from being fed unsafe food from outside. This family member stated there were no signs or measures in place to remind the resident not to eat or to tell others not to feed him, despite his poor memory and history of ingesting unsafe substances, including laundry detergent prior to admission. The DON confirmed that staff were informed of residents on aspiration precautions only verbally at morning huddles and that there were no posted signs for visitors regarding food brought by family or visitors. The medical director and registered dietitian both confirmed that the resident was ordered a pureed texture diet due to dysphagia and that only pureed foods should have been given, with the expectation that families would be educated and would not give food without consulting nurses. These combined failures in care planning, visitor education, supervision, and enforcement of the outside food policy led directly to the resident being given a regular-texture cookie, choking, and dying.
Removal Plan
- The Administrative Consultant educated the Administrator (ADM) and the Director of Nursing (DON) on the policy regarding Food Brought by Family/Visitors.
- The DON conducted in-services for all staff on the policy regarding Food Brought by Family/Visitors.
- A third-party software sent text and email messages to all residents and their responsible parties educating them to inform nursing staff when foods are brought to the facility for a resident and instructing them not to share/distribute food to other residents.
- The facility posted signage throughout the facility regarding the Food Brought by Family/Visitor policy.
- The receptionist or designee encouraged visitors to sign in on the Visitor Log and indicate whether they brought food/drinks; if food/drinks were brought, LVNs ensured the items were appropriate for the resident’s prescribed diet and educated visitors not to share food/drinks with other residents.
- The Registered Dietitian posted a Dietary Log outside the kitchen for staff to cross-check special requests from residents/staff/family to ensure requests follow physician dietary orders posted in the kitchen.
- The Interdisciplinary Team identified residents with mechanically altered diets and updated their care plans.
Failure to Develop Individualized Dysphagia Care Plans for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement specific, individualized person-centered care plans for residents with dysphagia. For Resident 1, the admission record showed diagnoses including oropharyngeal dysphagia, dementia, prior pneumonitis due to inhalation of food and vomit, COPD, and the need for GT care. The care plan report dated 9/15/2025 identified a risk for aspiration related to dysphagia but contained no nursing interventions. Physician orders later directed enteral feeding with Jevity 1.5 at a specified rate and duration, and a pureed diet for oral gratification, but these orders were not translated into a detailed dysphagia care plan with measurable interventions. During interview, the DON acknowledged that Resident 1’s care plan lacked nursing interventions to address dysphagia and the pureed diet, despite the resident’s diagnosis and aspiration risk. For Residents 2, 3, and 4, surveyors found similar omissions. Resident 2 was admitted with diagnoses including aphasia, dysphagia following cerebral infarction, dementia, and adult failure to thrive, and had severe cognitive impairment per the MDS. The MDS documented extensive assistance needs for ADLs, and a physician order directed a controlled carbohydrate, pureed texture, thin consistency diet. Resident 3 was admitted with gastrostomy, dysphagia, and dementia, had moderate cognitive impairment, was dependent for multiple ADLs, and had orders for a fortified pureed thin diet. Resident 4 was re-admitted with aphasia and dysphagia following cerebral infarction, had moderate cognitive impairment, required substantial to total assistance for eating and other ADLs, and had orders for a fortified/high protein, no added salt, pureed thin diet. Despite these diagnoses and diet orders, record review showed that none of these three residents had a specific dysphagia care plan initiated upon admission or thereafter. Multiple staff interviews confirmed the absence of required dysphagia care plans and clarified facility expectations. The DON, LVN 2, and the Quality Assurance Nurse each stated that every resident diagnosis and identified problem should have a care plan, that care plans are individualized guides for treatment, and that dysphagia care plans should include interventions such as diet orders, aspiration precautions (e.g., upright positioning, head of bed elevation), monitoring for coughing and shortness of breath, monitoring swallowing, speech therapy/swallow evaluations, and education for residents and families. They each acknowledged that Residents 2, 3, and 4 had dysphagia diagnoses and pureed diet orders but did not have dysphagia care plans initiated on admission. The facility’s written policy on comprehensive person-centered care plans required measurable objectives and timetables for each resident’s needs, ongoing assessment, and revision of care plans with changes in condition or orders, but these requirements were not met for the four residents with dysphagia. Staff further stated that the lack of dysphagia care plans created a potential for increased risk of aspiration and pneumonia because nurses would not know the specific plan of care, treatment, and interventions needed for these residents’ swallowing difficulties. The DON, LVN 2, and the QAN each articulated that without a dysphagia care plan, nurses lacked clear guidance on necessary precautions and monitoring. This combination of documented diagnoses, diet orders, and acknowledged facility policy, contrasted with the absence of corresponding individualized dysphagia care plans and interventions, formed the basis of the cited deficiency under the requirement to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for each resident. The facility’s own policy and staff descriptions emphasized that care plans should reflect recognized standards of practice, include services to attain or maintain the highest practicable well-being, and be updated on admission, quarterly, with changes in condition, and with new physician orders. Despite this, the care plan reports for all four residents lacked a specific dysphagia problem and associated interventions, even though each resident had documented swallowing disorders and specialized diet or feeding orders. The survey findings therefore centered on the gap between policy and practice: the facility did not translate known dysphagia diagnoses and physician orders into individualized, measurable care plan interventions for these residents, as confirmed by record review and staff interviews.
Failure to Complete Required Staff Competency Evaluations
Penalty
Summary
The facility failed to conduct required staff competency evaluations for two of three sampled certified nursing assistants (CNAs), as mandated by its own policies and procedures. Specifically, one CNA did not have a performance skills checklist in their employee file, and another CNA, who was hired several months prior, did not have a documented performance evaluation. The Director of Staff Development (DSD) acknowledged that she was new to the system and was unaware of when the skills checklist for one CNA was performed, and also confirmed that the performance evaluation for the other CNA had not been completed. The DSD stated that performance evaluations are generally performed ninety days after hire and then annually, but these were missing for the two CNAs in question. The Director of Nursing (DON) confirmed that an audit of employee files had been conducted, and without the required performance evaluations and skills checklists, the facility would not be able to determine if staff lacked knowledge or required additional training. The facility's policies require that job performance be reviewed at the end of a 90-day probationary period and at least annually thereafter, and that competency requirements and training for nursing staff are established and monitored by nursing leadership. The absence of these evaluations and documentation for the two CNAs represents a failure to ensure that staff have the appropriate competencies to care for residents as required by facility policy.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
Facility staff failed to maintain a clean, odor-free, and homelike environment for a resident with severe cognitive impairment and total dependence on staff for daily living activities. Observations revealed a strong urine odor around the resident's bed and room entrance, as well as a dirty, wet, and smelly gray fall mat at the right side of the bed. The fall mat was noted to have foot prints, scuff marks, and a drying sticky wet mark. A Certified Nursing Assistant (CNA) acknowledged the strong urine odor and the unclean condition of the fall mat, attributing the situation to not having had a chance to change the resident's incontinence brief due to being occupied with other residents. The resident involved had multiple medical diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, gastrostomy, hypertension, and dysphagia. The Minimum Data Set assessment indicated the resident was totally dependent on staff for bed mobility, dressing, toileting, bathing, and personal hygiene. The facility's policy required a safe, clean, comfortable, and homelike environment with pleasant, neutral scents, but these standards were not met in this instance.
Failure to Administer Prescribed Enteral Nutrition Due to Pump Malfunction
Penalty
Summary
Facility staff failed to administer the prescribed amount of enteral nutrition to a resident with multiple complex medical conditions, including diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, gastrostomy, hypertension, and dysphagia. The resident was totally dependent on staff for all activities of daily living and had severe cognitive impairment. The physician's order specified that the resident should receive diabetic source enteral feeding at 1.2 calories per milliliter, 80 ml per hour for 20 hours, totaling 1600 ml or 1920 calories, with a scheduled pause from 8 am to 12 pm. Observation at the resident's bedside revealed that the enteral feeding pump was turned off, and only 200 ml of formula had been infused over a 12-hour period, instead of the ordered 960 ml. The feeding bottle had been hung the previous evening, and the discrepancy was confirmed during an interview with the DON, who acknowledged the resident did not receive the required nutrition due to the pump not functioning as intended. The facility's policy required adequate nutritional support through enteral nutrition as ordered, but this was not followed in this instance.
Medication Administration and Controlled Substance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure safe medication administration and accurate accountability of controlled medications for four residents. For one resident with hypertension and dependence on a ventilator, blood pressure medication (Amlodipine) was administered late on six occasions, and the physician was not notified of the delays. Additionally, the nurse did not check the resident's blood pressure immediately prior to administering the medication, as required by the physician's order. The facility's policy required medications to be administered within one hour of the scheduled time and for vital signs to be checked if necessary, but these procedures were not followed. For the same resident, there was a discrepancy between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR) for a dose of Oxycodone/APAP, a controlled medication. The CDR indicated a dose was removed and administered, but the MAR lacked documentation of administration and pain assessment. The nurse responsible did not document the administration or the resident's pain level, contrary to facility policy, which requires immediate documentation of all medications administered, including PRN effectiveness. Another resident with epilepsy and anoxic brain damage had discrepancies in the documentation and administration of Ativan, a controlled medication. The CDR, MAR, physician's order, and pharmacy label did not match, and the inventory of the medication was inconsistent. The resident was not reassessed for effectiveness of PRN Ativan within the required 30 minutes, and the physician's order lacked a maximum dose and clear instructions for when to notify the physician. Additionally, two residents with diabetes received insulin injections in the same sites repeatedly, without proper rotation, despite care plans and facility policy requiring site rotation to prevent complications.
Failure to Follow RCS Diet Guidelines During Meal Service
Penalty
Summary
Staff failed to follow the facility's Reduced Concentrated Sweets (RCS) diet guidelines for residents requiring blood sugar control. On the specified lunch service, both regular and RCS diet trays were observed receiving garlic bread, despite the facility's food portioning and serving guide indicating that garlic bread should not be served to residents on the RCS diet. The lunch menu and the serving guide clearly differentiated between the regular and RCS diets, with the RCS diet omitting garlic bread and providing a reduced portion of dessert. During interviews, the dietary aide responsible for assembling trays confirmed that garlic bread was added to both regular and RCS trays, acknowledging that this was not in accordance with the diet spreadsheet and could affect blood sugar levels. The dietary supervisor and registered dietitian also confirmed that the RCS diet should not have included garlic bread and that staff are required to follow the diet spreadsheets to ensure residents receive the correct nutrition per diet orders. Facility policy on controlled-carbohydrate diets emphasized the importance of following specified portion sizes and meal components for blood sugar management.
Improper Cleaning and Storage of Kitchenware
Penalty
Summary
Surveyors observed that dietary staff failed to ensure proper cleaning and sanitization of resident cups, trays, and dishes in the kitchen. During the inspection, a dietary aide was seen removing trays, cups, and bowls from the dishwashing machine and storing them to air dry, despite visible food particles and residue remaining on the items. Some trays also had tape stuck to them, and the counter where clean dishes were placed was covered with food particles, including grains from breakfast cereal. The dietary aide admitted to returning visibly dirty dishes to be rewashed but did not notice other soiled items that were stored as clean. The dietary supervisor confirmed the presence of food residue and tape on the trays and acknowledged that the counter was contaminated with food particles from the dishes. Further interviews revealed that the dishwasher operator had not adequately scraped or rinsed the dishes before loading them into the dishwashing machine, resulting in grits and other food debris remaining on the trays and bowls after washing. The facility's policy required all utensils, counters, shelves, and equipment to be kept clean and in good repair, and the FDA Food Code specified that food debris should be scraped and, if necessary, pre-flushed or scrubbed before washing. These procedures were not followed, leading to improper cleaning and storage of kitchenware used by residents.
Failure to Complete Pre-Employment Background Checks for Direct Care Staff
Penalty
Summary
The facility failed to ensure that three out of ten staff members, including a registered nurse, a licensed vocational nurse, and a certified nurse assistant, had background checks completed prior to their employment. Review of employee files revealed that background checks for these staff members were either conducted years after their hire dates or only after a random review, rather than before employment as required by facility policy. The Director of Staff Development confirmed that some background checks were missing or delayed, and the Director of Nursing acknowledged the risk posed by employing staff without completed background checks. An incident involving a resident who required assistance with personal care, and who had diagnoses including gout and toxic encephalopathy, highlighted the deficiency. The resident reported being handled roughly by a CNA during incontinent care, leading to an abuse investigation. It was discovered that the CNA involved had not undergone a background check prior to hire. Facility policies reviewed indicated that background checks were to be completed before employment, but this was not followed in these cases.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for resident needs by not ensuring that the call light was within reach for two residents. For one resident with limited mobility, muscle weakness, pressure-induced deep tissue injuries, and a history of falls, multiple care plans specified that the call light should be within easy reach at all times and that the resident should be encouraged to use it for assistance. However, during an observation, the call light was found above the resident's head, resting on the mattress and facing the back wall, making it inaccessible. The resident was unable to call for assistance after an incontinent episode until staff intervened. Another resident, diagnosed with pressure ulcers and functional quadriplegia, also had care plans indicating the need for the call light to be within reach and for staff to encourage its use. During observation, the call light was clipped to the top of the mattress and left dangling off the side of the bed, again not within the resident's reach. Staff confirmed that if the call light was not accessible, the resident could not call for help. The assigned CNA was not present at the time, but other CNAs were reportedly available in the hallway. Interviews with staff, including the DON, confirmed that nursing staff are expected to ensure call lights are in place at the beginning of each shift and that call lights should always be accessible to residents. The facility's policy also requires that the call light be accessible to residents when in bed. Despite these policies and care plan interventions, the call lights were not within reach for the two residents at the time of observation.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident whose Medicare Part A skilled services were ending. The resident, who was admitted for acute kidney failure and was moderately cognitively impaired, required substantial assistance with daily activities. According to the facility's records, the resident's last covered day for Medicare Part A services was documented, and the discharge was planned with the resident returning home with home health services. However, there was no evidence that the NOMNC was issued to the resident as required. During interviews and record reviews, both the Business Office Administrator and the Director of Nursing were unable to locate the NOMNC or determine if the discharge was beneficiary-initiated. The facility's policy required that a NOMNC be issued at least two calendar days before Medicare benefits end, but the documentation and staff interviews confirmed that this did not occur for the resident in question.
Failure to Reposition Bedbound Resident with Pressure Ulcers Every Two Hours
Penalty
Summary
A deficiency was identified when a resident with multiple pressure ulcers, including Stage III and Stage IV wounds, was not repositioned every two hours as required by their care plan and facility policy. The resident, who was in a persistent vegetative state and fully dependent on staff for all activities of daily living, was observed lying on her left side for over three and a half hours without being repositioned. Multiple staff interviews confirmed that the resident should have been turned at least every two hours to prevent further skin breakdown and to comply with the care plan interventions. The resident's medical history included acute and chronic respiratory failure, non-traumatic subarachnoid hemorrhage, COPD, ventilator dependence, and persistent vegetative state. The care plan specifically addressed the need for frequent repositioning due to the presence of pressure ulcers on several body sites, and the use of a low air loss therapy mattress was ordered for wound management. Despite these interventions, direct observations and staff interviews revealed that the resident was not repositioned as required, and staff acknowledged the lapse in care. Facility policies on prevention of pressure injuries and repositioning outlined the necessity of individualized repositioning schedules, with a minimum standard of every two hours for bed-bound residents. The Director of Nursing and other staff verified that the resident had not been repositioned according to the care plan, and that simply placing a pillow under the resident did not constitute a proper repositioning. The failure to follow the established care plan and facility policy resulted in the identified deficiency.
Oxygen Tubing Found on Floor for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents who required ventilator and oxygen support. For both residents, observations revealed that oxygen tubing connected to their ventilators was resting on the floor. Resident 29, who was in a persistent vegetative state with chronic respiratory failure, tracheostomy, and under hospice care, was observed with oxygen tubing touching the floor in their room. Resident 63, who was ventilator-dependent with chronic respiratory failure, COPD, ALS, and had mental capacity, was also observed with oxygen tubing on the floor. Both residents had care plans with goals to remain free of infection, and physician orders for oxygen therapy and ventilator support. During interviews, the respiratory therapist acknowledged the tubing was on the floor and agreed it could be an infection control issue, stating the tubing would be replaced. The infection preventionist and DON also confirmed that oxygen tubing touching the floor constituted an infection control problem. The facility's infection control policy required maintaining a safe and sanitary environment to prevent and control infections, and staff were to be trained on these practices. Despite these policies, the observed practice of allowing oxygen tubing to rest on the floor represented a failure to adhere to infection control standards.
Failure to Clarify Physician Order for Topical Steroid After Pharmacist Recommendation
Penalty
Summary
The facility failed to clarify a physician's order for hydrocortisone cream as recommended by the consultant pharmacist during the monthly medication regimen review for one resident. The resident had been readmitted with multiple diagnoses, including Type 2 diabetes, rash, schizophrenia, dementia, and psychosis. The physician's order directed the use of 1% hydrocortisone cream to the right side of the nose and face every six hours as needed for itching, but did not include an end date, allowing for indefinite use. During the consultant pharmacist's medication regimen review, it was noted that the order for hydrocortisone cream lacked a stop date. The pharmacist recommended that the topical steroid be used for no more than four weeks at a time and advised facility staff to request the physician to add a stop date or discontinue the medication. Despite this recommendation, the order remained unchanged and the cream continued to be available for indefinite use. Interviews with facility staff, including an LVN and the DON, confirmed that the pharmacist's recommendation was not acted upon. Both staff members acknowledged that recommendations from the consultant pharmacist should be communicated to the physician and followed up, but in this case, the order was neither clarified nor discontinued as advised. The facility's policy required that such recommendations be acted upon and documented, but this process was not completed for the resident in question.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5%, as evidenced by seven medication errors out of 28 observed opportunities, resulting in a 25% error rate for one resident. The errors were identified during a medication administration observation for a resident with diagnoses including hypertension, ventilator dependence, and a gastrostomy tube. The resident required multiple medications to be administered via G-tube, with specific physician orders and parameters for administration, such as holding blood pressure medications if certain vital sign thresholds were not met. During the observed medication pass, a licensed vocational nurse prepared and administered eight scheduled morning medications several hours past the prescribed time without notifying a supervisor or the physician. The nurse did not check the resident's blood pressure or heart rate immediately prior to administering the antihypertensive medication, instead relying on vital signs taken four hours earlier. This was contrary to the physician's order, which required current vital sign assessment before administration. The nurse also failed to inform the nurse practitioner or physician about the delay in medication administration, as required by facility policy. Interviews with facility staff, including the nurse practitioner, registered nurse, director of nursing, and medical director, confirmed that the nurse should have checked the resident's vital signs immediately before administering the blood pressure medication and should have notified the physician about the late administration. Facility policy required medications to be given within one hour of the scheduled time and for staff to notify the physician if this was not possible. The failure to follow these procedures resulted in multiple medication errors for the resident.
Failure to Develop Care Plan for Resident's Depression
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident diagnosed with major depressive disorder. The resident, who was admitted with diagnoses including myopathy, schizophrenia, and major depressive disorder, was found to have no care plan addressing their depression. The comprehensive Minimum Data Set (MDS) indicated the resident was free of cognitive impairment and required assistance with bed mobility, transfer, and personal hygiene. Despite the diagnosis of depression being noted, the care plan revised on March 17, 2025, did not include measures to address this condition. During interviews, both a Licensed Vocational Nurse (LVN) and the MDS Nurse confirmed the absence of a care plan for the resident's depression. The LVN highlighted the need for a behavioral monitoring care plan to observe signs of depression, such as crying, lack of appetite, and refusal of care, which were not documented. The MDS Nurse acknowledged the lack of a care plan and stated that the issue should be discussed during the facility's quarterly interdisciplinary team meeting. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables, which was not implemented for this resident.
Failure to Implement Weekly Skin Assessments
Penalty
Summary
The facility failed to implement the care plan intervention of conducting weekly skin assessments for a resident, which was a requirement due to the resident's existing skin condition. The resident was admitted with multiple diagnoses, including visual loss, hypertension, morbid obesity, anemia, heart failure, and arrhythmia. The care plan, dated 11/14/24, specified weekly skin assessments due to moisture-associated skin damage (MASD). However, the facility did not perform these assessments for three consecutive weeks, as verified by the Director of Nursing (DON). The resident's condition worsened, with the MASD progressing to an unstageable pressure injury with necrotic tissue. The resident was at risk for unavoidable pressure injury due to complex medical conditions and episodes of noncompliance with care, including refusing turning, repositioning, and wound care. The facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables, which was not adhered to in this case.
Uncovered Linen Cart Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not ensuring that a mobile linen cart was covered while unattended. During an observation in the hallway outside the activity room, a mobile linen cart was found with its flap open, exposing the linen inside. This observation was confirmed during an interview with a Certified Nursing Assistant (CNA), who acknowledged that the cart should have been covered for infection control purposes. Further interviews with a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the linen cart should not be left uncovered to prevent the spread of infection. The Infection Preventionist (IP) also stated that uncovered linens could lead to the spread of infection and that staff had been trained to cover the carts. The facility's policy and procedure documents indicated that clean linen should be protected from dust and soiling during transport and storage, and that all personnel would be trained on infection control practices.
Failure to Develop Care Plan for Resident's Pressure Injury
Penalty
Summary
The facility failed to develop a care plan for a resident with a stage four pressure injury on the left trochanter. This deficiency was identified during a review of the resident's records and confirmed by the Director of Nursing (DON). The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, dysphagia, and cerebrovascular accident, was dependent on staff for activities of daily living and had severely impaired cognition. Despite these conditions, there was no care plan in place for the resident's significant wound, which required specific treatment with Santyl ointment as per physician's orders. The absence of a care plan for the resident's pressure injury was contrary to the facility's policy and procedures, which mandate the development and implementation of a comprehensive, person-centered care plan for each resident. This plan should include measurable objectives and timetables to address the resident's physical, psychosocial, and functional needs. The lack of a care plan for the resident's wound posed a risk of not providing appropriate, consistent, and individualized care, as confirmed by the DON during the survey.
Failure to Conduct Background Checks for Staff
Penalty
Summary
The facility failed to implement its policy and procedure titled 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program' by not conducting background checks for two staff members, a Licensed Vocational Nurse (LVN 1) and a Certified Nurse Assistant (CNA 2), prior to their employment. This oversight was discovered during a review of employee files with the Director of Staff Development (DSD), where it was found that the background checks were missing from the files of these two staff members. The DSD confirmed that the background checks should have been present in the files but were not, and a subsequent search with the OIG background check system yielded no results for these individuals. The Director of Nursing (DON) stated that background checks are a prerequisite for hiring to ensure that employees do not have any legal issues that could pose a risk to resident safety and well-being. The facility's policy, dated April 2021, mandates conducting employee background checks as part of its commitment to protecting residents from abuse, neglect, exploitation, or misappropriation of property by anyone, including facility staff. The failure to adhere to this policy increased the risk to the health and rights of the residents in the facility.
Failure to Document Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident had current documented diagnoses to support the administration of psychotropic medications. The resident was admitted with a diagnosis of dementia and muscle weakness. However, the care plans indicated the use of Ativan for anxiety and Prozac for compulsive hoarding disorder, neither of which were documented as active diagnoses in the resident's Minimum Data Set (MDS). The MDS, a federally mandated resident assessment tool, did not reflect diagnoses of compulsive hoarding disorder, depression, or anger outburst, which were necessary to justify the prescribed medications. During interviews, the Minimum Data Set Nurse (MDSN) confirmed a miscoding error, acknowledging that new orders were discussed in clinical meetings but not accurately captured in the MDS. The Director of Nursing (DON) also confirmed that the MDS did not indicate the necessary diagnoses, which could lead to unnecessary treatment without proper documentation. The facility's policy required the MDS coordinator to ensure appropriate edits before transmitting MDS data, but this was not adhered to, resulting in the deficiency.
Failure to Update Smoking Care Plan for Resident on Oxygen
Penalty
Summary
The facility failed to ensure that a resident, who was administered oxygen, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident was found smoking in his room, and the smoking care plan was not updated or revised. This oversight increased the risk of a negative outcome to the resident's physical and psychosocial well-being. The resident had been admitted with diagnoses including hemiplegia, hemiparesis, depression, anxiety, and intellectual disability. Despite these conditions, the Minimum Data Set indicated the resident was cognitively intact, which was inconsistent with the list of diagnoses. The facility's records showed discrepancies in the resident's smoking status, with initial assessments indicating the resident did not smoke. However, a later assessment confirmed the resident was a smoker and used electronic cigarettes. The facility's smoking care plan included interventions such as explaining the facility's smoking policies and fire safety, but there was no documentation verifying these interventions were implemented. The facility's policy required re-evaluation of a resident's smoking status upon significant changes, but the care plan was not updated after the resident was found smoking in his room. An LVN acknowledged that the smoking care plan should have been updated and that the smoking education provided to the resident was not documented.
Neglect in Resident Care for ADLs
Penalty
Summary
The facility failed to protect two residents from neglect, as observed in the care of their activities of daily living (ADLs). Resident 77, who required substantial assistance with personal hygiene, was left in a soiled incontinence brief for 45 minutes despite calling out for help multiple times. The resident expressed feelings of being dirty, unimportant, and frustrated due to the lack of timely assistance. Observations revealed that both a CNA and an LVN were aware of the resident's calls for help but did not provide immediate assistance, citing reasons such as the assigned CNA being on lunch break. Resident 48, who was dependent on others for personal hygiene due to visual impairment and other medical conditions, was observed with a dry flaky substance around the right eye, which had not been cleaned since the previous night. The resident expressed discomfort and requested assistance to clean the eye. The CNA acknowledged the resident's need for total care and the necessity to clean the eye to prevent further discomfort or potential infection. The facility's policies on ADLs and abuse and neglect emphasize the importance of providing necessary care to maintain residents' hygiene and prevent neglect. However, the observations and interviews indicate a failure to adhere to these policies, resulting in neglect of the residents' needs. The Director of Staff Development and the Director of Nursing acknowledged the expectations for staff to respond to residents' needs and the potential consequences of neglect, such as skin breakdown and eye infections.
Failure to Provide Behavioral Health Care for Resident with Depression
Penalty
Summary
The facility failed to provide necessary behavioral health care for a resident diagnosed with major depressive disorder. The resident, who was admitted with multiple diagnoses including major depressive disorder, was not monitored for signs and symptoms of depression as outlined in their care plan. The care plan, which was supposed to include interventions such as monitoring and reporting acute episodes of sad feelings, was not updated or reviewed quarterly, and there was no evidence of monitoring or reporting to the physician as needed. The resident expressed feelings of frustration and sadness, which were not adequately addressed by the facility. Despite the resident's care plan indicating the need for psychologist visits every three weeks, there was no record of such visits or evaluations by a psychiatrist or psychologist. Interviews with staff revealed that the resident's depressive symptoms were known, but there was no systematic monitoring or documentation of these symptoms, and the resident was not receiving medication for depression. The facility's policy on behavioral assessment and monitoring was not followed, as the nursing staff failed to identify, document, and inform the physician about changes in the resident's mental status. The Director of Nursing acknowledged that the resident was not being monitored due to the absence of medication for depression and a lack of orders from a psychologist or psychiatrist. This oversight resulted in the resident's behavioral health needs being unmanaged, contrary to the facility's obligation to provide necessary care.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to meet the needs of two residents, Resident 77 and Resident 39. Both residents experienced delays in receiving assistance for personal care needs, such as being cleaned and changed. Certified Nursing Assistants (CNAs) reported being assigned over 15 residents each, making it impossible to provide quality care. Observations and interviews revealed that Resident 77 was left calling for help to be changed, and staff were unable to respond promptly due to high workloads. Resident 77 was admitted with chronic osteomyelitis, abnormalities of gait and mobility, and congestive heart failure, requiring substantial assistance with activities of daily living. The resident was observed calling out for help to be changed, and staff were seen passing by without responding. Interviews with CNAs and Licensed Vocational Nurses (LVNs) confirmed that the facility was consistently short-staffed, leading to delays in responding to residents' needs and affecting the quality of care provided. Family members and staff expressed concerns about the facility's staffing levels, with reports of long wait times for phone calls and call lights. The Director of Staff Development acknowledged the potential impact of insufficient staffing on resident care, while the Director of Nursing admitted that the facility had not met required staffing hours in the subacute unit. Despite claims of stabilized staffing, the facility's policy indicated a need for sufficient nursing staff to ensure resident safety and well-being, which was not met in this instance.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and removal of undated and expired medications, specifically insulin, fluticasone-salmeterol, lansoprazole suspension, and gabapentin solution, as per manufacturer's requirements. This affected multiple residents across different medication storage areas, including the Station A Medication Room and various medication carts. Observations revealed that insulin vials and pens were either not labeled with an open date or were stored beyond their expiration dates, which could lead to ineffective treatment for residents with diabetes. In the Middle Medication Cart, several insulin products were found to be expired, including Insulin Lispro Kwik Pen, Basaglar Kwik Pen, Admelog SoloStar, and Humulin N KwikPen. Additionally, fluticasone and salmeterol inhalation powder was found to be expired. These medications were not removed from the cart as required, potentially compromising their effectiveness and safety for residents with conditions such as diabetes and respiratory issues. Furthermore, during medication administration, timolol eye drops were left unattended on a resident's bedside cart, posing a risk for misplacement or misuse. The facility's policy and procedure for medication labeling and storage were not adhered to, as medications were not stored in locked compartments or under proper conditions, and labels did not consistently include necessary information such as expiration dates and resident names.
Deficient Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. There was a carton of thickened milk stored in the refrigerator without an open date, and a carton of thickened apple juice was mislabeled with a use-by date that exceeded the facility's guidelines for fruit juice storage. Additionally, a peeled onion was improperly stored at room temperature in the bulk onion storage container, which should have been refrigerated. The Dietary Supervisor acknowledged these issues, stating that opened products should be marked and used within seven days according to facility guidelines. Furthermore, nutritional supplements labeled to be stored frozen and used within 14 days of thawing were not monitored for the correct thaw date. Thirty strawberry-flavored nutrition supplements were found in the refrigerator with different thaw dates, leading to uncertainty about their freshness. The Dietary Supervisor admitted to not knowing the real thaw date due to multiple dates being recorded and subsequently discarded the supplements. This oversight had the potential to cause foodborne illness among residents consuming these supplements. Additionally, a can opener blade in the kitchen was found to be dirty with sticky brown residue and was worn and nicked, making it difficult to clean properly. The Dietary Supervisor confirmed that the blade needed replacement as it could not be adequately cleaned and sanitized, posing a risk of contamination. The facility's policy on sanitization requires all equipment to be maintained in good repair and free from defects that could affect their use or cleaning, which was not adhered to in this instance.
Deficiency in Audible Call System Functionality
Penalty
Summary
The facility failed to ensure that the audible resident call system remained functional, which had the potential to prevent staff from answering call lights promptly. The call light for a specific room was not audible when pressed, as observed during the survey. A resident admitted with Guillain-Barre Syndrome, spinal stenosis, and muscle weakness, who was dependent on staff for mobility and at risk for pressure ulcers, reported that the call system was broken. The resident expected an automated voice announcement when the call light was activated, which was not functioning as intended. Interviews with staff revealed that the call light system was supposed to light up outside the room and announce the room number, but the announcement feature had not been working for about six months. Maintenance staff confirmed that while the light was visible on the panel across from the nurse's station and outside the room, the room number announcement was not audible. Observations on different days showed inconsistency in the audible system's functionality. The Director of Nursing emphasized the importance of both audible and visual systems working, while the Administrator mentioned that CNAs were stationed at the end of hallways to visually monitor call lights as a temporary measure.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to maintain dignity and privacy for Resident 63 by not closing the bedside curtain during medication administration. This incident was observed when the Director of Nursing (DON) instructed Licensed Vocational Nurse (LVN) 4 to assist LVN 3 with a medication pass. LVN 3 entered Resident 63's room with prepared medications but did not close the bedside curtain while administering them. This action violated the resident's right to privacy and dignity. Resident 63 was admitted to the facility with diagnoses including Type II Diabetes Mellitus and unspecified anemia. The resident had intact cognition and required assistance for personal hygiene. Interviews with the DON and LVN 4 confirmed the importance of closing the bedside curtain to ensure privacy and dignity, and it was noted that LVN 3 did not follow this protocol. The facility's policy on dignity, reviewed in August 2024, emphasized treating residents with dignity and respect, including maintaining privacy during care and treatment procedures.
Failure to Document Resident Representation
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 66, had legal documentation indicating that a family member was the resident's representative. This deficiency was identified during a review of the resident's records and interviews with facility staff. Resident 66 was admitted with diagnoses including an unspecified mental disorder and hypertension. The facility's records indicated that Family Member 1, who was initially responsible, had passed away, and Family Member 2 was to make decisions for the resident. However, there was no legal documentation in the resident's electronic chart to confirm Family Member 2 as the representative. During an interview, the Director of Nursing (DON) explained that the admission process should include identifying if a resident can represent themselves or if a responsible party is available. In the absence of a responsible party, the facility should contact the ombudsman or conservatorship. The lack of legal documentation for Resident 66's representative could lead to a delay in care. The facility's policy required the DON or a designee to obtain documentation designating the representative, but this was not done for Resident 66.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident 6, who was identified as being at high risk for falls. Despite the care plan's directive to place floor mats on both sides of Resident 6's bed to minimize falls and injuries, observations on multiple occasions revealed that no floor mats were present. Resident 6, who had severe cognitive impairment and required maximum assistance with daily activities, was observed in bed without the necessary fall prevention measures in place. Interviews with staff, including Certified Nursing Assistants (CNAs) and the Director of Staff Development (DSD), confirmed the absence of floor mats and acknowledged the increased risk of falls and injury due to this oversight. The CNAs were either unsure or aware of the requirement for floor mats but could not explain their absence. The DSD confirmed that the care plan included floor mats as an intervention for residents with a history of falls, and the lack of implementation for Resident 6 was a deviation from the facility's policy and procedure for comprehensive person-centered care plans.
Failure to Update Fall Care Plan for Resident
Penalty
Summary
The facility failed to revise the fall care plan for a resident who sustained a fall on 10/27/2024. This resident, identified as Resident 6, was readmitted to the facility with diagnoses including cerebral infarction and dementia, which contributed to severe cognitive impairment and a high risk of falls. Despite the resident's history of falls and the recent incident, the care plan was not updated to reflect the change in condition, as confirmed by both the Licensed Vocational Nurse and the Director of Staff Development during interviews. The facility's policy requires that care plans be reviewed and updated when there is a significant change in a resident's condition. However, after the fall on 10/27/2024, no revisions were made to Resident 6's care plan, which was a deviation from the facility's established procedures. The lack of an updated care plan increased the risk of injury and recurrent falls for the resident, as the care plan did not address the most recent fall incident.
Failure to Implement Safety Interventions for Residents
Penalty
Summary
The nursing staff failed to provide necessary interventions to prevent accidents for two residents, Resident 6 and Resident 63, in the facility. Resident 6, who had a history of falls and was assessed as a high fall risk, was not provided with floor mats as indicated in their care plan. Observations on multiple occasions revealed that Resident 6's bed was in the lowest position, but no floor mats were present on either side of the bed. Interviews with the resident's representatives and CNAs confirmed the absence of floor mats, which were supposed to be in place to minimize the risk of injury from falls. Resident 63, who had a history of epilepsy and was diagnosed with hemiplegia and hemiparesis, was not provided with padded bedside rails as per the physician's orders. Observations showed that while the side rails were up, they lacked the necessary padding. Interviews with the treatment nurse and the DON confirmed that the padded side rails were required to prevent injury during seizures, yet they were not in place, posing a risk to the resident. The facility's policies and procedures for fall prevention and bed safety were not adhered to in these cases. The Fall Risk assessment and care plan for Resident 6 clearly indicated the need for floor mats, while the physician's orders and care plan for Resident 63 specified the use of padded side rails. The failure to implement these interventions as outlined in the residents' care plans and physician's orders resulted in a deficiency in ensuring a safe environment for these residents.
Missed Quarterly Nutritional Assessment for Resident
Penalty
Summary
The facility failed to perform a quarterly nutritional assessment for a resident, which had the potential to impact the resident's nutritional needs. The resident was admitted with multiple diagnoses, including Type II diabetes, dysphagia, hyperlipidemia, end-stage renal disease, and dependence on renal dialysis. The initial nutritional assessment indicated the resident was at risk for significant weight change due to these conditions and had expected weight fluctuations related to ESRD and hemodialysis. However, no further nutritional assessments were documented after the initial assessment. Interviews with the Registered Dietitian (RD), Dietary Supervisor (DS), and Director of Nursing (DON) confirmed that the resident's last nutritional assessment was conducted shortly after admission, and a subsequent quarterly assessment was missed. The facility's policy required nutritional assessments to be completed on admission, quarterly, annually, and as needed. The RD and DS acknowledged that the missed assessment could have led to potential weight loss and unmet nutritional needs for the resident.
Failure to Timely Change PICC Line Dressing
Penalty
Summary
The facility failed to adhere to its policy and professional standards of practice regarding the timely changing of a peripherally inserted central catheter (PICC) line dressing for a resident. Resident 49, who was admitted with a right middle finger fracture, cellulitis, and bacteremia, had a PICC line for administering Vancomycin to treat osteomyelitis. The dressing on the PICC line was observed to be dated nine days prior, exceeding the facility's policy of changing the dressing every seven days. During an interview, a registered nurse acknowledged that the dressing should have been changed two days earlier and was unsure why it had not been done. The Director of Nursing confirmed that the failure to change the dressing as required put the resident at risk for infection and other complications. The facility's policy mandates that dressings for central vascular access devices be changed at least every seven days, which was not followed in this instance.
Inadequate CNA Training on Fall Risk Identification
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) were competent in identifying residents who were at risk of falls, which compromised the safety of residents, including Resident 6. Two CNAs, CNA 1 and CNA 2, were unable to recognize the significance of a yellow star above Resident 6's bed, which indicated a high fall risk. CNA 1, who was new to the facility, did not know the meaning of the yellow star and had to ask another CNA for clarification. Similarly, CNA 2 was unaware of the star's meaning and stated that she had not been educated on it. This lack of knowledge among CNAs had the potential to place residents at risk for injury and recurrent falls. Resident 6, who had a history of falls and was identified as a high fall risk, was admitted with diagnoses including cerebral infarction and dementia, leading to severe cognitive impairment and a need for maximum assistance with daily activities. Despite the facility's policy requiring nursing staff to be knowledgeable about fall prevention, the Director of Staff Development (DSD) and the Director of Nursing (DON) acknowledged that safety and fall prevention had not been a focus of in-service training. The facility's policy indicated that competency requirements and training should be monitored by nursing leadership, but there was no evidence of in-service training on safety and fall prevention from July to October 2024, leaving a gap in staff education and competency monitoring.
Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the availability of divalproex extended release (ER) in the correct dose for a resident with epilepsy, leading to a potential risk of seizures. The resident was supposed to receive a total dose of 750 mg of divalproex ER every 12 hours, consisting of one 500 mg tablet and one 250 mg tablet. However, the Licensed Vocational Nurse (LVN) administering the medication was unaware that an additional 250 mg tablet was required, and the facility did not have the 250 mg tablets in stock. This oversight was confirmed through interviews with the LVN and the Director of Nursing (DON), who acknowledged the potential harm to the resident due to the incorrect dosage. Another resident was affected by the facility's failure to provide pyridoxine (vitamin B6) as prescribed. The resident, who had a diagnosis of Type II diabetes mellitus and unspecified anemia, was supposed to receive two 50 mg tablets of pyridoxine daily. However, during medication administration, it was observed that the pyridoxine was not in stock, and therefore, not administered. The DON confirmed the importance of having such vitamins in stock to prevent deficiencies. The facility's policy and procedure for administering medications require that medications be administered safely, timely, and as prescribed. The policy also mandates that the individual administering the medication verifies the right resident and dosage. Despite these guidelines, the facility failed to ensure the correct medications and dosages were available and administered, as evidenced by the lack of divalproex ER 250 mg and pyridoxine 50 mg in stock for the affected residents.
Failure to Limit PRN Lorazepam to 14 Days
Penalty
Summary
The facility failed to limit the as-needed medication, Lorazepam, to 14 days for a resident diagnosed with generalized anxiety disorder. The resident was admitted with moderately impaired cognition and was dependent on assistance for personal hygiene. A physician's order dated 10/10/2024 prescribed Lorazepam 0.25 mg via G-Tube every 8 hours as needed for anxiety, without specifying a stop date. This oversight was identified during a review of the resident's records, indicating non-compliance with the facility's policy on psychotropic medications. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the physician's order did not adhere to the facility's policy, which mandates a 14-day limit for PRN psychotropic medications unless a rationale for extension is documented. Both the RN and DON acknowledged the potential risk of the resident receiving excessive doses of Lorazepam, which could lead to adverse effects. The facility's policy, reviewed on 8/30/2024, clearly states that PRN orders for psychotropic medications should be limited to 14 days unless extended with documented justification.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration, resulting in a 12.9% error rate. This deficiency was observed in the cases of two residents. For Resident 4, the facility did not ensure the availability and administration of the correct dose of divalproex ER, a medication used to treat seizures. The resident was supposed to receive a total dose of 750 mg, consisting of one 500 mg tablet and one 250 mg tablet every 12 hours. However, the facility only administered the 500 mg tablet, as the 250 mg tablet was not available in stock. This oversight was due to a failure in ordering the correct medication from the pharmacy, as the facility only requested refills for the 500 mg tablet. In the case of Resident 63, the facility failed to administer metformin, a medication for diabetes, in a timely manner. The resident was supposed to receive metformin with breakfast, but due to uncertainty about whether the resident had eaten, the medication was not administered until later in the morning. Additionally, the facility did not have pyridoxine, a vitamin B6 supplement, in stock, and administered an incorrect dose of cranberry, a supplement for UTI prevention. These errors were attributed to a lack of proper medication stock management and verification of medication doses before administration. The facility's policy and procedure for administering medications require that medications be administered safely, timely, and as prescribed. However, the facility staff failed to adhere to these guidelines, resulting in medication errors that placed the residents at risk for medical complications. The Director of Nursing acknowledged the potential harm to the residents due to these errors, emphasizing the importance of ensuring correct medication doses and timely administration to prevent adverse health outcomes.
Failure to Update and Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor and update the food preferences of a resident, leading to decreased meal satisfaction and overall caloric intake. The resident, who was readmitted with multiple diagnoses including acute embolism, Guillain-Barre Syndrome, and spinal stenosis, had specific food preferences documented in their care plan and dietary profile. However, these preferences were not consistently updated or honored. The resident's care plan indicated a preference for juice and milk for breakfast and a dislike for certain foods like tuna and chicken breast. Despite this, the resident received meals that did not align with their preferences, as observed during an interview where the resident expressed dissatisfaction with the food provided. The dietary profile for the resident was found to be incomplete and missing crucial information about their likes and dislikes. The Dietary Supervisor acknowledged that the resident's preferences were accidentally removed during a menu update and were not aware of the oversight. The facility's policy required the identification of food preferences upon admission or within 24 hours, but this was not adhered to in the resident's case. The lack of documentation and failure to update the dietary profile led to the resident receiving meals that did not meet their preferences, causing frustration and dissatisfaction.
Lack of Contract and Orientation for Cosmetologist
Penalty
Summary
The facility failed to establish a contract with a cosmetologist who provided services to residents, including Resident 47, for two years. The cosmetologist was not employed by the facility and did not receive an orientation program as required by the facility's policy. During an observation, the cosmetologist entered Resident 47's room without knocking or ensuring privacy, which raised concerns about adherence to professional standards of practice. Interviews with facility staff, including the Administrator, Director of Staff Development, and Social Services Director, revealed that there was no contract or vendor file for the cosmetologist, and it was unclear if the cosmetologist held a valid license. Resident 47, who was admitted with Alzheimer's disease and dementia, was observed receiving a haircut from the cosmetologist without any documented request from the family or facility for such services. The facility's policy required all vendors to have a contract and undergo a 10-hour orientation program, which the cosmetologist did not complete. The lack of a contract and orientation program for the cosmetologist posed an increased risk of services not being in accordance with professional standards, as noted by the Director of Nursing.
Inadequate Respirator Fit Testing for Staff
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically regarding the mandatory respirator fit testing for staff members. During observations and interviews, it was noted that several staff members, including Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs), were wearing Medline NON24506A Regular TC 64A5411 NIOSH N95 respirators without having been properly fit-tested for this specific model. This was confirmed through interviews with the staff and a review of their fit test records, which indicated that they had not been fit-tested for the respirators currently in use. The Infection Preventionist (IP) acknowledged that the staff had not been fit-tested for the Medline model N95 respirators, which were introduced during a COVID-19 outbreak in the facility. The facility's policy requires fit tests to be conducted annually or when there is a change in the respirator model. The lack of fit testing could result in improper sealing of the respirators, potentially exposing residents and staff to airborne infectious diseases. The facility was in the process of updating the fit testing for the employees, as confirmed by the Administrator.
Failure to Offer Vaccines to Cognitively Intact Resident
Penalty
Summary
The facility failed to offer influenza, pneumonia, and COVID-19 vaccines to a resident who was cognitively intact and capable of making her own medical decisions. The resident was admitted with several respiratory-related diagnoses, including acute respiratory failure, pulmonary emphysema, congestive heart failure, and COPD, and was dependent on supplemental oxygen. Despite being self-responsible, the facility sought consent from the resident's family member, who refused the vaccines on her behalf. The Minimum Data Set indicated that the resident was cognitively intact, and the facility's Infection Preventionist and Director of Nursing confirmed that the resident was capable of making her own decisions. However, the consent forms for the vaccines showed that the family member refused them, and the resident herself was not offered the vaccines. The resident expressed her desire to receive the vaccines and was unaware of why her family was consulted instead of her. The facility's policies required that all residents be offered the influenza and pneumococcal vaccines unless medically contraindicated. The Infection Preventionist acknowledged that the resident should have been asked directly about her vaccination preferences. The failure to offer the vaccines to the resident, who had not received a pneumonia vaccine previously, placed her at increased risk of acquiring these infections.
Resident Safety Compromised Due to Inadequate Monitoring
Penalty
Summary
The facility failed to ensure the safety and well-being of a resident when another resident entered their room uninvited during the night and kissed them on the cheek. This incident involved a resident with intact cognition and memory, who was unable to ambulate and required maximum assistance with activities of daily living. The resident reported feeling nervous and violated after the encounter. The other resident involved had moderate cognitive impairment due to dementia, was independent in using a wheelchair, and had a history of impaired decision-making and short-term memory loss. The incident occurred when the resident with dementia, who was known to be social and used a wheelchair to move around the unit, entered the other resident's room at night. Despite the resident's room being located near the nursing station, no staff observed the resident leaving their room or entering the other resident's room. The facility's policy on abuse and neglect defines sexual abuse as non-consensual sexual contact, which was applicable in this situation. Interviews with staff indicated that increased monitoring could have potentially prevented the incident, but no specific reason was provided for the lack of staff intervention at the time of the incident.
Inadequate Supervision of Dementia Resident Leads to Wandering Incident
Penalty
Summary
The facility failed to implement individualized interventions for a resident diagnosed with dementia, resulting in an incident where the resident wandered into another resident's room and kissed them on the cheek. The resident, who had moderate cognitive impairment and was independent in using a wheelchair, was not adequately supervised despite having a care plan that included redirection and communication with family. The care plan lacked specific interventions for supervision, which contributed to the incident. Interviews with staff revealed that the resident was known to have episodes of confusion and was supposed to be closely monitored for wandering. However, the Charge Nurse and Director of Staff Development acknowledged that the resident was not adequately supervised, as evidenced by the incident occurring without staff intervention. The Director of Nursing noted that the resident's room was near the nursing station, yet no staff witnessed the resident leaving their room, indicating a lapse in supervision. The facility's policy required direct care staff to supervise residents with dementia, but this was not effectively implemented in this case.
Failure to Maintain Clean and Sanitary Fall Mats
Penalty
Summary
The facility failed to maintain clean and sanitary fall mats in two out of four sampled residents' rooms, which could potentially expose residents to germs and spread infection. Resident 2, who was admitted with multiple diagnoses including metabolic encephalopathy, anemia, type two diabetes mellitus, paraplegia, and dysphagia, was observed to have soiled fall mats with shoe marks and dust on the floor beside their bed. Resident 2, who had severe memory problems and was dependent on staff for various activities, stated they had not seen anyone clean the fall mats. Similarly, Resident 1, who was cognitively intact but dependent on staff for daily activities, also had fall mats with dust, dark spots, and dirty footwear marks. Resident 1 reported that housekeeping mopped the floor around the mats but did not clean the mats themselves. Resident 3, who shared a room with Resident 2, confirmed that while the floor was cleaned daily, the fall mats were not. A review of the facility's maintenance logbook did not show any record of cleaning the fall mats, nor did it indicate a process for doing so. The facility's policy on cleaning and disinfection of environmental surfaces, dated August 2019, stated that surfaces should be cleaned regularly and when visibly soiled, but this was not adhered to in the case of the fall mats. This oversight in maintaining a clean environment for the residents was identified through observation, interviews, and record reviews.
Infection Preventionist Certification Records Unavailable
Penalty
Summary
The facility failed to ensure that their acting Infection Preventionist (IP) had accessible and available certification or training records in infection prevention and control. During a review of the Director of Staff Development's (DSD) employee file, no IP certificate or training records were found. The DSD, who was acting as the IP, claimed to have an Infection Preventionist certificate but was unable to provide a copy for review. This lack of documentation was identified during an interview with the DSD. The facility's job description for the Infection Preventionist role indicated a requirement for specialty training in Infection Prevention and Control through accredited continuing education. Additionally, the facility's policies and procedures stated that all personnel would be trained on infection control policies and practices upon hire and periodically thereafter. According to the All Facilities Letter issued by the California Department of Public Health, the IP must be qualified by education, training, clinical or healthcare experience, or certification, and must have completed specialized training in infection prevention and control. The absence of accessible training records for the acting IP posed a potential risk for the facility's infection prevention and control program not being maintained, thereby placing residents and staff at risk for healthcare-associated infections.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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