Tarzana Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tarzana, California.
- Location
- 5650 Reseda Blvd, Tarzana, California 91356
- CMS Provider Number
- 056124
- Inspections on file
- 97
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Tarzana Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, hearing loss, and impaired vision had care plans requiring use of eyeglasses and hearing aids when out of bed, with staff responsible for ensuring these devices were worn and functioning. During observation, the resident was seen in a wheelchair in the lobby without eyeglasses or hearing aids. The ADON and an LVN both acknowledged the resident should have been wearing these devices, and the LVN reported the hearing aids were not charged and thus unavailable, despite the documented plan of care and facility policies requiring assistance with hearing aids and implementation of comprehensive care plans.
A resident with severely impaired cognition, dependence in ADLs, and a left humerus fracture did not receive a recliner wheelchair that had been recommended by PT due to poor sitting balance and a non–weight-bearing upper extremity. The DORS did not order the recliner wheelchair because she believed it was not covered under Medicare Part A, despite facility policy and Medicare guidance indicating DME is covered under the SNF PPS. The DON later confirmed that the failure to order the recliner wheelchair and communicate with nursing caused a delay in treatment with potential for functional decline and decreased mobility.
A resident with a history of PTSD and major depressive disorder did not have a comprehensive care plan addressing PTSD, despite staff awareness and documented trauma history. The care plan lacked specific interventions for PTSD, contrary to facility policy requiring person-centered plans for all identified needs.
A resident with a history of PTSD and major depressive disorder did not receive appropriate behavioral health services beyond psychiatric visits, despite staff awareness and documentation of her condition. Facility staff confirmed that no additional interventions or assessments were implemented to address her PTSD, contrary to facility policy requiring person-centered behavioral health care.
A resident who lacked capacity to make decisions due to medical conditions had their admission packet e-signed by themselves instead of their designated representative. Facility staff and policy confirmed that the representative should have signed, but this did not occur, resulting in the resident not being properly represented in healthcare decisions.
During a COVID-19 outbreak, staff failed to follow infection control protocols, including improper mask use by two staff members, lack of hand hygiene by a therapist and a housekeeper after resident care and trash handling, and unsafe transport of trash bags in contact with clothing. These actions did not align with facility policy and CDC guidelines for infection prevention.
A resident did not receive the medically-related social services needed to achieve the highest possible quality of life, resulting in unmet social and psychosocial needs.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with severe cognitive impairment and multiple health conditions experienced a delay in laboratory testing after developing diarrhea. The initial stool specimen was not picked up by the lab, causing a delay in obtaining and processing a second sample. This resulted in a delayed diagnosis of C. diff and a subsequent delay in starting antibiotic treatment, contrary to facility policy requiring timely lab services.
A resident did not receive a comprehensive explanation or proper informed consent for a psychotropic medication, as the consent form lacked the physician's signature and dose frequency. Additionally, two residents were not informed of the names and indications of several medications before administration by an LPN, contrary to facility policy. These actions prevented residents from being fully informed and involved in their care.
A resident with limited mobility and a history of fractures did not receive active range of motion (AROM) exercises to both arms as recommended by occupational therapy. The care plan and restorative nursing aide documentation only included AAROM to the legs, and staff interviews confirmed that the AROM task for the arms was not entered into the electronic system. This omission resulted in the resident not receiving the prescribed interventions to maintain upper extremity range of motion.
Surveyors found multiple deficiencies, including a shower room with standing water and a leaking shower head that were not reported or repaired, incomplete and inaccurate fall risk assessments after resident falls, and failure to implement care plan interventions such as keeping beds in low positions and providing padded siderails for seizure precautions. These lapses involved residents with cognitive impairment, seizure disorders, and fall risks, and staff acknowledged the importance of these interventions and assessments.
Multiple residents did not receive prescribed medications as ordered due to lapses in pharmacy delivery, failure to reorder in advance, and staff not following physician parameters for administration. This included missed doses of antidepressants, migraine medication, vitamin D supplements, and improper administration of blood pressure and bowel management medications, with staff and leadership confirming these errors.
Two residents experienced medication errors when one did not receive a prescribed vitamin D supplement due to unavailability, and another received a calcium with vitamin D supplement outside the scheduled time window. These incidents resulted in a medication error rate above 5%, as facility staff did not follow established medication administration protocols.
An LVN prepared six medications for a resident and left them unattended on top of a medication cart while entering the resident's room to take vital signs. The medications remained unsupervised and accessible until the LVN returned to administer them in two trips. Both the LVN and DON acknowledged that this action failed to meet the facility's policy for safe and secure medication storage, which requires medications to be attended or locked at all times.
The facility did not consistently follow infection control protocols, including failing to use enhanced barrier precautions for a resident with a gastrostomy tube, not labeling or timely replacing oxygen tubing for two residents, and not labeling a urinal with a resident identifier. These actions were not in accordance with facility policy and staff expectations, as confirmed by interviews and record reviews.
Two residents experienced lapses in dignity and privacy when one resident's urinary catheter bag was left uncovered, and another resident was not afforded privacy during bathing as staff repeatedly entered the shower room without knocking. These actions were inconsistent with facility policies requiring the use of privacy bags for catheter drainage and staff to knock before entering rooms occupied by residents.
A resident with severe cognitive impairment and a history of falls was found with their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible. This was confirmed by a CNA and acknowledged by the DON.
A resident with bilateral lower extremity amputations showed significant improvement in performing sit-to-stand transfers with prosthetic legs, but this change was not documented or reported to the physician as required. As a result, the resident did not receive further PT services to support increased independence with mobility.
A resident with a history of left femur fracture and ongoing mobility issues was not accurately assessed for range of motion (ROM) limitations in three consecutive MDS assessments. Despite therapy evaluations, care plans, and staff observations confirming a left leg ROM impairment and the need for assistance, the MDS documentation repeatedly indicated no ROM limitations. This resulted in inaccurate information being reported in the federal database.
The facility did not develop care plans for two residents: one requiring continuous oxygen therapy for respiratory failure and another receiving regular hydromorphone for chronic pain. In both cases, staff confirmed that care plans addressing these specific needs were missing, despite facility policy requiring comprehensive, measurable care plans for all identified resident needs.
The facility did not timely update care plans for two residents: one with epilepsy did not have a care plan intervention for padded side rails added after a physician's order, and another with an indwelling catheter did not have their care plan reviewed or revised for over six months. Staff confirmed that care plans are required to be reviewed quarterly and after changes in condition, but these requirements were not met, resulting in deficiencies in individualized care.
A resident with recent knee surgery and mobility limitations was unable to participate in transfers or therapy for 12 days due to the facility's failure to provide a properly fitting knee immobilizer. Therapy and nursing documentation showed the resident remained bedbound, and interviews confirmed the resident experienced sadness and depression as a result. The delay in obtaining the necessary device led to a preventable decline in the resident's ability to perform activities of daily living (ADLs) and maintain mobility.
A resident requiring partial to moderate assistance with ADLs, including bathing, was not consistently offered or provided showers or bed baths according to facility policy. Staff failed to document whether bathing was offered, received, or refused on multiple days, and did not ask the resident for her bathing preference, resulting in inadequate personal hygiene care.
A resident with a history of diabetes, a foot ulcer, and prior DVT did not receive ordered vascular studies or a follow-up with a vascular surgeon after a staff transition led to a lapse in care coordination, despite these needs being documented in the care plan and medical record.
A resident with a stage 4 pressure ulcer and severe cognitive impairment was found with a low air loss (LAL) mattress set incorrectly at 225 lbs instead of the required 87 lbs, as indicated on the mattress. This error was confirmed by an LVN and occurred despite physician orders and care plans specifying the need for proper mattress settings to manage the resident's wound. The facility's policy and the manufacturer's guide both emphasized the importance of correct support surface settings for pressure injury prevention and care.
Two residents with indwelling catheters did not receive proper care: one did not receive catheter care or monitoring after hospital readmission due to missing physician orders, and another had a catheter collection bag positioned at bladder level instead of below, contrary to policy and care plan requirements.
A resident with a rib fracture and severe pain received PRN hydromorphone on several occasions without documentation that nonpharmacological pain interventions were attempted first, as required by physician orders and facility policy. Staff interviews confirmed the lack of documentation and awareness of the policy requirements.
A resident with multiple chronic conditions and impaired cognition had several PRN medications ordered for constipation. The Consultant Pharmacist recommended reviewing all PRN constipation medications and specifying the sequence for administration, but facility staff did not act on this recommendation or update the physician's orders as required by policy.
A resident with depression and a history of stroke did not receive prescribed doses of Paxil for several days due to a lapse in medication delivery and failure to reorder in a timely manner. Pharmacy records and staff interviews confirmed the medication was unavailable and not administered as scheduled, contrary to facility policy.
A resident with bilateral leg amputations and new prosthetic legs was discharged from PT after only six sessions, despite documented improvement and continued need for therapy. The resident, who was motivated to walk and had made progress in transfers and ambulation, was transitioned to RNA services limited to sit-to-stand training. The therapy team did not document communication with the physician to seek an extension of PT services, and the facility's actions did not align with its policy to restore residents to their highest level of function.
Two residents experienced deficiencies in medical record documentation: one had wound care treatment documented before it was actually provided, and another had an incomplete Change in Condition evaluation after a fall. These actions were not consistent with professional standards or facility policy, resulting in inaccurate and incomplete records.
Two residents were subjected to verbal abuse, one by a CNA who responded to a resident's remarks with profanities after removing a dinner tray without consent, and another by a roommate who repeatedly used offensive and discriminatory language. Staff and administration confirmed these actions met the facility's definition of verbal abuse, and multiple staff witnessed or were aware of the incidents.
A resident with cognitive impairment and total dependence on staff reported repeated verbal abuse, including discriminatory remarks, from a roommate. Multiple CNAs witnessed the incidents but did not report them, assuming others were aware. Facility leadership was unaware of the abuse, and required notifications to authorities were not made within the mandated timeframe, resulting in unaddressed abuse and lack of protection for the resident.
A resident with end stage renal disease and cognitive impairment did not have a physician's order documented to discontinue hemodialysis or to arrange for permcath removal, despite a directive from the dialysis center. The responsible RN failed to document the necessary communication and obtain the required order, resulting in a delay in permcath removal and potential risk for infection.
The facility did not complete trauma assessments for three residents with complex medical and psychosocial needs, despite evidence of cognitive impairment, fluctuating decision-making capacity, and incidents that could trigger trauma responses. Staff interviews revealed confusion over responsibility for trauma assessments, and record reviews confirmed the absence of required documentation, contrary to facility policy on trauma-informed care.
A resident with multiple complex medical conditions, including a pressure ulcer and gastrostomy tube, received wound care as ordered by the physician, but the LPNs responsible did not document the completion of these treatments in the TAR. The DON confirmed that documentation should have been completed per facility policy.
A resident with legal blindness and high fall risk was found in bed with the bed in a high position and a required side rail down, contrary to the care plan and physician order. Staff confirmed the side rail should have been up for mobility and fall prevention, and facility policy required adherence to individualized care plans.
A resident with diabetes was given insulin lispro significantly earlier than prescribed, with the injection occurring well before the dinner meal was served. The nurse administered the insulin ahead of schedule and did not provide a snack to the resident, contrary to physician orders and facility policy requiring medications to be given as directed.
A nurse administered a resident's scheduled morning medications, including Keppra for seizures, more than one hour after the prescribed time. Facility policy and the DON confirmed that medications should be given within one hour of the scheduled time, but this standard was not met during the observed medication pass.
Two patients did not have their call lights accessible or answered promptly. One patient with severe cognitive impairment and mobility issues had a call light out of reach on the floor, while another patient at high risk for falls had an activated call light ignored by a CNA who was not assigned to her. Facility policy requires all staff to ensure call lights are within reach and to respond to any activated call light.
A CNA failed to wear gloves and a gown when delivering and retrieving a lunch tray for a resident on contact isolation for an infectious disease, despite facility policy and signage requiring full PPE. The DON confirmed that staff must use complete protective equipment in such situations to prevent infection spread.
A resident with epilepsy did not receive prescribed doses of Lacosamide (Vimpat) and Clobazam on multiple occasions due to the medications not being available in the facility. Documentation in the MAR and nursing progress notes confirmed the unavailability, and interviews with the resident and nursing staff further substantiated the missed doses. Facility policy required timely medication acquisition and administration, but this was not followed, resulting in the deficiency.
Licensed nurses failed to document the administration of Norco for a resident with chronic pain syndrome on the Medication Administration Record (MAR) after signing the Controlled Drug Record (CDR), resulting in incomplete health records and lack of pain assessment documentation, as confirmed by both the nurse and DON.
A resident with chronic pain syndrome did not have pain assessments documented before and after receiving Norco, a controlled pain medication, on two occasions. The LPN failed to sign the MAR after removing the medication and signing the CDR, resulting in no record of pain assessment or medication administration as required by facility policy. Both the LPN and DON confirmed the documentation process was not followed, and facility policies mandate pain assessment and MAR documentation for pain medications.
A resident reported a grievance about bedbugs in her room, which was addressed by housekeeping but not documented in the facility's grievance log. The resident, capable of making decisions, informed staff, leading to actions like deep cleaning and mattress replacement. However, the grievance was not recorded as required by policy, highlighting a lapse in documentation and tracking.
A resident with a history of aggressive behavior physically assaulted another resident with impaired cognition in a LTC facility. The incident occurred during lunchtime and was witnessed by multiple staff members. The facility's policy on abuse prevention was not effectively implemented, leading to the failure to protect the resident from physical abuse.
A facility failed to conduct a thorough investigation into a physical altercation between two residents, where one resident punched another in the face. The Social Services Director did not interview all relevant staff, including a registered nurse who witnessed the incident. The facility's policy requires comprehensive documentation and interviews, which were not completed, potentially placing residents at risk for further abuse.
A facility failed to ensure that an LVN wore an identification badge while on duty, as required by policy. The LVN, who was newly hired and on orientation, was observed without a badge while assisting a resident. The ADON confirmed the importance of badges for staff identification and stated that they should be provided upon hire, highlighting a lapse in policy adherence.
A resident's call light was found inaccessible as it was underneath their back, potentially delaying assistance. The resident, with conditions like atrial fibrillation and chronic pain, required significant help with personal hygiene. An RN confirmed the call light's inaccessibility and repositioned it, acknowledging the importance of accessibility for safety. Facility policy requires call lights to be within reach, which was not followed.
Failure to Implement Care Plan for Vision and Hearing Devices
Penalty
Summary
Surveyors identified a deficiency in the implementation of a resident’s comprehensive care plan related to vision and hearing needs. The resident was admitted with diagnoses including metabolic encephalopathy, UTI, hearing loss, and dementia, with assessments showing severely impaired cognition and dependence on staff for most ADLs. The resident’s care plan for impaired visual function, revised 1/6/2026, directed staff to remind the resident to wear glasses when up and to ensure the glasses were worn, clean, free from scratches, and in good repair. A separate care plan for communication problems related to bilateral hearing loss, revised 1/7/2026, indicated the resident required hearing aids to communicate and that staff were to ensure the availability and functioning of adaptive communication equipment. On observation on 2/26/2026 at 1:45 p.m., the resident was seen sitting in a wheelchair in the lobby without eyeglasses or hearing aids in place. During a concurrent observation and interview at 1:50 p.m., the ADON confirmed that the resident should be wearing eyeglasses and hearing aids when out of bed. In a later interview at 2:45 p.m., an LVN stated the resident should be wearing hearing aids and eyeglasses when out of bed, but reported the hearing aids were not currently charged and therefore not available for the resident to wear, despite the plan of care requiring their use. The Administrator also confirmed that the resident should be wearing hearing aids and eyeglasses when out of bed as indicated in the care plans. Facility policies on care and use of hearing aids and on comprehensive care plans required assistance with hearing aids and implementation of person-centered care plans with measurable objectives and timeframes to meet identified needs.
Failure to Provide Recommended Recliner Wheelchair DME
Penalty
Summary
The facility failed to provide a recliner wheelchair, a recommended piece of DME, to a resident following a physical therapist’s assessment and order. The resident had been readmitted with diagnoses including an unspecified displaced fracture of the neck of the left humerus, UTI, and metabolic encephalopathy, and had a Minimum Data Set indicating severely impaired cognition and dependence on staff for toileting hygiene, bathing, dressing, personal hygiene, and mobility. On 12/26/2025, Physical Therapist 1 documented that the resident was compliant with skilled interventions, required extra time to process new information, and recommended a recliner wheelchair due to poor sitting balance and a non–weight-bearing left upper extremity. Despite this recommendation, the resident did not receive a recliner wheelchair and was later observed awake and lying in bed. The Director of Rehabilitation Services stated that the resident did not have a recliner wheelchair and explained that she initially believed the recliner wheelchair would not be covered under Medicare Part A, so she did not order it. After reviewing the Medicare Benefit Policy Manual, she acknowledged that the recliner wheelchair should have been ordered at the time of the therapist’s recommendation and that it was important to follow the recommendation to prevent the resident from sliding or falling forward from the wheelchair. The DON confirmed that the recliner wheelchair should have been ordered following the therapist’s assessment and that the failure of the Director of Rehabilitation Services to order the equipment and communicate with nursing resulted in a delay in treatment, with the potential to cause functional decline and decreased mobility. The facility’s policy, based on the Medicare Benefit Policy Manual Chapter 8, indicated that DME for Part A inpatients is covered as part of the SNF prospective payment system and is not separately payable.
Failure to Develop PTSD-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's history of post-traumatic stress disorder (PTSD). The resident was admitted with diagnoses including major depressive disorder and had a positive trauma screen, with documentation indicating a history of trauma related to an attempted assault in her 20s. The resident's Minimum Data Set showed intact cognitive skills and a need for assistance with daily activities. Despite these findings and a psychiatric note confirming ongoing PTSD-related anxiety, the care plan did not specifically address PTSD. During interviews and record reviews, it was confirmed that staff were aware of the resident's PTSD, but no care plan interventions specific to PTSD were in place. The Assistant Director of Nursing acknowledged that a care plan for PTSD should have been developed, including interventions such as referral to a female psychologist. The facility's policy requires comprehensive care plans with measurable objectives and timeframes for all identified needs, but this was not followed for the resident's PTSD.
Failure to Provide Resident-Centered Behavioral Health Services for PTSD
Penalty
Summary
The facility failed to provide resident-centered behavioral health services to a resident with a documented history of post-traumatic stress disorder (PTSD) and major depressive disorder. The resident was admitted with these diagnoses, and assessments, including the Trauma Informed Care Screener and the Minimum Data Set, confirmed both the presence of trauma and intact cognitive skills. Despite the resident's disclosure of PTSD to staff and documentation in the care plan and psychiatric notes indicating ongoing PTSD-related anxiety, the facility did not implement specific behavioral health interventions beyond psychiatric visits. Interviews with facility staff, including the LVN, DON, and ADON, revealed that no additional behavioral health services or interventions were provided to address the resident's PTSD. Staff acknowledged awareness of the resident's condition but confirmed that no assessments or services were in place to identify triggers or prevent behavioral responses related to PTSD. The facility's own policy required person-centered behavioral health care, but this was not followed for the resident in question.
Failure to Obtain Representative Signature for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that a resident who lacked decision-making capacity had their admission packet e-signed by their designated representative. Instead, the admission assistant obtained an electronic signature from the resident, despite documentation in the resident's History and Physical (H&P) examinations indicating the resident did not have the capacity to understand or make decisions due to conditions such as metabolic encephalopathy, urinary tract infection, immunodeficiency, and dementia. The admission occurred after the resident was diagnosed with these conditions, and both the H&P dated shortly after admission and a subsequent H&P confirmed the resident's incapacity. During interviews and record reviews, both the admission assistant and the admission director acknowledged that the resident's representative should have been the one to e-sign the admission packet, as per the facility's policy and the resident's documented incapacity. The facility's policy states that a resident's representative has the right to exercise the resident's rights to the extent those rights are delegated. The failure to have the representative sign the admission documents resulted in the resident not being rightfully represented in important healthcare decisions.
Failure to Implement Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection control practices during an ongoing COVID-19 outbreak, as evidenced by multiple staff not adhering to mask-wearing protocols and hand hygiene requirements. Specifically, two staff members, an Activity Assistant and a Certified Occupational Therapy Assistant, were observed wearing surgical masks below their noses, only covering their mouths, while in resident care areas. Both staff acknowledged awareness of the ongoing outbreak and their training on proper mask use, but did not maintain correct mask positioning during their duties. Additionally, hand hygiene lapses were observed among staff. A Physical Therapist did not perform hand hygiene after removing gloves and before touching a resident and their wheelchair following a therapy session. The therapist admitted that hand hygiene should have been performed to prevent the spread of germs. Similarly, a Housekeeping staff member failed to perform hand hygiene after handling trash in a restroom and before touching the janitor cart. The staff member acknowledged the lapse and the importance of hand hygiene in infection control. Further, the same Housekeeping staff member was observed transporting four trash bags with bare hands, allowing the bags to come into contact with her clothing. The staff member stated that the bags were heavy and difficult to keep away from her body. The Director of Nursing confirmed that a cart should have been used to prevent cross-contamination. Facility policies and CDC guidelines reviewed during the survey supported the need for proper mask use, hand hygiene, and safe trash handling to prevent the transmission of infectious diseases.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated residents did not receive adequate social services support as required to address their individual needs and promote their well-being. The lack of appropriate social services limited residents' ability to attain or maintain their optimal physical, mental, and psychosocial functioning.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Delay in Laboratory Services Resulted in Delayed Diagnosis and Treatment
Penalty
Summary
The facility failed to provide timely laboratory services as ordered by a nurse practitioner for a resident with multiple medical conditions, including thyroid disorder, diabetes mellitus, and obesity. The resident, who was severely cognitively impaired and fully dependent on staff for care, experienced a change in condition marked by three episodes of foul-smelling diarrhea. The nurse practitioner ordered laboratory tests, an anti-diarrheal solution, and a registered dietician consult. A physician order was placed to collect a stool specimen, which was collected and stored in the refrigerator. However, the laboratory did not pick up the initial stool specimen, resulting in a delay in obtaining a second specimen. The second specimen was sent out two days later, and the positive result for C. difficile toxins was not received until several days after the initial collection. This delay in laboratory processing led to a delay in confirming the diagnosis and starting the necessary antibiotic treatment. Facility policy required timely provision of laboratory services, but this was not followed in this instance.
Failure to Obtain Informed Consent and Inform Residents of Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and able to participate in their care and treatment, specifically regarding medication administration and informed consent for psychotropic medications. For one resident with diagnoses including post-traumatic stress disorder and schizophrenia, the facility did not obtain a complete informed consent for the administration of Zyprexa, a psychotropic medication. The consent form lacked the physician's signature and did not specify the dose frequency. According to facility policy, the physician's signature is required to confirm that the risks and benefits of the medication were explained to the resident or their responsible party. The resident's records indicated that while the individual could make needs known, they could not make medical decisions, further emphasizing the importance of proper consent procedures. Additionally, during medication administration observations, a nurse failed to inform two residents of the names and indications of several medications prior to administration. The nurse admitted to not providing this information because the medication cups were not clearly labeled, which prevented the residents from being informed about their treatment and making choices such as refusing specific medications. The Director of Nursing confirmed that this omission was contrary to facility policy and restricted the residents' rights to be informed and involved in their care. The facility's own policies require that residents be informed in advance about the care and treatments they will receive, including the names and purposes of medications, and that informed consent be obtained for psychotropic medications. The failure to follow these procedures resulted in residents not being fully informed or able to participate in decisions regarding their care, as evidenced by the lack of proper consent documentation and the omission of medication information during administration.
Failure to Provide Recommended Active Range of Motion Exercises to Resident's Arms
Penalty
Summary
The facility failed to provide active range of motion (AROM) exercises to both arms for a resident with limited range of motion and mobility concerns, as recommended by occupational therapy (OT) upon discharge. The resident, who had a history of morbid obesity, healed traumatic fracture, and falls, was admitted with specific OT and physical therapy (PT) recommendations for restorative nursing aide (RNA) interventions. The OT discharge summary specifically recommended AROM to both arms, while the PT discharge summary recommended AROM to both legs. However, the resident's care plan and RNA documentation only included active assistive range of motion (AAROM) to both legs, with no mention or documentation of AROM to the arms. Multiple reviews of the resident's records, including the care plan, RNA documentation, and joint mobility assessments, confirmed that AROM to the arms was not provided or documented from January through June. Interviews with staff, including the RNA, interim director of rehabilitation, occupational therapist, and MDS coordinator, revealed that the OT's recommendations for AROM to both arms were not entered into the facility's electronic documentation system by the previous director of rehabilitation. As a result, the RNA program for the resident did not include the required AROM exercises for the arms, despite clear recommendations and supporting documentation from therapy staff. Observations further confirmed that the RNA only performed AAROM to the resident's legs and did not provide any ROM exercises to the arms. The facility's policy on prevention of decline in range of motion required interventions to maintain or improve ROM, but this was not followed in the resident's case. The failure to implement and document the recommended AROM exercises for both arms had the potential to result in a decline in the resident's upper extremity range of motion.
Failure to Prevent Accident Hazards and Implement Fall Risk Interventions
Penalty
Summary
A deficiency was identified when a shower room was found to have accident hazards, including a broken shower head leaking water onto the floor and a clogged drain resulting in approximately two inches of cloudy water accumulating in one of the showers. Maintenance staff confirmed that these issues had not been reported prior to the surveyor's observation, and acknowledged that such hazards could lead to slips and falls. Facility policy required prompt reporting and repair of non-functioning equipment to maintain a safe environment, but this was not followed in this instance. Another deficiency involved the failure to implement and accurately complete fall risk assessments for residents after falls. In one case, a resident with a history of falls and cognitive impairment experienced a fall, but the post-fall risk assessment was incomplete, omitting critical information such as recent fall history, gait and balance status, and predisposing diseases. In a separate case, a resident's post-fall risk assessment was inaccurately completed, with the nurse failing to document the correct number of falls in the past three months, resulting in a lower risk score than appropriate. Facility policy required thorough and accurate completion of fall risk assessments to guide interventions, but this was not adhered to. Additional deficiencies were observed in the implementation of care plan interventions. One resident, identified as being at risk for falls, was found in bed with the bed in a high position, contrary to the care plan directive to keep the bed in the lowest position. Staff confirmed the bed should have been kept low to prevent injury. Another resident with a seizure disorder and a care plan intervention for padded siderails was observed in bed without the required padding. Nursing staff acknowledged that the absence of padded siderails did not align with the care plan and could result in injury during a seizure. These findings demonstrate failures to follow individualized care plans and facility policies designed to prevent accidents and injuries.
Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the timely availability and administration of prescribed medications for multiple residents, resulting in missed doses and medication errors. One resident with depression and a history of stroke did not receive the antidepressant Paxil from 5/31/2025 to 6/04/2025 due to a lapse in pharmacy deliveries, as confirmed by pharmacy records and staff interviews. The same resident also experienced a gap in the availability of Sumatriptan, a medication for migraines, which was not available for several days and had to be supplied by a family member after insurance issues delayed pharmacy delivery. Staff and the DON acknowledged that the medications were not available as required, and the facility's own policies for medication reordering and handling unavailable medications were not followed. Another resident with chronic kidney disease and heart failure was prescribed Hydralazine for hypertension, with specific instructions to hold the medication if systolic blood pressure was below 120 mmHg. However, the MAR showed that Hydralazine was administered on multiple occasions when the resident's systolic blood pressure was below the prescribed threshold. The nurse involved confirmed that the medication should have been held according to the physician's order, and the facility's policy required adherence to such parameters. A third resident with chronic pain and polyneuropathy was prescribed senna for bowel management, with orders to hold the medication if the resident had loose stools. Despite documentation of loose stools on several days, senna was administered as scheduled, and the resident reported not ingesting the medication after realizing its purpose. The nurse admitted to administering senna despite the resident's report of loose stools, and the ADON confirmed that this was not in accordance with the physician's order. Additionally, another resident did not receive ergocalciferol as prescribed because the medication was not available in the facility at the scheduled time, which was acknowledged as a medication error by the nurse and DON.
Medication Error Rate Exceeds 5% Due to Missed and Mistimed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with two medication errors identified out of 27 opportunities, resulting in a 7.41% error rate. One error involved a resident with chronic kidney disease who did not receive their prescribed ergocalciferol supplement because the medication was not available in the medication cart or anywhere in the facility at the time of administration. The nurse responsible acknowledged that medications should be ordered in advance and available for timely administration, but this did not occur, leading to the omission. Another error occurred when a different resident received their prescribed calcium with vitamin D3 supplement at a time inconsistent with the physician's order. The medication was administered outside the facility's policy-defined 60-minute window for scheduled medication times. The nurse administering the medication recognized this as a failure to follow the '5 rights' of medication administration and the facility's guidelines for medication timing. Interviews with the Director of Nursing and the involved nurses confirmed that both incidents were considered medication errors according to facility policy and procedures. The facility's policies require medications to be administered as ordered by the physician and within a specified time frame, and both errors were attributed to failures in following these established protocols. The documentation review further supported that the medications were not administered as prescribed, confirming the deficiencies.
Unattended Medications Left on Cart by LVN
Penalty
Summary
A Licensed Vocational Nurse (LVN) was observed preparing six medications, including calcium with vitamin D, aspirin, atenolol, losartan, sennosides, and vitamin B12, for a resident. The LVN placed these medications in cups on top of a medication cart and left them unattended while entering the resident's room to take vital signs. During this time, the medication cart was not supervised, and the medications remained accessible on top of the cart. The LVN then returned to the cart, took three medication cups into the resident's room for administration, and subsequently returned for the remaining three cups to complete the administration process. During interviews, the LVN acknowledged leaving the medications unattended and stated that medications should always be supervised and securely stored. The Director of Nursing (DON) confirmed that the LVN failed to safely store and supervise the medications, noting that without supervision, other residents could potentially access the medications. Review of the facility's policy indicated that medications must be stored safely and securely, accessible only to authorized personnel, and that medication carts must be locked or attended by authorized staff.
Failure to Implement Infection Control Practices for Medical Devices and Equipment
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices for multiple residents. One resident with a gastrostomy tube was not placed on enhanced barrier precautions (EBP) as required by facility policy, despite the presence of an indwelling medical device. The room lacked EBP signage and a PPE supply cart, and the Infection Prevention Nurse confirmed that these should have been in place to reduce the risk of bacterial transmission. The facility's policy indicated that EBP is necessary for residents with devices such as feeding tubes, but this was not followed for the resident in question. Another deficiency was observed with a resident receiving oxygen therapy. The oxygen tubing was not labeled with the date it was last changed, and staff could not confirm when it had been replaced. Facility policy and staff interviews indicated that oxygen tubing should be changed and labeled at least weekly to prevent infection, but this was not done. In a separate instance, a different resident's oxygen tubing was not replaced weekly as required, with the tubing in use for more than three weeks, contrary to the facility's infection control protocol. Additionally, a resident's urinal was found at the bedside without a resident identifier label. Staff confirmed the urinal was not labeled, and the DON stated that labeling is necessary to prevent cross-contamination. However, the Director of Medical Records noted that there was no specific policy addressing urinal labeling. The facility's general infection prevention and control policy requires measures to prevent the development and transmission of communicable diseases, but these specific practices were not consistently implemented.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity in two separate instances involving two residents. In the first case, a resident with a history of falls, major depressive disorder, and type 2 diabetes mellitus, who was cognitively moderately impaired and required assistance with hygiene, had an indwelling urinary catheter. During observation, it was noted that the resident's urinary catheter bag was not covered with a privacy bag, contrary to facility policy and staff statements that such coverage is required to promote dignity. Both the MDS Coordinator and Assistant Director of Nursing confirmed that the catheter bag should have been covered, and the facility's policy explicitly stated that privacy bags must be used at all times for catheter drainage bags. In the second instance, another resident with type 1 diabetes mellitus, end stage renal disease, and a below-knee amputation, who required moderate assistance for bathing, reported that staff did not knock before entering the shower room while he was showering. The resident stated that staff entered multiple times to drop off soiled linens without knocking, which he felt violated his dignity and privacy. The CNA assisting the resident confirmed that several staff members entered the shower room without knocking, and the Director of Nursing acknowledged that staff are required to knock before entering any room occupied by a resident to preserve privacy and dignity. Both incidents were found to be inconsistent with the facility's policies on promoting and maintaining resident dignity, which require staff to treat residents with respect, ensure privacy, and use privacy bags for catheter drainage. The deficiencies were identified through interviews, record reviews, and direct observation, with staff and leadership confirming the expectations and acknowledging the lapses.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident's call light was not kept within reach, as required by the facility's policy and the resident's care plan. The resident, who had a history of falls, severe cognitive impairment, and required maximal assistance for most activities of daily living, was observed asleep in bed with the call light found on the floor. This was confirmed by a Certified Nursing Assistant during the observation. The resident's care plan specifically included the intervention to keep the call light within reach and encourage its use for assistance. The Director of Nursing confirmed that call lights should be accessible to residents. The facility's policy also required staff to ensure call lights are within reach and secured as needed. The failure to keep the call light accessible represented a lack of adherence to both the care plan and facility policy.
Failure to Notify Physician of Resident's Significant Improvement in Mobility
Penalty
Summary
The facility failed to notify the primary physician of a significant improvement in a resident's condition, specifically regarding the resident's ability to perform sit-to-stand transfers using both prosthetic legs. The resident, who had a history of bilateral lower extremity amputations and was admitted with diagnoses including Type 1 diabetes mellitus, was initially assessed by physical therapy (PT) as requiring moderate to maximal assistance for transfers and was not ambulating due to safety concerns. After discharge from PT, the resident was placed on a Restorative Nursing Aide (RNA) program for sit-to-stand transfers in the parallel bars, with the care plan instructing staff to monitor for changes and refer to nursing or rehabilitation with any change in condition. Over time, the resident demonstrated significant improvement, becoming able to perform sit-to-stand transfers with minimal or no assistance and expressing a strong desire to progress to walking. Despite this improvement, the change was not documented in the medical record, nor was it reported to the charge nurse or the primary physician as required by facility policy. Interviews with staff revealed that while the improvement was verbally communicated among RNA and PT staff, it was not formally reported or documented, and the required notification to the physician did not occur. As a result of this failure to communicate and document the resident's improvement, the resident continued with the RNA program and did not receive a reassessment or further PT services that could have supported greater independence with mobility, including walking. The facility's policy required notification of the physician and consultation when there was a significant change in a resident's physical condition, but this process was not followed in this case.
Failure to Accurately Assess and Document Resident's Range of Motion Limitation
Penalty
Summary
The facility failed to accurately assess a resident's range of motion (ROM) limitations, specifically regarding the left leg, during three consecutive quarterly Minimum Data Set (MDS) assessments. Despite multiple therapy evaluations and care plans indicating a history of left femur fracture, ongoing ROM impairment, and the need for assistance with mobility and activities of daily living, the MDS assessments consistently documented that the resident had no functional ROM limitations in either leg. This discrepancy was identified through a review of therapy evaluations, care plans, and direct observation, all of which confirmed the presence of a left leg ROM limitation. The resident in question was admitted with significant medical history, including morbid obesity, a healed traumatic fracture, and a history of falls. Therapy records from both occupational and physical therapy documented the resident's need for moderate to maximal assistance with bed mobility, transfers, and lower body care, as well as specific recommendations for active and active assistive ROM exercises to both legs. Observations and interviews with staff and the resident further confirmed the left leg's reduced ROM and ongoing need for restorative interventions. Despite this clear documentation and direct evidence, the MDS assessments failed to reflect the resident's actual ROM limitations, resulting in inaccurate data being entered into the federal database. The MDS Coordinator acknowledged that the assessments were inaccurate and that the information from therapy evaluations should have been incorporated into the MDS to ensure an accurate representation of the resident's condition.
Failure to Develop Comprehensive Care Plans for Oxygen Therapy and Opioid Use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. For one resident with diagnoses including atrial fibrillation and congestive heart failure, who was dependent on staff for all activities of daily living and had severely impaired cognitive skills, there was a physician's order for continuous oxygen therapy due to acute respiratory failure with hypoxia. However, upon review, staff could not locate a care plan addressing the resident's oxygen therapy, and both the MDS Coordinator and DON confirmed that a care plan should have been in place. In a separate case, another resident with chronic pain syndrome and intact cognition was receiving hydromorphone for moderate to severe pain on a regular basis, as documented in the Medication Administration Record. Despite the consistent administration of this opioid medication, there was no care plan addressing the resident's use of hydromorphone, including monitoring for adverse reactions or effectiveness. The DON acknowledged that a care plan should have been developed for this medication regimen. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs.
Failure to Timely Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to timely update and revise care plans for two residents, resulting in deficiencies related to individualized care. For one resident with a history of epilepsy and a physician's order for padded side rails to reduce injury risk, the care plan was not updated to include this intervention until over two months after the order was issued. The care plan for seizure disorder was only revised to include padded side rails well after the physician's directive, despite staff acknowledging that timely updates are necessary to ensure consistent implementation of safety measures. Another resident with an indwelling catheter for urinary retention had a care plan that was not reviewed or revised for more than six months, despite facility policy requiring quarterly reviews. The care plan, which included interventions to monitor for urinary tract infection and proper catheter bag positioning, was last updated in November of the previous year and not subsequently reviewed, even though the resident continued to require catheter care. Interviews with facility staff confirmed that care plans are expected to be reviewed quarterly and after any change in condition, to ensure interventions remain effective and all pertinent information is included. The failure to adhere to these review and revision schedules was acknowledged by staff, who stated that such lapses could result in inadequate care and supervision. Facility policy also mandates comprehensive, person-centered care plans that are regularly updated to reflect residents' needs as identified in assessments.
Failure to Provide Timely Medical Device Resulting in Decline in ADLs and Mobility
Penalty
Summary
A resident with a history of sepsis, falls, left knee injury requiring surgery, and major depressive disorder was admitted to the facility and required a left knee immobilizer and right CAM walker boot for safe mobility and transfers. Therapy assessments indicated the resident previously functioned independently but now required assistance for mobility and ADLs due to recent injuries. Both physical and occupational therapy documented that the left knee immobilizer did not fit properly, causing it to slide down and making transfers and ambulation unsafe. As a result, therapy sessions were halted, and the resident was unable to participate in standing activities, ambulation, or transfers out of bed. Despite physician orders for orthopedic and orthotic consultations to obtain a properly fitting knee immobilizer, there was a significant delay in acquiring the device. The resident remained in bed for 12 days, as documented by therapy and nursing staff, due to the absence of a suitable knee immobilizer. During this period, the resident did not receive therapy or assistance with transfers, and documentation indicated that transferring was not applicable or that the resident was totally dependent with at least two-person assistance. The case management team was unaware of the resident's current status and the arrival of a new immobilizer, and there was no documentation of the facility's efforts to expedite obtaining the device. Interviews with staff, the resident, and family confirmed that the resident was confined to bed and unable to participate in therapy or transfers due to the lack of a properly fitting knee immobilizer. The resident expressed feelings of sadness and depression as a result of being bedbound and unable to progress with therapy. The facility's policy required that residents' abilities in ADLs not decline unless unavoidable, but the lack of timely provision of the necessary medical device led to a preventable decline in the resident's mobility and ADL participation.
Failure to Provide Consistent Bathing Care and Document Resident Preferences
Penalty
Summary
A resident with diagnoses of morbid obesity and type 2 diabetes mellitus, who was assessed as having moderately impaired cognitive skills and requiring partial to moderate assistance with activities of daily living (ADLs), was not consistently provided with appropriate bathing care. The resident reported only receiving bed baths and not being offered showers, despite expressing varying preferences for either a shower or a bed bath. Staff did not ask the resident for her preference, and documentation was lacking regarding whether the resident was offered, received, or refused showers or bed baths on multiple days. Review of the Certified Nurse Assistants' ADL task documentation revealed that during two separate weeks, the resident received only one bed bath each week, with no documentation for the remaining days to indicate if bathing was offered or refused. The Assistant Director of Nursing confirmed that, based on the resident's functional abilities, she should be able to shower with partial assistance and that residents are to receive either a shower or bed bath twice weekly. Facility policy also required staff to assist residents with bathing to maintain proper hygiene. The lack of consistent bathing care and documentation constituted a failure to ensure the resident's personal hygiene needs were met.
Failure to Coordinate Ordered Vascular Studies and Follow-Up
Penalty
Summary
The facility failed to ensure that a resident with a history of diabetes mellitus, a foot ulcer, and a previous deep vein thrombosis (DVT) received ordered vascular studies and a follow-up appointment with a vascular surgeon. The resident was admitted with significant medical concerns, including chronic left arm swelling and pain following a DVT and removal of a peripherally inserted central catheter (PICC). The vascular surgeon ordered comprehensive venous and arterial ultrasounds of both the upper and lower extremities, with instructions for a follow-up appointment after the studies were completed. These orders were documented in the resident's medical record and care plan, which also included interventions to obtain and monitor diagnostic work as ordered. Despite these documented orders, the resident did not receive the required vascular studies or the follow-up appointment. The resident reported that he had been waiting several weeks for the studies and was unaware of the reason for the delay, noting that the staff member who previously coordinated his appointments had left. The current case manager confirmed that the need for these studies and follow-up was not communicated to her during the transition. Facility leadership acknowledged responsibility for coordinating such care and recognized the importance of the ordered tests. The facility's policy requires that residents receive care and services according to professional standards and care plans, but this was not followed in this instance.
Incorrect LAL Mattress Setting for Pressure Ulcer Management
Penalty
Summary
A resident with a history of a stage 4 pressure ulcer of the sacral region, who was dependent on staff for activities of daily living and had severely impaired cognitive skills, was admitted and readmitted to the facility. Physician orders and the resident's care plan specified the use of a low air loss (LAL) mattress for wound management, with instructions to determine and set the appropriate mattress settings based on the resident's needs. The manufacturer's guide for the LAL mattress indicated that the mattress should be set according to the patient's weight or comfort level. During an observation, the resident was found asleep in bed with the LAL mattress set to 225 lbs, despite a sticker on the mattress indicating it should be set to 87 lbs. This incorrect setting was confirmed by a Licensed Vocational Nurse, who acknowledged the discrepancy. The Director of Nursing also confirmed the importance of correct mattress settings for pressure ulcer prevention and management. The facility's policy emphasized the use of appropriate pressure-redistributing support surfaces for residents at risk or with existing pressure injuries. The failure to set the LAL mattress to the correct setting constituted a deficiency in providing appropriate pressure ulcer care.
Failure to Provide Proper Catheter Care and Positioning
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling catheters, resulting in two deficiencies. For one resident with a history of falls, major depressive disorder, and type 2 diabetes mellitus, the facility did not provide indwelling catheter care or monitoring after the resident was readmitted from the hospital. The resident's physician order summary and treatment administration records showed no evidence of catheter care or monitoring after the readmission, and there were no physician orders for catheter care in the medical record. The assistant director of nursing confirmed that catheter care was not reinstated upon the resident's return from the hospital, despite facility policy requiring catheter care every shift and as needed. For another resident with urinary retention and type 2 diabetes mellitus, the facility failed to ensure proper positioning of the urinary catheter collection bag. During observation, the resident was seen sitting in a wheelchair with the catheter collection bag placed at the same level as the bladder, rather than below it as required. The registered nurse present confirmed that the collection bag should be positioned below the bladder to prevent backflow of urine, in accordance with facility policy and the resident's care plan. Both deficiencies were identified through interviews, record reviews, and direct observation. The facility's own policies and procedures, as well as the residents' care plans, specified the required catheter care and positioning, but these were not followed in the cases observed.
Failure to Document Nonpharmacological Pain Interventions Prior to PRN Opioid Administration
Penalty
Summary
The facility failed to ensure that nurses documented the use of nonpharmacological interventions prior to administering as-needed (PRN) hydromorphone to a resident with a left rib fracture. The resident, who had intact cognition and required maximal assistance with most activities of daily living, had a physician's order specifying that nonpharmacological interventions should be attempted before administering opioid medication for severe pain. However, review of the Medication Administration Record showed that the resident received hydromorphone on multiple occasions, and there was no documentation indicating that nonpharmacological interventions were attempted prior to medication administration. During interviews, the MDS Coordinator was unable to locate any documentation of nonpharmacological interventions before the administration of hydromorphone, and the Director of Nursing acknowledged the importance of such interventions to avoid unnecessary medication. The facility's pain management policy, which was current at the time, required the use of various nonpharmacological strategies before medicating for pain, but these were not documented as being attempted for the resident in question.
Failure to Act on Consultant Pharmacist's Recommendations for PRN Constipation Medications
Penalty
Summary
The facility failed to act upon recommendations from the Consultant Pharmacist regarding a resident's medication regimen for constipation. The resident, who had diagnoses including type 2 diabetes mellitus, major depressive disorder, and insomnia, was dependent on staff for several activities of daily living and had moderately impaired cognitive skills. The resident's physician orders included multiple PRN medications for constipation, such as bisacodyl suppository, lactulose, magnesium citrate, magnesium hydroxide, and polyethylene glycol, as well as a scheduled senna tablet. The Consultant Pharmacist's monthly medication regimen review specifically recommended that all PRN orders for constipation be reviewed and that the physician's orders specify the sequence in which these medications should be administered. Despite this recommendation, facility staff did not review the resident's PRN constipation medications or ensure that the physician's orders included the required sequencing. The Assistant Director of Nursing confirmed that the recommendation was received but not acted upon, acknowledging that licensed staff did not follow up as required by facility policy. The facility's policy states that staff must act upon all recommendations from the Consultant Pharmacist, but this procedure was not followed in this instance.
Failure to Ensure Timely Administration of Antidepressant Medication
Penalty
Summary
Resident 89, who was admitted with diagnoses including depression and a history of cerebrovascular accident, was prescribed Paxil 40 mg daily for depression. According to the resident's medication administration records (MAR) and pharmacy delivery records, the facility failed to ensure the resident received Paxil from 5/31/2025 until 6/04/2025. The pharmacy delivery records confirmed that there was no Paxil delivered to the facility to cover these dates, resulting in missed doses for the resident. Interviews with the resident, nursing staff, and the Director of Nursing (DON) revealed that the medication was not available during this period, and the staff had to request a new supply from the pharmacy. The resident reported a time when the facility ran out of Paxil, and the DON confirmed the medication was not delivered in time for scheduled administration. The MAR indicated that the medication was not administered during the gap, and the pharmacy confirmed the absence of delivery for the missing days. Facility policies required timely reordering of medications and immediate action when medications were unavailable, including notifying the physician and monitoring the resident. However, these procedures were not followed, as there was no evidence of timely reordering or alternative arrangements during the period when Paxil was unavailable. This resulted in the resident missing several doses of a significant medication prescribed for depression.
Failure to Provide Ongoing PT for Resident with New Prosthetics
Penalty
Summary
A deficiency occurred when the facility failed to provide ongoing physical therapy (PT) interventions for a resident with bilateral leg amputations and new prosthetic legs, despite documented improvement and continued need for therapy. The resident, who had a history of Type 1 diabetes mellitus and both right above-knee and left below-knee amputations, was initially referred to PT for assessment and training in sit-to-stand transfers and ambulation with new prosthetics. The PT evaluation and subsequent treatment notes showed the resident required varying levels of assistance for transfers and ambulation, but demonstrated progress over six PT sessions, improving from maximal to moderate assistance for both sit-to-stand transfers and walking in parallel bars. Despite this progress, PT services were discontinued after only six sessions, with the discharge summary citing a decision made in accordance with the physician or case manager, and referencing the resident's health insurance coverage as a limiting factor. The discharge summary recommended that the Restorative Nursing Aide (RNA) continue sit-to-stand training, but did not include further gait training or ambulation, which the resident had not yet mastered. Interviews with the resident, therapy staff, and the interim director of rehabilitation confirmed that the resident was motivated to walk, had requested more therapy, and that the therapy team believed the resident could have benefited from additional PT to reach a higher level of function. However, there was no documentation that the therapy department discussed the resident's progress or the possibility of extending therapy services with the physician prior to discharge. Observations of RNA sessions showed that the resident was able to perform sit-to-stand transfers with minimal assistance and was eager to progress to walking, but the RNA sessions were limited in scope and duration. The facility's policies required that therapy services be provided to restore residents to their highest level of function, but the lack of communication with the physician and failure to advocate for continued therapy services resulted in the resident being discharged from PT before achieving the goal of independent ambulation with prosthetics.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident, the nursing staff documented the administration of wound care treatment to the left knee prior to actually providing the treatment. The Treatment Nurse stated that Betadine was applied and the dressing was changed at the end of the day, but the Treatment Administration Record (TAR) showed documentation of the treatment earlier in the day. The nurse admitted to documenting the treatment as completed before actually performing it, which was not consistent with professional standards and could result in missed treatments. The Director of Nursing confirmed that documentation should occur after the treatment is provided and acknowledged that the TAR was not accurate, which could have led to missed care. For another resident, the facility did not develop a complete Change in Condition (COC) Evaluation form after the resident experienced a fall. The COC evaluation form was marked incomplete and could not be reviewed by the surveyor. The Assistant Director of Nursing confirmed that the charge nurse did not sign and complete the form, and stated that licensed staff are required to develop a complete and accurate evaluation after a resident's change of condition. The incomplete documentation meant that the resident's medical record was not valid and could result in the resident not receiving appropriate care due to inaccurate information. Both deficiencies were identified through interviews, record reviews, and observations. The facility's policies required that all services provided be documented in the resident's medical record in accordance with state law and facility policy, and that documentation be factual and completed at the time of service or no later than the end of the shift. The failures in documentation for both residents were not in accordance with these policies and accepted professional standards.
Failure to Protect Residents from Verbal Abuse by Staff and Peers
Penalty
Summary
The facility failed to protect residents from verbal abuse in two separate incidents involving both staff and resident-to-resident interactions. In the first incident, a resident with a history of confirmed adult physical abuse and moderate cognitive impairment reported a verbal altercation with a Certified Nursing Assistant (CNA) after the CNA removed the resident's dinner tray without consent. Both the resident and the CNA admitted to exchanging profanities, and the CNA acknowledged responding to the resident's remarks with offensive language. The Director of Nursing (DON) confirmed that staff should not use profane language toward residents and should maintain professionalism, while the Administrator (ADM) stated that the CNA's actions met the facility's definition of verbal abuse as outlined in their policy. In the second incident, a resident with mild cognitive impairment and total dependence for activities of daily living was subjected to repeated offensive and discriminatory language by a roommate who had severe cognitive impairment. Multiple CNAs reported hearing the roommate use profanities and discriminatory remarks directed at the resident, particularly regarding the resident's race and choice of television programming. The Social Services Director and the DON both acknowledged that such language constitutes verbal abuse and can cause psychosocial distress. The ADM confirmed that the roommate's words met the facility's definition of verbal abuse and should have been reported to supervisors and external entities. Both incidents were substantiated through interviews with residents, staff, and review of facility records and policies. The facility's policy defines verbal abuse as willful use of disparaging or derogatory terms, regardless of the recipient's ability to comprehend, and requires the prevention and prohibition of such abuse. The failure to prevent and address these incidents resulted in residents being subjected to verbal abuse by both staff and another resident.
Failure to Timely Report and Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure regarding abuse, neglect, and exploitation by not reporting an allegation of verbal abuse from one resident to another to the required authorities within the mandated timeframe. Specifically, a resident with mild cognitive impairment and total dependence on staff for activities of daily living reported that his roommate had repeatedly yelled at him, used offensive language, and made discriminatory remarks about his race. Multiple certified nursing assistants (CNAs) confirmed hearing these profanities and discriminatory remarks on several occasions, particularly when the resident was watching television. Despite this, none of the CNAs reported the incidents to supervisory staff, assuming that everyone was already aware of the behavior. The Social Services Director (SSD) and other facility leadership, including the Director of Nursing (DON) and the administrator, were unaware of the ongoing verbal abuse until it was brought to their attention during the survey. Interviews revealed that staff did not follow the facility's policy, which requires immediate reporting of all alleged violations of the abuse policy to the administrator, state agency, and other required agencies, no later than two hours after the allegation is made. The SSD and administrator acknowledged that the language used constituted verbal abuse and should have been reported and investigated according to policy. A review of the facility's policy confirmed that verbal abuse includes disparaging and derogatory communication directed at residents or within their hearing, regardless of their ability to comprehend. The policy also specifies that all alleged violations must be reported promptly to ensure resident protection. The failure to report the abuse resulted in unidentified abuse within the facility and a lack of protection for the affected resident.
Failure to Document Discontinuation of Hemodialysis and Permcath Removal
Penalty
Summary
The facility failed to document a physician's order to discontinue hemodialysis treatment and to send a resident for permcath removal, as required for a resident with end stage renal disease. The resident, who was cognitively impaired and dependent on staff for daily care, had an existing order for hemodialysis three times weekly. On review, it was found that a Dialysis Visit Note indicated an order to discontinue hemodialysis and arrange for permcath removal, but this was not documented in the resident's clinical record. The registered nurse involved acknowledged receiving the information from the dialysis center and discussing it with the nurse practitioner, but did not document the conversation or obtain the necessary order from the primary provider. The delay in obtaining and documenting the order for permcath removal resulted in the resident being sent for the procedure at a later date. The facility's policy required care and treatment to be consistent with professional standards, physician orders, and the resident's care plan, but these standards were not met in this instance. The lack of documentation and delay in action had the potential to result in health complications, including the risk of infection at the permcath site.
Failure to Conduct Trauma Assessments for Residents
Penalty
Summary
The facility failed to conduct trauma assessments for three sampled residents, each with significant medical and psychosocial histories. For one resident, the admission record showed diagnoses including type 2 diabetes, dementia, and chronic pain, with documentation of fluctuating decision-making capacity and moderate cognitive impairment. After an incident where the resident reported being struck, further review and family input revealed the report was likely a trauma response triggered by pain and past experiences. Despite these indicators, there was no documented trauma assessment in the resident's records. A second resident, with a history of diabetes with neuropathy and suicidal ideations, also exhibited fluctuating capacity for decision-making and moderate cognitive impairment. This resident required substantial assistance with daily activities. Review of clinical records confirmed that no trauma assessment was documented for this individual, despite their complex psychosocial and medical needs. A third resident, admitted with a recent fracture and cerebral infarction affecting the dominant side, also had moderate cognitive impairment and required significant assistance with personal care. Again, no trauma assessment was found in the records. Interviews with facility staff revealed confusion regarding responsibility for trauma assessments, with the Social Services Director and Director of Nursing each indicating it was the other's responsibility. Facility policy required trauma-informed care and culturally competent services, but these were not implemented as trauma assessments were not completed for the residents involved.
Failure to Document Wound Care in Medical Record
Penalty
Summary
The facility failed to document wound care treatment provided to one resident in the Treatment Administration Record (TAR) as required by professional standards and facility policy. The resident was admitted with multiple diagnoses, including type 2 diabetes, alcoholic cirrhosis of the liver, dysphagia, chronic kidney disease, an unstageable pressure ulcer of the sacrum, and a gastrostomy tube. Physician orders directed daily wound care for both the sacrum and gastrostomy tube site. However, review of the TAR for the relevant period showed that documentation of these treatments was left blank for several days. Interviews with the licensed vocational nurses responsible for the resident's care confirmed that the treatments were provided as ordered, but the nurses did not document the completion of these treatments in the TAR. The Director of Nursing also acknowledged that documentation should have occurred after the treatments were provided, in accordance with facility policy, which requires that care and services be documented at the time of service or by the end of the shift.
Failure to Follow Care Plan for Side Rail Use
Penalty
Summary
A deficiency was identified when staff failed to implement a patient's care plan as ordered. The patient, who was legally blind, dependent on staff for activities of daily living, and at high risk for falls, had a care plan and physician order specifying that one fourth side rails should be up while in bed to assist with positioning and turning. During an observation, the patient was found lying in bed with the bed in the highest position and the left one fourth side rail down, contrary to the care plan and physician order. Certified Nursing Assistant 2 confirmed that the side rail should have been up and that the patient required it for mobility and fall prevention. Further interviews with nursing staff confirmed that beds should not be left in a high position unattended and that the care plan required the side rail to be up while the patient was in bed. Review of facility policy indicated that comprehensive care plans with patient-specific interventions must be implemented. The failure to follow the care plan and physician order for side rail use constituted the deficiency.
Plan Of Correction
C835: T22 DIV5 CH3 ART3- 72311(a)(2) Nursing Service - General Corrective action for resident found to have been affected by this deficiency: On 3/10/2025, both rails were verified to be up by DSD for resident 5. Identify any other residents who may have been affected by the deficient practice: On 3/10/25, ADONS and DSD performed rounds of the entire facility to ensure that any patients who had orders for side rails were following MD orders and adhering to the care plan. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur: Beginning 3/10/2025, DSD initiated in-servicing of CNA and licensed nursing staff regarding ensuring side rails are being utilized in accordance with physician's orders and patient plan of care. (To continue page 3 of 25) Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: Beginning 3/10/25, DSDS will perform weekly rounds of all in-house patients to ensure that if side rails are ordered, they are in place as per MD orders and plan of care. These audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by DSD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25
Insulin Administered Too Early Before Meal
Penalty
Summary
A patient with diabetes mellitus, who was cognitively intact and required some assistance with daily activities, was prescribed insulin lispro to be administered subcutaneously 15 minutes before meals and at bedtime, according to a sliding scale based on blood glucose levels. On the day in question, the patient received 8 units of insulin lispro at 4:00 p.m. for a blood sugar reading of 301 mg/dL, prior to the scheduled dinner. The patient's care plan specified that diabetes medication should be given as ordered by the physician. Observation and interviews revealed that the insulin was administered significantly earlier than the prescribed time, as the patient had not yet received the dinner meal more than an hour after the injection. The nurse who administered the insulin stated that it could be given up to an hour before the meal and did not provide a snack to the patient before dinner, citing being busy with other tasks. Facility policy required medications to be administered as ordered and in accordance with manufacturer specifications, which was not followed in this instance.
Plan Of Correction
C900: T22 DIV5 ART3-72313(a)(2) Nursing Service - Administration of Medication Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, DON assessed Patient 7 for any adverse reactions related to the early administration of insulin lispro. There was no change in condition noted. Identify any other residents who may have been affected by the deficient practice. On 3/12/2025, MRD audited the last 7 days of insulin administration to ascertain if any other patients had been given insulin before it was due. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, in-servicing of licensed nurses regarding the proper timing and administration of insulin was initiated. (To continue page 5 of 25) continued Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/12/2025, MRD will spot check insulin administrations of 5 patients per week to ensure they are not being administered before they are due. These weekly audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed. 04/03/25 C 900
Late Administration of Scheduled Medications
Penalty
Summary
A deficiency was identified when a registered nurse administered a resident's scheduled 9 a.m. medications approximately one hour later than the prescribed time. The medications included aspirin, Zyprexa, vitamin D, and Keppra, which were observed being given at 10:57 a.m. The nurse confirmed that these were the resident's 9 a.m. medications and acknowledged they were administered about an hour late. The facility's policy and the Director of Nursing both stated that medications should be administered within one hour before or after the scheduled time unless otherwise ordered by a physician. The resident involved had a history of hypertension and traumatic brain injury, and required moderate assistance with certain activities of daily living, but had intact cognitive skills. The late administration of medications was observed during a medication pass, and the facility's records and staff interviews confirmed the deviation from the required medication administration schedule.
Plan Of Correction
C945: T22 DIV5 CH3 ART3-7231(a)(6) Nursing Service - Administration of Medication. Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, RN assessed Patient 2 for any adverse reactions related to the late administration of morning medications. There was no change in condition noted. On 3/10/2025, RN notified the attending physician of Patient 2 of the late administration with no new orders obtained. (To continue page 8 of 25) Identify any other residents who may have been affected by the deficient Practice. On 3/12/2025, audited the last 7 days of medication administration to ascertain if any other patients had been administered routine medications late. There were none other issues identified. Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, DSD initiated in-servicing of licensed nurses regarding the proper timing and administration of medications. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/12/2025, MRD will spot check medication administrations of 5 patients per week to ensure they are not being administered after they are due. (To continue page 9 of 25) These weekly audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25 C1115: T22 DIV5 CH3 ART3-72315(m) Nursing Service - Patient Care Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, RN placed the call light in reach of Patient 1. On 3/10/2025, RN answered the call light and attended to the needs of Patient 4. Identify any other residents who may have been affected by the deficient Practice. On 3/10/2025, ADONs and DSD made rounds of all in-house patients to ensure all call lights are in place and within reach. There were none other issues identified. On 3/10/2025, ADONs and DSD made rounds of all units to ensure staff is not walking past call lights that are engaged and ensuring that all call lights have been answered. There were none other issues identified. (To continue page 11 of 25)
Failure to Ensure Call Light Accessibility and Prompt Response
Penalty
Summary
The facility failed to ensure that patient call lights were accessible and answered promptly for two patients. For one patient with severe cognitive impairment, muscle weakness, and a history of traumatic brain injury, the call light was observed on the floor under the headboard, out of the patient's reach while the patient was lying in bed. This was confirmed by a registered nurse, who acknowledged that the call light was unreachable and that this could delay the patient's care needs. Facility policy requires that call lights be within reach and accessible to patients at all times. For another patient with a history of falls, reduced mobility, and a recent femur fracture, the call light was activated while the patient needed assistance with toileting. A certified nursing assistant walked past the room, saw the lit call light, but did not respond because the patient was not assigned to her that day. The CNA later confirmed she should have checked on the patient regardless of assignment. Facility policy states that any staff member who sees or hears an activated call light is responsible for responding. These failures had the potential to delay the provision of services and result in unmet patient needs.
Plan Of Correction
Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/11/2025, DSD initiated in-servicing for CNA and licensed nursing staff regarding ensuring call lights are in place and in reach of patients as well as ensuring that call lights are not passed in the hallway without answering. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/11/2025, DSDs will make weekly rounds of all patient rooms to ensure call lights are in place and within reach as well as that staff is not walking past call lights that are engaged in the hallways. These rounds will continue for 1 month or until substantial compliance is obtained. Any ongoing noncompliance will be reported by DSD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25 C1115
Failure to Use PPE During Contact Isolation Precautions
Penalty
Summary
Nursing staff failed to wear required personal protective equipment (PPE), specifically gloves and a gown, when delivering and removing a lunch tray for a patient who was on contact isolation due to an infectious disease. Observation showed a Certified Nurse Assistant (CNA) entering the patient's room without donning PPE, and later accepting an empty lunch tray from the patient without gloves. The CNA acknowledged this was a breach of the facility's contact isolation protocol, which is intended to prevent the spread of infection. The patient involved had been admitted with diagnoses including shortness of breath and cellulitis of the back, and required supervision for several activities of daily living. Facility policy, as well as statements from the Director of Nursing (DON), confirmed that staff are required to wear full PPE when entering the room of a patient on contact isolation, including when handling food trays. The facility's policy also indicated that PPE should be readily available near the entrance to the patient's room and must be donned before or upon entry.
Plan Of Correction
C1245: T22 DIV5 CH3 ART3-72321(a) Nursing Service - Patients with infectious disease Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, CNA 1 was provided 1:1 education regarding transmission-based precaution requirements and encouraged to perform prompt hand hygiene. Identify any other residents who may have been affected by the deficient practice. On 3/10/2025, DSD and IP made rounds of all isolation rooms in the facility to ascertain if there were any other staff members entering contact isolation rooms without proper PPE. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, IP initiated in-servicing to CNA and licensed nursing staff regarding proper PPE use as indicated when delivering or picking up meal trays. (To continue page 15 of 25) Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/10/2025, IP will perform weekly rounding of all isolation rooms to ascertain if staff is utilizing PPE as indicated. These rounds will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by IP nurse at the monthly QA meeting. Date of corrective action would be completed. 04/03/25 C1245
Failure to Provide Prescribed Seizure Medications as Ordered
Penalty
Summary
The facility failed to ensure that prescribed seizure medications, Lacosamide (Vimpat) and Clobazam, were available and administered as ordered for a patient diagnosed with epilepsy. Multiple instances were documented where these medications were not available in the facility, as evidenced by medication administration records (MAR), controlled drug records (CDR), and nursing progress notes. Specific dates were noted where the medications were not present, and nurses documented the unavailability in the patient's records, with no signatures on the CDR to indicate administration. Interviews with the patient confirmed that there were multiple days when the prescribed medications were not received. Nursing staff also acknowledged that there were times when the medications were not available, and one nurse admitted to incorrectly documenting that a medication was given when it was not, due to its unavailability. The Director of Nursing confirmed the absence of the medications on the specified dates and acknowledged that the medications were not present in the facility to be administered as prescribed. A review of facility policies indicated that there should be a systematic approach to ensure timely acquisition and administration of medications, but these procedures were not followed in this case. The failure to provide the necessary medications as ordered was substantiated by direct observation, interviews, and record reviews, demonstrating a breakdown in the facility's pharmaceutical service requirements.
Plan Of Correction
C1930: T22 DIV5 CH3 ART3- 72355(a)(1)(D) Pharmaceutical Service - Requirements Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, DON ensured the Lacosamide and Clobazam was available for use for Patient 8. Identify any other residents who may have been affected by the deficient practice. On 3/12/2025, MRD performed an audit of all patients on seizure medications to ensure that the medications were available for use in the medication carts. There were no other issues identified. (To continue page 17 of 25) Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, DSD initiated in-servicing of licensed nursing staff regarding prompt ordering of medications and strategies for follow-up with pharmacy and physician to ensure prompt delivery. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/12/2025, MRD will perform an audit of all patients on seizure medications to ensure that the medications are available for use in medication carts. These audits will continue weekly for 1 month. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25
Failure to Document Pain Medication Administration on MAR
Penalty
Summary
Licensed nurses at the facility failed to properly document the administration of pain medication for a patient with chronic pain syndrome. Specifically, on two occasions, Norco was removed from the medication cart and signed out on the Controlled Drug Record (CDR) for the patient, but there was no corresponding entry on the Medication Administration Record (MAR) to indicate that the medication was administered. The MAR is required to be signed after medication administration to ensure accurate documentation and assessment of the patient's pain and response to treatment. During interviews, both the licensed nurse involved and the Director of Nursing confirmed that the established process requires signing the CDR, administering the medication, and then signing the MAR. The absence of documentation on the MAR meant that there was no record of the patient's pain assessment or the effectiveness of the pain medication for those times. Facility policy also requires the MAR to be signed after medication administration, and the CDR, in conjunction with the MAR, serves as the official record for controlled substance administration.
Plan Of Correction
C4975: T22 DIV5 CH3 ART5-72543(f) Patients' Health Records Corrective action for resident found to have been affected by this deficiency: On 3/11/2025, DON provided 1:1 in-servicing to LVN 4 regarding proper PRN controlled medication administration documentation and accountability. Identify any other residents who may have been affected by the deficient practice: On 3/12/2025, MRD audited the last 7 days of PRN Norco administration for in-house patients to ensure all documentation is complete. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur: Beginning 3/11/2025, DSD initiated in-servicing for licensed nursing regarding proper documentation and signing for administration of controlled medications. (To continue) Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: Beginning 3/12/2025, MRD will perform weekly audits of the last 7 days of PRN Norco administration for in-house patients to ensure all documentation is complete. These audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25
Failure to Document Pain Assessment and Medication Administration
Penalty
Summary
The facility failed to ensure that pain assessments were conducted and documented before and after the administration of pain medication for one patient. Specifically, a licensed nurse did not sign the Medication Administration Record (MAR) after removing Norco, a controlled pain medication, from the medication cart and signing the Controlled Drug Record (CDR) for two separate instances. This omission resulted in no documentation of pain assessment at the time the medication was administered. The patient involved had a diagnosis of chronic pain syndrome and was moderately impaired in cognition, requiring assistance with daily activities. Physician's orders indicated that Norco was to be administered as needed for severe pain, and the CDR showed that the medication was removed and presumably given on two occasions. However, the MAR for those dates did not reflect any pain assessment or documentation of medication administration. During interviews, both the nurse involved and the Director of Nursing confirmed that the process requires signing the MAR after administering medication to document pain levels and effectiveness. Facility policies also require pain assessment and documentation in conjunction with medication administration. The lack of documentation on the MAR meant that there was no record of pain assessment or reassessment for the patient during those times.
Plan Of Correction
A029: 1254.7(b) Health & Safety Code 1254 Corrective action for resident found to have been affected by this deficiency. On 3/11/2025, DON provided 1:1 in-servicing to LVN 4 regarding proper PRN controlled medication administration documentation and accountability. On 3/11/2025, RN assessed Patient 9's pain to ensure pain was well managed. Identify any other residents who may have been affected by the deficient practice. On 3/12/2025, MRD audited the last 7 days of PRN Norco administration for in-house patients to ensure all documentation is complete. There were none other issues identified. On 3/12/2025, MRD performed an audit of the last 7 days of PRN Norco administration for in-house patients to ascertain if their pain levels were documented at the time of PRN medication administration. There were none other issues identified. Measures that will be put into place to ensure that this deficiency does not recur: Beginning 3/11/2025, DSD initiated in-servicing for licensed nursing regarding pain assessment, proper documentation, and signing for administration of controlled medications. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: Beginning 3/12/2025, MRD will perform weekly audits of the last 7 days of PRN Norco administration for in-house patients to ensure all documentation is complete and that pain has been assessed. These audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25
Failure to Document Resident Grievance on Bedbugs
Penalty
Summary
The facility failed to document and file a grievance made by a resident regarding bedbugs in her room, which was not recorded in the facility's grievance log. The resident, who was cognitively intact and capable of making decisions, reported seeing bedbugs on her bed and in her room to a staff member. The housekeeping department was informed, and actions were taken to address the issue, including stripping linens, washing clothes, deep cleaning the room, and replacing the mattress. However, the grievance was not documented as required by the facility's policy. Interviews with the Social Services Designee and the Social Services Director revealed that the grievance was communicated to the housekeeping department but was not logged in the facility's grievance log. The facility's policy mandates that grievances be documented on a grievance form and logged to ensure timely resolution and tracking. The Social Services Director acknowledged the absence of documentation for the grievance, emphasizing the importance of logging grievances to track and resolve them effectively.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically assaulted another. On 10/17/2024, during lunchtime, a registered nurse witnessed a resident punch another resident twice in the face while the latter was seated in a wheelchair. This incident involved two residents with severely impaired cognition, one of whom had a history of aggressive behavior. The assaulted resident had been admitted to the facility with diagnoses including hemiplegia, hemiparesis, and dysphagia following a cerebral infarction, and required assistance with daily activities. The aggressor resident had diagnoses of schizophrenia, an unspecified mood disorder, and a history of traumatic brain injury, and also required assistance with daily activities. The incident was corroborated by multiple staff members who witnessed the event. The facility's policy on abuse, neglect, and exploitation, last reviewed in September 2024, mandates the protection of residents' health, welfare, and rights. However, the facility did not adequately monitor the aggressive resident's behavior, which led to the physical abuse incident. The Social Services Director acknowledged the facility's lack of proactive measures in preventing such incidents.
Inadequate Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its policy and procedure by not conducting a thorough investigation into an allegation of physical abuse involving two residents. On 10/17/2024, a registered nurse witnessed Resident 5 punching Resident 4 twice in the face with a closed fist. Despite this observation, the facility's investigation, led by the Social Services Director (SSD), was inadequate. The SSD's investigation summary, dated 10/22/2024, did not include interviews with all relevant staff, such as RN 2, who directly witnessed the incident, and Resident 5's assigned charge nurse. Resident 4, who was admitted to the facility with diagnoses including hemiplegia and severely impaired cognition, was the victim of the physical altercation. Resident 5, who has a history of schizophrenia and traumatic brain injury, was identified as the aggressor. The SSD's investigation relied on information provided by the Director of Nursing and did not thoroughly document or interview all involved parties, as required by the facility's policy. The SSD admitted to not conducting a thorough investigation and acknowledged the need to investigate again. The facility's policy on abuse, neglect, and exploitation mandates identifying and interviewing all involved persons and providing complete documentation, which was not adhered to in this case. This deficiency had the potential to place residents at risk for further abuse.
Failure to Ensure Staff Identification Badges Worn
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) wore an identification badge while on duty, which is a requirement for all staff members. This deficiency was observed during an incident where LVN 1 was seen pushing a resident in a wheelchair without wearing an identification badge. During an interview, LVN 1 acknowledged the importance of wearing an identification badge for residents and staff to recognize her and her role within the facility. She mentioned that she was newly hired and currently on orientation, having been employed part-time since September. The Assistant Director of Nursing (ADON) confirmed that all staff are required to wear identification badges to inform residents, visitors, and other staff of their name and title. The facility's policy, reviewed in September, mandates that identification badges must be worn during working hours and be clearly visible, containing the employee's first name, last name, and job title. The ADON stated that identification badges should be provided upon hire, indicating a lapse in the facility's adherence to its own policy regarding staff identification.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 2, which could potentially delay the provision of services and result in the resident's needs not being met. Resident 2 was admitted to the facility with diagnoses including atrial fibrillation, chronic pain syndrome, and dorsalgia. According to the Minimum Data Set dated 8/26/2024, Resident 2 required substantial assistance with personal hygiene and setup assistance with eating. During an observation on 10/28/2024, it was noted that Resident 2 was lying on the call light, making it inaccessible. A registered nurse (RN 1) confirmed during an interview and observation that the call light was underneath Resident 2's back, rendering it unreachable. RN 1 then placed the call light within the resident's reach, acknowledging the importance of having the call light accessible for the resident's safety. The facility's policy, reviewed on 9/25/2024, mandates that staff ensure call lights are within reach and secured, which was not adhered to in this instance.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
