The Beach Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 2725 Pacific Avenue, Long Beach, California 90806
- CMS Provider Number
- 055041
- Inspections on file
- 41
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at The Beach Post-acute during CMS and state inspections, most recent first.
A resident with ESRD and scheduled HD three times weekly missed two consecutive HD treatments due to transportation issues, and staff failed to implement the dialysis-related care plan or change-in-condition procedures. Although HD orders and transportation times were in place and an extra HD session was arranged and reportedly communicated among staff, there was no documentation that the resident received HD on the missed days, no monitoring or assessment for fluid overload or other complications, and no physician notification. When the resident next arrived at the dialysis center, she was found by dialysis staff to have facial and generalized edema and to be significantly above her prescribed target weight, indicating the facility did not follow its own ESRD, transportation, and change-in-condition policies.
A resident with a history of joint replacement surgery and ESRD on hemodialysis had physician orders and a care plan requiring pain assessment every shift and PRN Hydrocodone-Acetaminophen for moderate to severe pain. On one morning, an LVN obtained the resident’s vital signs but did not document a pain score, and later assessed the resident’s pain as a 6 yet failed to record this updated level in the medical record, even though PRN pain medication was administered. The resident reported telling the LVN that her pain was worsening but felt the LVN did not pay attention or further assess her pain, leading the resident to contact a family member. The DON confirmed that the LVN was responsible for complete and accurate documentation of pain levels in line with facility pain management policy.
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of live and dead roaches in the staff breakroom and a report from a resident with anoxic brain damage and moderately impaired cognition who saw large roaches on the wall in his room. Staff, including CNAs and housekeepers, reported seeing roaches daily in the breakroom and described an ongoing roach problem, while the Maintenance Supervisor acknowledged roach activity in the breakroom but not in resident rooms. The Administrator was unaware of the roach issue in the breakroom, despite a facility policy requiring an ongoing pest control program to keep the building free of insects and rodents.
Staff did not consistently maintain the bed in the lowest position for a resident with severe cognitive impairment and hemiplegia who was dependent for transfers and identified as a fall risk. Despite a care plan intervention to keep the bed low after a fall, the bed was repeatedly observed in the highest position, and staff interviews revealed lapses in following this safety measure.
A CNA used derogatory and offensive language toward a resident with cognitive impairment and physical dependence during incontinence care, causing the resident to feel humiliated and emotionally distressed. The incident was reported by the resident, and the CNA admitted to making inappropriate comments that resulted in the resident's emotional upset.
Two residents experienced deficiencies in care, including the development of MASD due to inadequate incontinence care, repeated failures in telephone communication between a resident and her family, and ongoing delays in call light response. Grievances and meeting minutes documented that staff did not consistently provide timely assistance or follow established protocols, impacting resident dignity and access to care.
A resident with multiple health conditions was admitted with a stage I sacrococcyx pressure injury, which progressed to stage II with deep tissue involvement due to the facility's failure to implement key interventions such as a low air-loss mattress and nutritional supplements like zinc and vitamin C. Despite being at risk for pressure injuries and facility policies requiring comprehensive assessment and intervention, appropriate wound care measures and nutritional support were not provided, and the registered dietitian was not involved in the initial assessment.
A resident with a history of GI bleeding and anemia experienced a delay in obtaining and reporting a stat CBC after exhibiting symptoms such as confusion and black tarry stools. Miscommunication among nursing staff led to the stat order not being properly conveyed to the lab, and when the blood draw was refused, neither the physician nor the responsible party was notified. Critical lab results were further delayed due to unsuccessful attempts by the lab to reach facility staff, resulting in the resident's transfer to a hospital for urgent care.
A resident with a history of GI bleeding and anemia, who was unable to make consistent decisions, refused a physician-ordered STAT CBC after returning from a medical procedure. Nursing staff did not notify the physician or responsible party of the refusal, as required by facility policy, resulting in a delay in obtaining critical lab results.
The facility failed to provide emergency dialysis kits at the bedside for residents receiving hemodialysis, posing a risk of delayed treatment during emergencies. Observations and staff interviews confirmed the absence of these kits, which are crucial for managing potential severe hemorrhages. The Director of Nursing acknowledged the issue, noting that the kits were stored in central supply instead of being readily available at the bedside.
The facility failed to label open bags of frozen pancakes and cinnamon rolls with an open date and use by date, as observed during a survey. This lack of labeling could potentially expose residents to food-borne illnesses. The Dietary Supervisor and DON acknowledged the importance of labeling to ensure food quality and prevent gastrointestinal illness. The facility's policy requires labeling and dating of food items upon opening, which was not followed.
A facility failed to update the PASARR for a resident with psychoses and anxiety, despite ongoing episodes of paranoia and delusional behavior. The resident's PASARR Level 1 Screening from 2022 indicated no need for a Level II evaluation, but subsequent assessments showed a need for further review. The DON confirmed the oversight, acknowledging the resident should have had a PASARR Level II review to reflect their medical condition.
A resident with a pressure ulcer on the right heel did not receive the prescribed daily wound care treatment due to an LVN's oversight. The LVN mistakenly thought the wound was healed and failed to verify the physician's orders, resulting in a missed treatment. The resident was at high risk for pressure sores and required extensive assistance with daily activities.
A resident with amputations and muscle weakness did not receive the recommended Restorative Nursing Assistant (RNA) program after a referral by the physical therapist. Despite being at risk for decline in range of motion, the RNA services were not provided due to a missed referral by the nursing staff. The facility's policy required referrals to the RNA program, but the oversight led to a potential decline in the resident's condition.
A resident in an LTC facility did not receive new dentures as recommended by a dentist, despite having multiple health issues and being dependent on staff for daily activities. The facility failed to follow up on dental recommendations, with staff admitting to overlooking communications from the dental office. This oversight could lead to negative health and psychosocial outcomes for the resident.
A facility failed to ensure proper hand hygiene practices by an LVN and a CNA, leading to potential cross-contamination risks. An LVN did not change gloves or wash hands during wound care for a resident with multiple health issues, while a CNA neglected hand hygiene after handling dirty linen and assisting another resident. Interviews confirmed the importance of hand hygiene to prevent infection spread, as outlined in the facility's infection control policy.
A resident was prescribed Augmentin for facial pain without using the McGeer criteria or conducting necessary assessments and lab tests. The IP was not informed of the prescription, violating the facility's Antibiotic Stewardship Program, which requires staff to assess suspected infections and notify the IP of antibiotic orders.
Two residents in an LTC facility refused influenza, pneumonia, and COVID-19 vaccines without receiving documented education on the risks and benefits of refusal. Despite facility policy requiring such education, interviews with the IP and DON confirmed the lack of documentation. This oversight violated residents' rights to informed decision-making and increased their risk of disease transmission.
A resident with Parkinsonism and osteoporosis, identified as high risk for falls, experienced multiple unwitnessed falls due to the facility's failure to update the care plan. Despite high fall risk assessments, the care plan was not revised to include necessary interventions, resulting in a third fall and a subdural hematoma. Staff interviews revealed a lack of communication and awareness of the resident's fall risk and care plan.
A resident with a history of aggressive behavior hit another resident on the knee twice, following a verbal exchange. Despite having intact cognitive skills, the aggressive resident had previous altercations with roommates, yet lacked continuous monitoring or intervention adjustments. The facility failed to implement its abuse prevention policy effectively, leading to this incident.
A resident with multiple diagnoses, including major depressive disorder and anxiety, exhibited aggressive behavior by throwing water at a roommate. Despite the incident, the LTC facility failed to develop a baseline care plan to address the behavior, as required by their policies. The resident's cognitive skills were intact, and she required assistance for daily activities. The facility's DON acknowledged the oversight, which was not in line with their care plan development procedures.
Two residents experienced significant delays in call light response, leading to them sitting in urine and feces for extended periods. One resident, with diabetes and depression, reported staff turning off the call light without returning, causing embarrassment. Another resident, with hemiplegia, had to transfer herself to find staff. Facility policy requires prompt response, but practice did not align.
The facility failed to provide written notice to two residents or their responsible parties before room changes, violating their rights. One resident with severe cognitive impairment and another with intact cognition were moved without proper notification, contrary to facility policy.
A resident with a history of verbal abuse was allowed to continue sharing a room with other residents, leading to multiple incidents of harassment and intimidation. Despite staff awareness of the resident's behavior, the facility failed to prevent further abuse, affecting six residents with cognitive impairments and mental health conditions.
The facility failed to report multiple allegations of resident-to-resident verbal abuse within the required timeframe, involving a resident with a history of behavioral issues who verbally abused his roommates. Despite staff awareness and reports to the Administrator, the incidents were not reported to the necessary authorities, delaying investigations.
A resident with a history of verbal abuse and threats towards roommates did not have a comprehensive care plan to prevent further incidents. Despite the resident's intact cognition and known behavioral issues, the care plan lacked interventions to prevent other residents from being admitted to the same room. This resulted in multiple residents experiencing verbal abuse and threats, leading to roommate incompatibility and room changes.
A medication cart on Station two was found unlocked and unattended, allowing potential access to medications by unauthorized individuals. LVN admitted to forgetting to lock the cart, and the DON confirmed the responsibility of nurses to secure medication carts. The facility's policy requires medications to be stored securely and only accessible to authorized personnel.
A resident undergoing physical therapy was verbally abused by a CNA who used a curse word in Tagalog, a language the resident understood, during a session. The incident, witnessed by staff, left the resident feeling hurt and embarrassed. Despite the Administrator's initial belief that the language was meant to motivate, the facility's policy affirms residents' right to be free from verbal abuse.
A resident reported two separate incidents of abuse by different CNAs, but the facility failed to conduct thorough investigations, including interviews with other residents and staff, as required by their policy.
A resident with a history of elopement and under conservatorship eloped twice from the facility due to inadequate supervision and ineffective alarm systems. The resident was placed in a room with access to an alley, and the facility lacked a proper care plan for the resident's elopement risk. Staff failed to monitor the resident effectively, and there was insufficient communication and documentation regarding the resident's behavior and risk.
A facility failed to report a resident-to-resident physical abuse allegation to CDPH and the LTC Ombudsman within the required timeframe. Resident 4 alleged that Resident 1, who has paranoid schizophrenia, hit him. Despite Resident 4 calling the police, the facility's investigation deemed the incident an unusual occurrence and did not report it, contrary to their policy.
A resident with a high elopement risk, diagnosed with paranoid schizophrenia and psychosis, eloped twice from the facility. The QAA/QAPI committees failed to identify and address the initial elopement, and no care plan was in place for the resident's elopement risk or refusal to wear a wander guard. The administrator did not report the first incident to the committees, leading to a lack of preventive measures and a second elopement.
Missed Hemodialysis Treatments and Lack of Monitoring for ESRD Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with ESRD received ordered hemodialysis (HD) treatments and that her dialysis-related care plan was implemented. The resident was admitted with diagnoses including joint replacement surgery and ESRD requiring HD, with physician orders for HD on Monday, Wednesday, and Friday at a specified time, and transportation arranged for pickup prior to each treatment. Her care plan, initiated shortly after admission, identified a need for dialysis with goals of avoiding complications related to fluid overload and maintaining normal weight, and included interventions to provide HD on the ordered schedule and to monitor for changes in level of consciousness, vital signs, heart and lung sounds, and edema, with reporting to the primary physician as needed. Record review showed no documentation that the resident received HD on two ordered treatment days and no documentation that licensed nurses identified, monitored, or assessed her for complications related to the missed HD treatments on those days. The resident’s emergency contact reported that the resident missed an HD treatment because transportation did not pick her up, and that an additional treatment scheduled for the following day was also missed due to the same transportation issue. The emergency contact expressed concern that the resident would retain excess fluids because her kidneys were no longer functioning. Multiple staff interviews confirmed breakdowns in both transportation coordination and nursing follow-through. The RN Supervisor acknowledged that on the morning shift when the resident reported missing HD due to lack of transportation, she did not assess or monitor the resident for a change in condition, did not notify the primary physician, and did not initiate monitoring for potential complications. The Case Manager stated she had confirmed transportation and arranged an extra HD treatment, documented it on the communication board, and informed the RN Supervisor, while another RN reported endorsing the extra HD appointment to the next shift. However, the RN working the following morning shift stated she did not receive endorsement or see any communication board note about the appointment. Staff also confirmed that despite the resident missing two HD appointments, there was no monitoring initiated, no specific plan of care formulated for the missed HD, and no notification of the primary physician. When the resident presented to the dialysis center at the next scheduled treatment, the dialysis clinical coordinator assessed her with facial and generalized body edema and documented that she was 11 kg above her prescribed target weight. Policy review showed that the facility’s transportation policy required assistance with arranging transportation as needed, the ESRD policy required that residents with ESRD be cared for according to recognized standards and that licensed nursing staff be trained to recognize signs and symptoms of worsening condition or complications, and the change-in-condition policy required prompt physician notification and detailed documentation, including at least 72 hours of monitoring, vital signs each shift, evident care plan, and reassessment when a change in condition occurred. These policy requirements were not followed in relation to the missed HD treatments and lack of monitoring and assessment for this resident.
Failure to Accurately Assess and Document Resident Pain Level
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess and document a resident’s pain level in accordance with physician orders, the care plan, and facility policy. The resident had been admitted with diagnoses including joint replacement surgery and end stage renal disease requiring hemodialysis. The resident’s MDS indicated she was able to make reasonable decisions and required only partial to supervision-level assistance with ADLs. Physician orders and the care plan directed staff to assess and monitor the resident’s pain level every shift and to manage her pain, including the use of Hydrocodone-Acetaminophen 5/325 mg as needed for moderate to severe pain. On the date in question, the resident’s vital signs were taken in the morning, and the Weights and Vitals Summary documented blood pressure and heart rate but did not include a pain level, despite the order to assess pain every shift. The MAR for that month showed a recorded pain level of 3 for the day shift on that date and an order to administer Hydrocodone-Acetaminophen 5/325 mg every four hours as needed for pain levels 4–10. The MAR also showed that the resident received one tablet of Hydrocodone-Acetaminophen at 11:01 a.m. In interviews, the resident reported that one morning, a few hours after breakfast, she told an LVN that her pain was getting worse, but the LVN did not pay attention, did not ask questions about her pain, and the resident ultimately called a family member because the pain was making her anxious. The LVN later stated she had checked the resident’s vital signs around 9:17 a.m. but did not document the pain level with the vital signs, and that she identified the resident’s pain level as 6 around 11:00 a.m. but did not document that pain level in the medical record at that time. The DON confirmed that the LVN should have documented complete vital signs, including pain, and updated and recorded the accurate pain level during the shift to reflect the resident’s condition and ensure continuity of care, consistent with the facility’s pain assessment and management policy requiring documentation of the resident’s reported level of pain with adequate detail.
Failure to Maintain Effective Pest Control for Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the building was free of insects, specifically roaches. During a tour of the facility, surveyors observed two large dead roaches on the floor behind a water dispenser and a live cockroach crawling from under the water machine in the staff breakroom. Shortly thereafter, another roach was seen crawling from underneath the refrigerator in the same breakroom. Staff present in the breakroom, including a CNA and housekeepers, reported that roaches had been an ongoing problem in that area and that they saw roaches daily while eating lunch. One housekeeper stated she killed roaches when she saw them and then reported the sightings to her supervisor, who provided pesticide spray for her to use. A resident with anoxic brain damage, moderately impaired cognition, and dependence on staff for multiple activities of daily living reported seeing a couple of large roaches crawling across the wall in his room about three weeks prior and stated he informed the Maintenance Supervisor. Staff interviews confirmed that nurses and housekeeping staff had reported roaches in the breakroom to the Maintenance Supervisor, who acknowledged awareness of a roach problem in that area but stated he had not seen evidence of roaches in resident rooms. The Administrator stated he was not aware of roaches in the breakroom. Review of the facility’s pest control policy indicated the facility was to maintain an ongoing pest control program to ensure the building was free of insects and rodents, but observations and staff and resident reports showed the presence of roaches in both a resident room and the staff breakroom.
Failure to Maintain Bed in Lowest Position for Fall-Risk Resident
Penalty
Summary
Facility staff failed to implement post-fall interventions for a resident identified as a fall risk. The resident, who had diagnoses including hemiplegia and hemiparesis following an intracranial hemorrhage, was assessed as having severe cognitive impairment and was dependent on staff for transfers. Despite a care plan intervention to keep the bed in the lowest position to prevent further falls, the resident's bed was repeatedly observed in the highest position during multiple observations and interviews. Staff present in the room did not lower the bed after providing care, and the bed remained in the highest position until the surveyor exited the room. Interviews with staff revealed inconsistent practices regarding bed positioning, with one CNA stating she left the bed in the highest position due to being rushed and suggesting that licensed staff may have raised it for other reasons. The Registered Nurse Supervisor confirmed that the intervention after the resident's fall was to keep the bed in the lowest position, and acknowledged that failure to do so could lead to another fall. The facility's policy required staff to monitor and document residents' responses to fall prevention interventions, but this was not followed in the case of this resident.
Failure to Ensure Dignity and Respect During Personal Care
Penalty
Summary
A certified nursing assistant (CNA) failed to treat a resident with dignity and respect during personal care. The resident, who was dependent on staff for toileting, showering, sitting, standing, and transferring due to a broken left leg, broken left wrist, and generalized muscle weakness, was subjected to derogatory and offensive language by the CNA. The CNA made comments such as "It smells bad and stinky," "You are trash, messy, and stinky," and "This is smelly and disgusting" while providing incontinence care. These remarks caused the resident to feel humiliated, insulted, and emotionally distressed, resulting in her crying and staying awake all night after the incident. The resident reported the incident to facility staff, including a nurse and the social worker, and later filed a grievance. The CNA acknowledged making inappropriate comments and recognized that his words had offended and hurt the resident. Interviews with facility staff confirmed that the language used by the CNA was inappropriate and constituted verbal abuse, as it caused mental anguish and emotional distress to the resident.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents in several key areas. One resident, who was cognitively intact and dependent on staff for most activities of daily living, developed Moisture Associated Skin Damage (MASD) in the peri-area. This was attributed to prolonged exposure to urine, as documented in progress notes and a change of condition report. The resident and her family reported that certified nursing assistants (CNAs) did not change her throughout the night, and grievances were filed regarding the lack of timely incontinence care. Staff interviews confirmed that the resident was sometimes left uncleaned overnight, and that perineal care protocols were not consistently followed. Additionally, the same resident's family experienced repeated difficulties contacting her by telephone while she was in the facility. Grievance reports and interviews revealed that calls to the facility often went unanswered, particularly after receptionist hours, due to technical issues with the phone system and lapses in call transfer procedures. The family reported making numerous unsuccessful attempts to reach the facility, and staff acknowledged that calls were not always picked up or properly routed to the nursing station after hours. Both this resident and another resident were affected by ongoing issues with call light response times. Resident council meeting minutes and grievances documented that call lights were not answered promptly, with some residents waiting up to two hours for assistance and concerns about call lights being disconnected. Staff interviews confirmed that all staff were responsible for answering call lights, but this was not consistently done. Facility policies required timely response to call lights and emphasized the importance of maintaining resident dignity and respecting resident rights, but these standards were not met in practice.
Failure to Implement Pressure Ulcer Prevention and Wound Healing Interventions
Penalty
Summary
The facility failed to provide appropriate care and services to promote wound healing and prevent the worsening of pressure injuries for one resident. The resident, who was admitted with multiple diagnoses including radiculopathy, vertebrogenic low back pain, spinal fusion, and Type II Diabetes Mellitus, was identified as having a stage I pressure injury on the sacrococcyx upon admission. Despite being at moderate risk for pressure injuries according to the Braden Scale, the care plan interventions were limited to notifying the physician if the ulcer failed to heal and providing offloading of the ulcer site. There was no evidence that a low air-loss mattress or nutritional supplements such as zinc, vitamin C, or a multivitamin were implemented, even though these interventions were indicated in the facility's policies and were recognized by staff as beneficial for wound healing. Over the course of the resident's stay, the pressure injury progressed from stage I to stage II with a deep tissue injury, as documented in skin assessments. Interviews with staff revealed that the treatment nurse would typically request a wound consult and supplements if a wound worsened to stage II, but no such orders were placed for this resident. The dietary assistant manager confirmed that no vitamin C or zinc orders were present and stated that these should have been recommended. The primary physician also acknowledged that ordering vitamin supplements would have been beneficial for the resident's wound healing, given the presence of a pressure injury upon admission. Further review of facility policies indicated that residents with wounds should receive a comprehensive nutritional assessment and appropriate interventions, including recommendations for supplements and specialized mattresses. However, the registered dietitian was not present during the initial assessment to provide recommendations, and the necessary interventions were not implemented. Family members also expressed concern that the resident was not being turned regularly, which may have contributed to the worsening of the wound. The facility's failure to follow its own policies and to implement recognized interventions resulted in the resident's pressure injury worsening during their stay.
Failure to Timely Obtain and Report Stat Lab Results for Resident with GI Bleed and Anemia
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a stat (immediate) laboratory order for a Complete Blood Count (CBC) was carried out as ordered for a resident with a history of gastrointestinal bleeding, anemia, and low hemoglobin. The resident exhibited symptoms including increased confusion, fatigue, drowsiness, and black tarry stools, which prompted the physician to order a stat CBC. Despite the urgency, there was a significant delay in obtaining the blood specimen and in communicating the stat nature of the order to the laboratory. The delay was caused by miscommunication among licensed nursing staff across multiple shifts. The nurse who contacted the laboratory did not specify that the order was stat, resulting in the blood draw being attempted many hours after the order was placed. When the resident refused the blood draw, there was no documentation that the physician or responsible party was notified, and the order was not promptly followed up. Additionally, when the laboratory eventually obtained a critical result, multiple attempts to notify the facility were unsuccessful because staff did not answer the phone, further delaying the reporting of the critical value. As a result of these failures, the resident's critical laboratory results were not obtained or reported in a timely manner, and the physician was not notified of the resident's refusal or the critical results. This led to a delay in necessary medical intervention, and the resident was ultimately transferred to a general acute care hospital, where he required a blood transfusion and was admitted to a telemetry unit due to his unstable condition.
Removal Plan
- Update Resident 1's Alteration for Hematological care plan for lab orders and nursing interventions to include observing, reporting, and documenting signs and symptoms of anemia, monitoring vital signs every day and as needed, and notifying the Medical Doctor via phone of abnormalities.
- Notify the MD via phone if abnormal labs are reported or the patient refuses lab work, and document the lab report and orders in the patient’s chart under progress notes.
- Track pending labs and results via the communications tab in Point Click Care, verbal reports from nurse to nurse, and progress notes documented in Point Click Care. If results are late, the nurse will call the lab to follow up, and if no result is available, the MD will be notified for further orders. If the patient’s MD doesn’t respond timely, the Medical Director will be notified.
- Audit and review residents with STAT lab orders for residents with diagnoses of Anemia, GI bleeding, and low hemoglobin.
- Review and update care plans for residents with diagnoses of Anemia, GI bleeding, and low hemoglobin to reflect lab orders and nursing interventions including observing, reporting, documenting signs and symptoms of anemia, monitoring vital signs every day and as needed, and notifying the MD via phone for abnormalities.
- Provide all licensed nurses in-service training on STAT lab orders policy and procedures, timely reporting of labs, timely reporting of Change of Conditions and resident refusals to physicians, how to correctly communicate accurate orders to the lab to obtain STAT lab blood draws timely, following care plans for residents, follow up procedure for all STAT lab orders, facility policy and procedure for lab results, physician orders and Change of Condition, and how to properly endorse resident status to oncoming shifts.
- Use verbal endorsements and a written endorsement log between shifts to communicate pending labs and orders.
- Complete audit of the endorsement log and Point Click Care communications of all new STAT lab orders daily to ensure orders are completed and results are obtained in a timely manner.
- Review prior to daily stand up meeting any Change of Condition and/or refusal of the resident using the endorsement log and Point Click Care to ensure staff communicate with the physician to allow the physician to assess the resident’s care needs and give instructions for treatment.
- Complete an audit of all STAT lab orders daily using the endorsement log and Point Click Care to ensure that orders are followed up and results obtained in a timely manner.
- Complete audit of new STAT lab orders daily using Point Click Care to verify the communication between the lab and the nurse matches the physician’s order. This is to ensure orders are communicated accurately to the lab to obtain STAT lab blood draws, and results are obtained in a timely manner.
- Audit residents’ new or changed care plans pertaining to lab work or Change of Conditions during daily stand-up meetings. The Interdisciplinary Team will review and update care plans as needed to ensure they follow lab orders and that nursing interventions are measurable.
- Complete an audit of all STAT lab orders daily to ensure orders are followed up on, and results are obtained in a timely manner.
- Complete an audit of all STAT lab orders daily to ensure lab test results are completed and results are obtained and reported in a timely manner. Audit any Change of Conditions and new physician orders prior to daily stand-up meetings to ensure physician orders and Change of Condition policy and procedure are followed correctly.
- Audit the shift endorsement log and Point Click Care communications daily to ensure that facility staff are endorsing resident status and Change of Conditions to oncoming shifts for continuity of care.
- Report the findings of the audits to the Quality Assurance meeting monthly until sustained compliance is achieved for at least one month, then quarterly for 6 months or according to the Quality Assessment and Assurance committee to ensure STAT lab orders are completed and results obtained and reported in a timely manner.
Failure to Notify Physician and Responsible Party of Resident's Refusal of Critical Blood Draw
Penalty
Summary
The facility failed to notify both the physician and the responsible party when a resident with a history of gastrointestinal bleeding, anemia, and low hemoglobin refused a physician-ordered blood draw for a Complete Blood Count (CBC). The resident was unable to make consistent and reasonable decisions for himself, as documented in his Minimum Data Set. On the day in question, the resident experienced hypotension and was scheduled for a paracentesis. After returning from the appointment, a STAT CBC was ordered, but when the phlebotomist attempted to collect the blood sample, the resident refused. There was no documentation that the physician or responsible party were notified of the resident's refusal to have his blood drawn, despite facility policy requiring such notifications in the event of a change of condition or difficulty completing an order. Interviews with staff confirmed that the nurse on duty did not inform the physician or responsible party of the refusal. The responsible party later stated she was not notified and should have been given the opportunity to make medical decisions for the resident. The physician also confirmed that he was not informed of the refusal and indicated that, had he been notified, he could have taken alternative actions. The Director of Nursing Services stated that staff are expected to notify both the physician and responsible party in such situations. Facility policies reviewed also supported the requirement for timely notification of changes in resident status and participation in treatment decisions.
Absence of Emergency Dialysis Kits at Bedside for Hemodialysis Residents
Penalty
Summary
The facility failed to ensure that emergency dialysis kits were available at the bedside for three residents receiving hemodialysis, which could lead to a delay in treatment during a medical emergency. The residents involved were diagnosed with end-stage renal disease and were dependent on renal dialysis. Observations revealed that emergency dialysis kits were not present at the bedside of these residents, despite the facility's policy requiring such kits to be available. Resident 61, who was readmitted with diagnoses including end-stage renal disease and type 2 diabetes mellitus, was observed without an emergency dialysis kit at the bedside. Similarly, Resident 31, with moderate cognitive impairment and receiving hemodialysis, also lacked an emergency dialysis kit in their room. Resident 26, who had severe cognitive impairment and was dependent on others for activities of daily living, was found without the necessary emergency supplies at their bedside. Interviews with facility staff, including a CNA and an LVN, confirmed the absence of emergency dialysis kits at the bedside of these residents. The LVN acknowledged the risk of severe hemorrhage for residents on hemodialysis and the importance of having emergency kits readily available. The Director of Nursing was aware of the issue and confirmed that the kits were stored in central supply instead of being at the bedside, which posed a safety concern for residents receiving hemodialysis.
Failure to Label Open Food Items in Kitchen Freezer
Penalty
Summary
The facility failed to ensure that open bags of frozen pancakes and cinnamon rolls in the kitchen freezer were labeled with an open date and use by date. This oversight was observed during a survey, where it was noted that the absence of these labels could potentially expose residents to food-borne illnesses. The Dietary Supervisor confirmed that the bags lacked the necessary labels and acknowledged the importance of labeling to maintain food quality and palatability for residents. The Director of Nursing also emphasized the need for labeling to ensure food freshness and prevent gastrointestinal illness. The facility's policy and procedure on food receiving, dated February 2009, requires labeling and dating of food items upon delivery or opening, which was not adhered to in this instance.
Failure to Update PASARR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 40, had an updated Pre-admission Screening and Resident Review (PASARR) to reflect their current medical condition. Resident 40 was admitted with diagnoses including psychoses and anxiety, and the Minimum Data Set (MDS) indicated moderate cognitive impairment and a need for assistance with activities of daily living. Despite these conditions, the PASARR Level 1 Screening from 2022 indicated a negative result, suggesting that a Level II mental health evaluation was not required. However, subsequent assessments and records, including the Social Service assessments and Order Summary Report, documented ongoing episodes of paranoia and delusional behavior, indicating a need for a PASARR Level II review. During an interview, the Director of Nursing acknowledged that any resident with a mental illness should have a PASARR Level II completed, and confirmed that Resident 40 should have undergone this review to accurately reflect their medical condition. The facility's policy and procedure on resident assessment coordination with the PASARR program also mandates prompt referral for a Level II review for residents exhibiting serious mental disorders. The failure to update the PASARR potentially resulted in inappropriate placement and unidentified specialized services for Resident 40.
Failure to Administer Daily Wound Care as Ordered
Penalty
Summary
The facility failed to provide daily wound care treatment and services for a resident as per physician order. The resident, who was admitted with a gastrostomy tube, chronic obstructive pulmonary disease, muscle weakness, and a pressure ulcer on the right heel, was observed to have missed the prescribed wound treatment. The resident's Minimum Data Set indicated a need for extensive assistance with daily activities, and the Braden Scale assessment showed a high risk for developing pressure sores. During an observation, a Licensed Vocational Nurse (LVN) was seen performing a dressing change on the resident's gastrostomy tube site but failed to administer the required treatment for the right heel pressure ulcer. The LVN admitted to forgetting the treatment, mistakenly believing the wound was healed, and did not verify the physician's orders against the treatment administration record. The Director of Nursing confirmed that licensed nurses should follow physician orders and ensure treatments are completed to prevent wound infections.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that a resident received the Restorative Nursing Assistant (RNA) program as recommended by the physical therapist. The resident, who was admitted with diagnoses including amputations of both legs below the knee, muscle weakness, and diabetes mellitus, was at risk for decline in range of motion and strength in both lower legs. Despite a referral to the RNA program on 12/12/2024, the resident did not receive RNA services, as confirmed by interviews with the RNA and the Registered Nurse Supervisor. The RNA stated that there was no order for RNA services, and the Registered Nurse Supervisor acknowledged that the referral should have been followed up by the licensed nursing staff, and the resident's physician should have been contacted to get an order for the RNA program. The Minimum Data Set Coordinator and the Director of Nursing were not aware of the RNA referral, and the Director of Nursing stated that the referral for the RNA program was missed by the licensed nurses. The facility's policy indicated that referrals to the Restorative Nursing Program should occur at the termination of therapy services or when deemed appropriate. The failure to follow up on the RNA referral had the potential to result in a decline in the resident's range of motion and contracture, as noted by the Registered Nurse Supervisor.
Failure to Provide Dentures to Resident
Penalty
Summary
The facility failed to ensure that a resident received new upper and lower dentures as recommended by the dentist. The resident, who was admitted with multiple diagnoses including diabetes mellitus, end-stage renal disease, dysphagia, and severe protein-calorie malnutrition, was dependent on staff for various activities of daily living. Despite a dental consultation on August 22, 2024, where dentures were recommended, there was no follow-up from the facility to provide the dentures. Interviews with facility staff revealed a breakdown in communication and follow-up procedures. The Licensed Vocational Nurse stated that the Social Service Director was responsible for scheduling dental visits and that there had been no follow-up for the resident's dentures. The Assistant Social Service Director confirmed that a referral was sent, but they were waiting for the dental office to call. The Dental Office Manager indicated that reminders were sent to the facility, but no action was taken until a follow-up call was made on January 9, 2025. The Social Service Director admitted to overlooking emails from the dental office and failing to follow up on the recommendations. The Director of Nursing acknowledged the importance of dental services and the potential for weight loss if the resident did not receive the necessary dental care. The facility's policy highlighted the negative effects of unmet dental needs, including the potential for diet downgrades and negative psychosocial outcomes.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to observe proper infection control measures, specifically in hand hygiene practices, involving a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA). During an observation, LVN 2 did not perform hand hygiene or change gloves during and after providing wound care to Resident 41, who had a pressure ulcer on the right heel and a healing wound on the buttocks. The LVN used the same gloves to perform multiple tasks, including covering the resident with linen and turning off the bed headlight, without washing hands. Additionally, CNA 2 was observed not performing hand hygiene after handling dirty linen and before assisting another resident, citing rushing as the reason for forgetting to wash hands. Resident 41 was admitted with several diagnoses, including gastrostomy status, chronic obstructive pulmonary disease, muscle weakness, and a pressure ulcer. The resident required extensive assistance with daily activities. Interviews with the LVN, CNA, and the Director of Nursing (DON) confirmed the expectation for staff to perform hand hygiene before and after resident care to prevent the spread of infection. The facility's policy on infection prevention and control emphasized the importance of hand hygiene in maintaining a safe environment, aligning with national standards and guidelines.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program for a resident, which led to the inappropriate use of antibiotics. The resident, who was admitted with conditions including temporomandibular joint disorder, muscle weakness, and chronic viral hepatitis C, was prescribed Augmentin for left facial pain of unclear etiology. The Infection Preventionist (IP) noted that the McGeer criteria, which helps determine the presence of an infection, was not used, and no assessment or laboratory tests were conducted before prescribing the antibiotics. The IP was not informed of the antibiotic prescription, which is a crucial step in the facility's policy for ensuring appropriate antibiotic use. The facility's policy requires nursing staff to assess residents suspected of having an infection before notifying the physician and to use the McGeer and Loeb Minimum Criteria to determine the necessity of antibiotics. However, in this case, the IP was unaware of the prescription, and the necessary criteria were not applied, leading to the potential for antibiotic resistance and inappropriate use. The Registered Nurse Supervisor confirmed that the IP should be notified of any antibiotic orders to ensure the correct antibiotics are administered, highlighting a breakdown in communication and adherence to the facility's Antibiotic Stewardship Program.
Failure to Educate Residents on Vaccine Refusal Risks
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 42 and 71, were provided with education regarding the risks and benefits of refusing influenza, pneumonia, and COVID-19 vaccines. This failure violated the residents' rights to make informed decisions and increased their risk of acquiring and transmitting these diseases to other vulnerable residents. The deficiency was identified through interviews and record reviews conducted by surveyors. Resident 42 was admitted with diagnoses including hepatitis C, asthma, and schizophrenia. Despite having intact cognition according to the Minimum Data Set (MDS), the resident's History and Physical indicated a lack of decision-making capacity. The resident refused the vaccines, but there was no documentation of education provided about the risks and benefits of this refusal. Similarly, Resident 71, who had moderate cognitive impairment and required substantial assistance with activities of daily living, also refused the vaccines without documented education on the implications of this decision. Interviews with the Infection Preventionist and the Director of Nursing revealed that the facility's policy required nurses to educate residents on the risks and benefits of refusing vaccines and to document this education in the clinical record. However, both staff members acknowledged the absence of such documentation for Residents 42 and 71. The facility's Infection Prevention and Control Program policy emphasized the importance of providing education prior to offering vaccines, but this was not adhered to in these cases.
Failure to Revise Care Plan for High-Risk Resident Leads to Injury
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced multiple unwitnessed falls, despite being identified as high risk for falls. The resident, who had a history of Parkinsonism, osteoporosis, and previous falls, was admitted with a care plan that included interventions such as assessing toileting needs and encouraging the use of a call light. However, after two unwitnessed falls on 10/4/2024 and 10/12/2024, the care plan was not updated to include additional interventions to address the resident's forgetfulness and overestimation of abilities. The resident's fall risk assessments on 9/17/2024 and 10/14/2024 indicated a high risk for falls, with scores of 55 and 80, respectively. Despite these assessments, the care plan was not revised to include necessary interventions such as frequent visual checks, cueing, and anticipation of the resident's needs. This oversight led to a third unwitnessed fall on 10/17/2024, resulting in a subdural hematoma and subsequent hospitalization. Interviews with staff revealed a lack of communication and awareness regarding the resident's fall risk and care plan. Certified Nursing Assistant 2 was unaware of the resident's fall risk or previous incidents, and Licensed Vocational Nurse 2 confirmed that the resident's forgetfulness and impulsivity were not addressed in the care plan. The Director of Nursing Services acknowledged that the care plan should have been updated to ensure the resident's safety, and the facility's policies emphasized the need for individualized care plans and regular evaluations to prevent falls.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an incident where one resident hit another on the right knee twice. Resident 1, who has multiple medical conditions including pancytopenia, hypertension, heart failure, end-stage renal disease, and Type II Diabetes, was involved in the incident. The resident's cognitive skills were mildly impaired, and they required assistance for various daily activities. On the day of the incident, Resident 1 returned from dialysis and expressed a desire to use the bathroom, which led to a verbal exchange with Resident 2, culminating in physical aggression. Resident 2, who has diagnoses including hemiplegia, major depressive disorder, anxiety disorder, and Type II Diabetes, was identified as the aggressor. Despite having intact cognitive skills, Resident 2 had a history of altercations with roommates, including an incident where they tossed a pitcher of water on a roommate's bed. The facility's records indicated that Resident 2 had previously exhibited aggressive behavior, yet there was no continuous monitoring or adjustment of interventions to address these behaviors effectively. The facility's policy and procedure on abuse prevention were not adequately implemented, as evidenced by the failure to monitor and manage Resident 2's aggressive tendencies. The incident was reported and investigated, but the lack of proactive measures to prevent such occurrences highlights a deficiency in ensuring residents' right to be free from abuse. The facility's inaction in addressing Resident 2's behavioral issues contributed to the incident, which could have been mitigated with appropriate interventions and monitoring.
Failure to Develop Baseline Care Plan for Resident's Aggressive Behavior
Penalty
Summary
The facility failed to initiate a person-centered baseline care plan for a resident who exhibited aggressive behavior by throwing water at her previous roommate. This incident was not addressed in a care plan, potentially leading to an escalation of the resident's aggression and compromising the safety of other residents. The resident was admitted with diagnoses including hemiplegia, hemiparesis, major depressive disorder, anxiety disorder, and Type II Diabetes. Despite these conditions, the resident's cognitive skills were intact, and she was dependent on assistance for transferring, bathing, and toilet hygiene. A Change of Condition (COC) report indicated that the resident had an altercation with her roommate, which involved exchanging words and tossing water on the roommate's bed. The residents were separated and moved to different rooms, and the COC noted behavioral symptoms such as agitation and psychosis. However, the follow-up nursing notes did not specify the type of behavior exhibited, and there was no care plan developed for this incident. The facility's Director of Nursing acknowledged that a care plan should have been created to address the behavior based on the resident's medical diagnosis, current medications, and side effects. The facility's policies and procedures require the development of a baseline care plan for each resident, including instructions for providing effective and person-centered care. The comprehensive care plan should be developed by an interdisciplinary team and reviewed at least quarterly or following a significant change in condition. Despite these guidelines, the facility did not have a care plan for the resident's behavior, and the Medication Administration Record did not include specific monitoring for agitation. This oversight highlights a failure to adhere to the facility's policies and procedures for care plan development and implementation.
Delayed Call Light Response Leads to Resident Distress
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for two residents, resulting in them sitting in their urine and feces for extended periods. Resident 2, who has diabetes mellitus type 2, depression, and a history of transient ischemic attack, reported that staff on the 3 pm to 11 pm shift would turn off the call light and promise to return but often did not, leading to delays of 30-40 minutes. This resulted in Resident 2 having a bowel movement in his pants, causing feelings of embarrassment. Similarly, Resident 4, who has hemiplegia, depression, and muscle weakness, experienced delays in assistance, leading her to sit in a urine-soaked diaper. She reported having to transfer herself in her wheelchair to find staff when she had a bowel movement. The issue of delayed call light response was also highlighted in Resident Council Meeting Minutes from July and August, where improvements were recommended for staff communication and timely response to call lights. Interviews with the Activities Director, Director of Staff Development, and Director of Nursing confirmed that call lights should be answered promptly, ideally within 2-3 minutes, and that all staff are responsible for responding to call lights. The facility's policy emphasizes the importance of timely response and proper communication with residents, but the practice observed did not align with these guidelines.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to inform two residents, or their responsible parties, about room changes, violating their right to receive written notice before such changes. Resident 2, who was admitted with unspecified dementia and major depressive disorder, was moved to another room without any documentation indicating that he or his power of attorneys were informed. Despite Resident 2's severe cognitive impairment, as noted in his Minimum Data Set, there was no evidence of communication regarding the room change. Similarly, Resident 5, who had an intact cognition and was capable of understanding and being understood, was also moved to another room without receiving a written notice. The facility's policy requires that residents and their representatives be given advance notice of room changes in writing, including the reasons for the move. However, the Social Services Director confirmed that this procedure was not followed for these residents, resulting in a lack of awareness and understanding of the room changes.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect six residents from verbal abuse by another resident, who had a known history of threatening and harassing behavior. Despite being aware of this resident's behavior, the facility continued to place other residents in the same room, leading to multiple incidents of verbal abuse, bullying, and harassment. The affected residents included individuals with cognitive impairments and mental health conditions, making them particularly vulnerable to such abuse. Resident 1, who had intact cognition and a history of behavioral symptoms, was reported to have verbally abused his roommates, including making derogatory and threatening remarks. The facility's staff, including the Administrator and Director of Nursing, were aware of Resident 1's behavior but failed to take appropriate action to prevent further incidents. Interviews with staff and residents revealed that Resident 1's behavior was well-known, yet the facility continued to place residents in his room, resulting in ongoing abuse. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the continued placement of residents with Resident 1 despite his history of abuse. Staff interviews indicated that concerns about Resident 1's behavior were raised but not adequately addressed by the administration. The facility's failure to act on these concerns and protect residents from abuse constituted a significant deficiency in care.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report four allegations of resident-to-resident verbal abuse to the California Department of Public Health (CDPH), the State Long Term Care Ombudsman, and local law enforcement within the required two-hour timeframe. This deficiency involved four of five sampled residents, specifically Residents 2, 4, 8, and 9, and occurred between February 22, 2024, and August 1, 2024. The delay in reporting these incidents resulted in CDPH not being informed of the abuse allegations until August 6, 2024, hindering the timely investigation of these allegations. Resident 1, who had a history of behavioral symptoms that put others at risk, was involved in multiple incidents of verbal abuse towards his roommates. Despite having intact cognition and the ability to understand and be understood by others, Resident 1 exhibited verbal behavioral symptoms directed towards others. For instance, Resident 1 made derogatory comments towards Resident 2, who had severe cognitive impairment, and Resident 4, who was threatened with deportation and physical harm. Additionally, Resident 1 verbally threatened Resident 8 and disrupted Resident 9's environment with loud noises and vulgar language. Interviews with facility staff revealed that the facility's Administrator (ADM) was aware of Resident 1's behaviors but failed to report them as required. Certified Nurse Assistants and Licensed Vocational Nurses reported Resident 1's verbal abuse to the ADM and other supervisory staff, but the ADM did not consider these incidents as verbal abuse that needed reporting. The facility's policy mandates immediate reporting of abuse allegations, but this was not adhered to, resulting in a failure to protect residents from verbal abuse and ensure timely investigation by the appropriate authorities.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of verbal abuse, threats, and harassment towards roommates. This deficiency resulted in multiple residents being subjected to verbal abuse and threats from the resident. Despite the resident's known behavior, the care plan did not include interventions to prevent other residents from being admitted to the same room. The resident in question had a history of behavioral symptoms that put others at risk and disrupted the living environment. The resident's Minimum Data Set (MDS) indicated intact cognition and the ability to understand and be understood by others. However, the care plan lacked specific interventions to address the resident's behavior, leading to repeated incidents of verbal abuse and threats towards roommates, including derogatory language and threats of violence. Several residents were admitted to the same room as the resident with known behavioral issues, resulting in roommate incompatibility and the need for room changes. The facility's policy and procedure emphasized individualized care plans, but the failure to update the care plan after incidents of abuse and threats led to continued exposure of other residents to the abusive behavior.
Unsecured Medication Cart Found Unattended
Penalty
Summary
The facility failed to ensure that a medication cart located on Station two was locked, resulting in unsecured medications. During an observation, the medication cart was found unlocked and unattended in the hallway. Licensed Vocational Nurse 1 (LVN 1) admitted to forgetting to lock the cart before stepping away, acknowledging that this oversight allowed anyone in the facility to access the medications. The Director of Nursing (DON) confirmed that all licensed nurses assigned to a medication cart are responsible for locking it before leaving it unattended. The facility's policy and procedure, updated in August 2019, mandates that medications and biologicals must be stored securely and only accessible to authorized personnel. The failure to adhere to this policy created a situation where residents, staff, and visitors could potentially access and consume medications not intended for their use.
Verbal Abuse Incident During Physical Therapy
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA) during a physical therapy session. The incident involved a resident who was undergoing physical therapy to improve his physical abilities following a diagnosis of lobar pneumonia and pulmonary embolism. During a session in the physical therapy gym, the resident expressed fear of falling and hesitated to stand up from his wheelchair. The Physical Therapy Assistant (PTA) present invited the CNA to assist, during which the CNA used a curse word in Tagalog, a language the resident understood, in a loud and aggressive tone. The resident, who was capable of making independent decisions and communicating effectively, was hurt and embarrassed by the CNA's language. Despite the resident's familiarity with the language and his attempt to maintain peace, he felt humiliated in front of others. The incident was witnessed by the Director of Rehabilitation and two Physical Therapy Assistants, all of whom were shocked by the CNA's behavior. The Director of Staff Development and the Director of Nursing emphasized the residents' right to be free from verbal abuse, highlighting the potential psychological and physical impact of such mistreatment. The facility's Administrator, upon learning of the incident during an Interdisciplinary Team meeting, acknowledged the CNA's unprofessional conduct but did not initially classify the behavior as verbal abuse, believing it was intended to motivate the resident. However, the facility's policy clearly states that residents have the right to be free from verbal abuse, and the incident was documented as a deficiency in the facility's obligation to protect residents from abuse by staff.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct a thorough investigation following two separate allegations of abuse by a resident. The resident, who was admitted with right hemiplegia and hemiparesis following a stroke, reported that a CNA punched her in the lower back. The facility's investigation did not include interviews with other residents assigned to the CNA on the day of the incident to identify if there were any other allegations of abuse. Additionally, the facility's policy required all reports of alleged abuse to be thoroughly investigated, including interviews with anyone with direct knowledge of the incident, which was not followed in this case. In a second incident, the same resident reported that another CNA hit her in the chest and pulled her hair while being showered. The facility's investigation again failed to include interviews with other residents assigned to the CNA or with staff members who were present or involved immediately after the incident. The administrator confirmed that no additional interviews were conducted beyond what was reported in the facility's Verification of Incident/Administrative Summaries. This lack of thorough investigation is contrary to the facility's policy and procedure, which mandates a comprehensive investigation of all alleged abuse reports.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident who was under conservatorship and assessed as high risk for elopement. This resident, with a history of unauthorized departures, managed to elope from the facility twice. The first incident occurred when the resident left the facility without informing the staff and was missing for approximately 11.5 hours before being found at a nearby laundromat. The second elopement happened when the resident was seen outside the facility crossing the street in a wheelchair, despite having a wander guard bracelet, which was later found ripped off and lying on the resident's side table. The facility did not have adequate systems in place to prevent these elopements. The resident was placed in a room with access to an outside patio leading to an alley, and the door's alarm was faint and shut off quickly, making it ineffective. Additionally, there was no system to alert staff when the facility's front entrance or the rehabilitation patio door was opened. The facility also failed to develop and implement a care plan for the resident's elopement risk, despite being identified as high risk. Furthermore, there was no care plan addressing the resident's behavior of removing the wander guard bracelet. Interviews and record reviews revealed that the facility staff were not adequately monitoring the resident, and there was a lack of communication and documentation regarding the resident's elopement risk. The staff were unaware of how the resident managed to elope, and there was no immediate response when the resident was seen outside the facility. The facility's policies and procedures for managing incidents and elopements were not effectively implemented, contributing to the resident's ability to leave the facility without supervision.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse to the California Department of Public Health (CDPH) and the State Long Term Care Ombudsman within the required two-hour timeframe. Additionally, the facility did not report the results of their investigation to CDPH within five working days. This deficiency involved Resident 4, who alleged that Resident 1 physically assaulted him. The incident occurred in December 2023, but CDPH was not made aware of the allegation until April 2024, hindering their ability to investigate the matter. Resident 1, who was admitted with diagnoses including paranoid schizophrenia and psychosis, was reported to have hit Resident 4, who has paraplegia and depression. Despite Resident 4 calling the police immediately after the alleged assault, the facility's investigation deemed the incident an unusual occurrence and not reportable. The Social Services Director confirmed that the previous administrator did not report the incident, considering it unsubstantiated. The facility's policy requires all allegations of abuse to be reported immediately, but this protocol was not followed in this case.
Failure to Address Elopement Risk
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to identify and address the elopement of a resident on January 19, 2024. The committees did not develop or implement appropriate plans of action to monitor, review, and analyze data for performance improvement regarding elopements. This oversight resulted in the resident eloping again on April 13, 2024, and the resident remains missing as of April 22, 2024. The resident, who was admitted with diagnoses including paranoid schizophrenia and psychosis, was assessed as a high elopement risk. Despite this, there was no care plan in place addressing the resident's history of elopement or the risk identified in December 2023. After the first elopement incident, a wander guard was ordered, but the resident refused to wear it, and there was no care plan addressing this behavior. The resident expressed intentions to leave the facility when staff was not around, yet these warnings were not adequately addressed. The facility's administrator did not report the initial elopement to the QAA/QAPI committees, as it was not considered an elopement due to the resident being found within 24 hours. This misinterpretation of the facility's policy on elopement reporting contributed to the lack of action by the committees. The facility's policies required such incidents to be reported for tracking and trending, but this was not done, leading to a failure in preventing the second elopement.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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