The Grove Post-acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylmar, California.
- Location
- 14122 Hubbard Street, Sylmar, California 91342
- CMS Provider Number
- 056382
- Inspections on file
- 46
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at The Grove Post-acute Care Center during CMS and state inspections, most recent first.
A resident with encephalopathy, epilepsy, and HTN, and with severely impaired cognition and dependence for multiple ADLs, repeatedly refused showers and declined participation in activities, sometimes screaming when refusing care. A CNA reported these refusals but did not notify the charge nurse about the resident’s refusal to attend activities, and there was no documentation that activities were offered or refused over several days. Record review showed the resident had minimal group activity participation due to physical limitations and that assistance to and from activities had been identified as a needed intervention, but this intervention was not added to the activities care plan. The resident also lacked a care plan addressing refusal of care, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives, timeframes, and inclusion of services not provided due to the resident’s exercise of the right to refuse treatment.
A resident with intact cognition and a history of joint replacement, depression, and anxiety reported to the SSD that a transportation company personnel inappropriately touched her face and made inappropriate comments. Although the SSD notified the DON and Administrator, the incident was not reported to the SSA until 27 days later, despite facility policy requiring reporting within two hours.
A resident with a history of depression and anxiety reported being inappropriately touched by transportation personnel. Following the report, neither licensed nurses nor social services documented any monitoring of the resident's psychological or psychosocial health, despite facility policy requiring such actions for residents with behavioral health needs.
A resident reported being verbally and physically abused by a CNA, but the facility failed to report the incident to the SSA within the required two-hour timeframe. The misunderstanding of the facility's policy by the DON and ADM led to the delay, as they believed incidents without bodily injury could be reported within 24 hours. The facility's policy was outdated and incorrectly interpreted, contributing to the deficiency.
A resident with a fracture, diabetes, and hypertension alleged abuse by a CNA, but the LVN failed to document this in the medical record. The DON confirmed the omission, which violated the facility's documentation policy, potentially leading to confusion in care.
A resident with dysphagia was served improperly prepared pureed food that did not meet IDDSI Level 4 standards, including bread soaked in milk, lumpy oatmeal, and non-pureed scrambled eggs. The dietary staff failed to follow recipes, posing a risk to the resident's safety.
The facility failed to properly dispose of garbage, with a kitchen trash can lacking a plastic liner and an overflowing dumpster not fully closed. These issues were acknowledged by the Dietary and Maintenance Supervisors as unacceptable due to potential pest attraction and germ spread, contrary to facility policies and the Food Code 2022.
A facility failed to ensure the Infection Preventionist (IP) was competent in managing a scabies outbreak. A resident diagnosed with scabies was removed from isolation prematurely, contrary to policy, risking the spread of infestation. The IP was unsure of the correct isolation duration and did not report the case to the state agency as required. The Director of Nursing highlighted the importance of IP competence in infection control to prevent transmission risks.
The facility failed to properly dispose of discontinued medications for three residents, did not label multidose medication bottles with open dates, and did not maintain accurate records for controlled substances. These deficiencies were observed during a survey, with staff acknowledging the lapses in following facility policies.
The facility failed to ensure kitchen staff were trained and evaluated for competency, leading to improper preparation and portioning of meals. Staff did not follow recipes for regular and puree diets, resulting in potential nutritional inadequacies for residents. The Director of Food Services acknowledged the lack of competency evaluations for staff.
The facility failed to adhere to the prescribed menu and portion sizes, affecting 62 out of 63 residents on regular and puree diets. The staff could not locate the menu spreadsheet, leading to incorrect portion sizes and deviations from the menu, such as serving plain scrambled eggs instead of puree baked Western omelet and regular cake instead of coffee cake. Incorrect scoop sizes were also used, potentially causing unintended weight changes among residents.
The facility failed to follow food preparation guidelines, resulting in a plain cake instead of coffee cake and incorrect portion sizes for a baked Western omelet. These deviations affected the taste, flavor, and presentation of the food, potentially leading to unplanned weight loss among residents.
The facility failed to maintain safe food storage and preparation practices, with expired and undated foods in the refrigerator, improper hand hygiene by staff, and unclean food preparation areas. These deficiencies could lead to contamination and illness among residents.
The facility did not designate a Medical Director (MD) for 12 months, lacking a job description or policy outlining the MD's responsibilities in coordinating medical care. Interviews revealed that while the MD was involved in resident care and attended quality assurance meetings, the absence of formal documentation could lead to confusion among staff regarding clinical decision-making and accountability.
The facility failed to maintain accurate medical records for two residents, leading to potential inaccuracies in their clinical documentation. A resident with Alzheimer's disease did not have showers accurately documented, and their hygiene needs were not properly addressed. Another resident with hemiplegia was incorrectly documented as having received a shower when only a bed bath was provided due to equipment unavailability. These discrepancies highlight a failure to adhere to the facility's policy on accurate documentation.
The facility failed to implement effective infection control measures, including not following the water management plan to prevent legionella, maintaining a sanitary medication room, and ensuring proper contact isolation for a resident with scabies. Additionally, a resident was observed using a nasal cannula without a labeled date, increasing infection risk.
The facility failed to maintain the dignity of two residents by not ensuring proper feeding assistance and failing to provide a shower. A CNA stood over a resident while assisting with a meal, contrary to policy requiring sitting at eye level. Another resident, dependent on staff for showering, did not receive a shower due to insufficient slings for mechanical lifts, receiving a bed bath instead.
A facility failed to inform a resident and their representative about the right to formulate an advance directive upon admission. The resident, with fluctuating decision-making capacity due to developmental delay, had no advance directive noted in their records. Interviews with staff confirmed the absence of documentation offering an advance directive, despite the facility's policy requiring such information to be provided.
A resident with severe cognitive impairment and a history of infections did not receive a complete course of azithromycin due to the facility's failure to notify the physician about the unavailability of the medication. The prescribed doses were missed for three consecutive days, and the facility's staff did not follow the policy of informing the physician to obtain new orders.
A resident in an LTC facility experienced a disruption in their daily routine due to a non-functional wall clock in their room. The resident, who has COPD, muscle weakness, and hypertension, relied on the clock for time orientation. Staff confirmed the clock was not working and should have been reported to maintenance, as per the facility's policy on providing a homelike environment.
The facility failed to maintain personal hygiene and grooming for two residents. One resident with Alzheimer's disease had long, chipped nails due to staff not trimming them, while another resident with hemiplegia did not receive a scheduled shower due to a lack of slings for the mechanical lift. Both deficiencies were acknowledged by the facility's staff, highlighting a failure to adhere to the policy on supporting activities of daily living.
Two residents at risk for pressure ulcers were found with improperly set low air loss (LAL) mattresses, not aligned with their actual weights. One resident, weighing 86 lbs, had a mattress set for 175 lbs, while another, weighing 97 lbs, had a mattress set for 164 lbs. Both discrepancies were confirmed by nursing staff, highlighting a failure to follow guidelines for preventing skin tissue damage.
The facility failed to supervise a resident who was identified as a smoker requiring supervision, leaving them unsupervised while smoking without a smoking apron. Additionally, the facility did not properly manage cords near another resident's bed, posing a potential hazard. Staff acknowledged these lapses, which contravened the facility's safety policies.
The facility failed to have an RN on duty for eight consecutive hours, affecting 57 residents. A review of staffing records confirmed no RN was assigned, and the DON acknowledged the lack of a policy requiring RN coverage. The Facility Assessment indicated the need for an RN to supervise LVNs and provide critical care support.
A resident with pneumonia did not receive the prescribed doses of azithromycin due to staff failing to administer the medication as ordered. Despite the medication being available in the facility's emergency kit, the initial 500 mg dose and subsequent 250 mg doses were missed, leading to an incomplete antibiotic course.
A facility failed to accurately code the MDS for a resident, who was discharged home with home health services, but was incorrectly coded as discharged to a hospital. This error was identified through a review of the resident's records, and both the MDS Coordinator and DON acknowledged the mistake, emphasizing the need for accurate coding to prevent miscommunication and ensure proper care planning.
A facility was found in violation of room capacity requirements, with room [ROOM NUMBER] containing five beds and four residents. Despite this, residents had adequate space, and staff could safely provide care. A waiver request was submitted, and no resident complaints were reported.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical conditions requiring such measures and did not ensure staff wore appropriate PPE during a COVID-19 outbreak. Observations showed a lack of signage and PPE outside residents' rooms, and staff were seen without necessary eye protection when caring for COVID-19 positive residents, increasing the risk of infection transmission.
The facility failed to document education and offer COVID-19 and flu vaccines to staff, as required by their policies. Six staff members' records lacked evidence of education on vaccine risks and benefits, and there was no documentation of consent or declination. The Director of Staff Development admitted to only verbal consent and refusal, contrary to policy. The Infection Preventionist confirmed the requirement for annual flu vaccination or mask-wearing if declined, but no documentation was maintained.
A facility failed to submit a 5-day report to the SSA within the required timeframe following an alleged family-resident financial abuse incident. The report was submitted eight days late, potentially leading to unidentified abuse and lack of protection for other residents. The resident involved had intact cognitive skills and was diagnosed with bipolar disorder, COPD, and hypertension.
A resident's medications were left unattended at the bedside, and a blood pressure medication was administered earlier than prescribed. The facility's policy requires medications to be administered safely and timely, with nurses witnessing the resident taking them. This failure to follow protocol led to a deficiency in pharmaceutical services.
An emergency exit door in a LTC facility was found blocked by a medication cart and a dirty linen bin, as observed during a survey. A nurse admitted to not knowing the proper storage location for the cart, and both she and the MDSN acknowledged that the exit should remain unobstructed. The facility's policy requires exits to be clear at all times.
Failure to Care Plan for Refusal of Care and Assistance With Activities
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s refusal of care and need for assistance with activities. The resident, originally admitted with encephalopathy, epilepsy, and essential hypertension, had an MDS dated 1/5/2026 indicating severely impaired cognitive function and dependence on staff for multiple ADLs, including oral care, toileting, bathing, lower body dressing, and personal hygiene. Observations on 2/19/2026 and 2/20/2026 found the resident in bed, either asleep or watching television. A CNA reported that on 2/19/2026 the resident initially refused a shower, sometimes screaming when refusing in the past, but was later convinced to shower. The CNA also stated the resident did not want to participate in activities on 2/19/2026 and 2/20/2026, and acknowledged not informing the charge nurse of the resident’s refusal to participate in activities. During concurrent interview and record review, an RN confirmed there was no documentation in the prior 72 hours that the resident had been offered or had refused activities, despite the expectation that such offers and refusals be documented and that residents have the right to decline. The RN also confirmed that the resident did not have a care plan addressing refusal of care. Review of an Activities-Quarterly/Annual Participation Review dated 1/5/2026 showed the resident had very little participation in group activities due to physical limitations and that new interventions were to include assistance to and from group activities. However, the resident’s activities care plan dated 3/31/2026 did not include the intervention that assistance would be provided to and from group activities. The facility’s policy on comprehensive person-centered care plans required measurable objectives, timeframes, and inclusion of services not provided due to the resident exercising the right to refuse treatment, but these elements were not reflected in the resident’s care plan related to refusal of care and activity participation.
Failure to Timely Report Alleged Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of visitor-to-resident sexual abuse to the State Survey Agency (SSA) within the required timeframe. A resident, who had diagnoses including aftercare following joint replacement surgery, major depressive disorder, and anxiety disorder, and was assessed as having intact cognition and decision-making capacity, reported to the Social Services Director (SSD) that a transportation company personnel inappropriately touched her face and made inappropriate comments. This report was made to the SSD on 7/3/2025, who then notified the Director of Nursing (DON) and the Administrator (ADM). Despite the facility's policy requiring that any allegation of abuse be reported to the SSA within two hours, the Abuse Coordinator did not report the incident until 27 days after the initial allegation. Interviews confirmed that the DON and SSD were aware of the policy and the requirement for timely reporting. The delay in reporting the allegation constituted a failure to follow established procedures for abuse reporting.
Failure to Monitor and Document Psychosocial Well-being After Alleged Incident
Penalty
Summary
Licensed nurses and social services staff failed to monitor and document the psychological and psychosocial well-being of a resident following the resident's report of being inappropriately touched by transportation company personnel. The resident, who had diagnoses including major depressive disorder and anxiety disorder, reported the incident to the Social Services Director (SSD), but there was no documented evidence in the resident's progress notes that any follow-up monitoring occurred after the allegation. The SSD confirmed that she did not document any follow-up visits and acknowledged that if monitoring was not documented, it was considered not to have happened. The Director of Nursing (DON) also confirmed that neither licensed nurses nor social services documented any monitoring of the resident's psychological and psychosocial health after the incident was reported. The facility's policy required assessment, care planning, and monitoring of residents with needs and behaviors that might lead to conflict or neglect, but this was not followed in this case. The lack of documentation and monitoring occurred despite the resident's intact cognition and known mental health diagnoses.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe to the State Survey Agency (SSA). The incident involved a resident who was admitted with diagnoses including an unspecified fracture of the right femur, diabetes mellitus, and essential hypertension. On the day following the resident's admission, a family member reported to a Licensed Vocational Nurse (LVN) that a Certified Nursing Assistant (CNA) had verbally abused the resident and grabbed their forearm. The family member subsequently called 911 and local law enforcement, who arrived and spoke with the involved parties. However, the facility did not report the incident to the SSA and Ombudsman until the following day, exceeding the two-hour reporting requirement. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed a misunderstanding of the facility's policy regarding the reporting of abuse allegations. The DON and ADM believed that incidents without bodily injury could be reported within 24 hours, contrary to the facility's policy, which mandates reporting to the SSA, local law enforcement, and the Ombudsman within two hours for all abuse allegations, regardless of injury. The facility's policy, last reviewed in January 2025, was found to be outdated and incorrectly interpreted by the ADM, contributing to the delay in reporting the incident.
Failure to Document Abuse Allegation in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, leading to a deficiency in documentation. The resident was admitted with diagnoses including an unspecified fracture of the right femur, diabetes mellitus, and essential hypertension. On the day following admission, the resident allegedly informed a family member of verbal and physical abuse by a Certified Nursing Assistant (CNA). However, this allegation was not documented in the resident's Change of Condition (COC) or Progress Notes by the Licensed Vocational Nurse (LVN) responsible for the resident's care. The Director of Nursing (DON) confirmed that the LVN did not document the abuse allegation, which was a failure to adhere to the facility's policy and procedure for charting and documentation. The facility's policy requires that all services, changes in condition, and incidents involving residents be documented to facilitate communication among the healthcare team. The lack of documentation in this case could lead to confusion in care and inaccurate medical records, as the DON emphasized the importance of accurate documentation for communication and ensuring the medical record reflects actual events.
Failure to Provide Proper Pureed Diet
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs for a resident on a pureed diet. The resident, who had a diagnosis of dysphagia, was served food that did not meet the International Dysphagia Diet Initiative (IDDSI) Level 4 standards. Specifically, the resident was given bread soaked in milk, oatmeal with lumps, and scrambled eggs that were not smooth and pureed, which did not comply with the required texture for a pureed diet. The deficiency was identified during an observation and interview with the dietary staff, where it was revealed that the cook did not follow the recipe for pureed foods. The dietary supervisor confirmed that the cook failed to blend the foods as required, resulting in the resident receiving food that was not safe for their swallowing difficulties. The registered dietitian and speech-language pathologist both emphasized the importance of adhering to the IDDSI Level 4 standards to prevent potential harm to residents with swallowing impairments. The resident involved had a history of swallowing problems and was on a pureed diet as per physician's orders. The facility's policy and procedures required that pureed foods be smooth, free of lumps, and meet specific testing requirements, which were not followed in this instance. The failure to adhere to these standards posed a risk of choking and aspiration for the resident.
Removal Plan
- The Registered Dietitian (RD) provided an in-service to [NAME] 2, [NAME] 3, and Dietary Aide 1 (DA 1) regarding food preparation of IDDSI Level 4 foods.
- The RD provided an in-service and competency test to the Dietary Supervisor (DS) regarding puree food consistency to meet IDDSI Level 4 standards. The DS provided supervision to the dietary staff to ensure a blender was used on pureed foods for dinner service to meet IDDSI Level 4 standards. The RD verified the DS's competency through return demonstration and the RD acknowledged the DS to be competent in providing in-services to the dietary staff.
- The DON assessed Resident 214 for signs and symptoms of respiratory distress and for presence of food particles in the oral cavity and there were no issues found.
- The DON provided an in-service to Licensed Vocational Nurse 1 (LVN 1) on food texture and consistency based on IDDSI Level 4 standards. The DON verified LVN 1's competency through return demonstration by observing and verbalizing the correct texture of puree diets using IDDSI Level 4 standards.
- The Infection Preventionist (IP) and the Minimum Data Set Coordinator (MDSC) checked all residents receiving pureed food to ensure proper consistency and texture for lunch and dinner meals. The licensed nursing staff will continue to check meal trays for breakfast, lunch, and dinner on an ongoing basis for proper puree consistency and texture of food.
- The DS checked the puree food items for proper texture and consistency per IDDSI Level 4 standards using the spoon tilt test and fork drip test. The DS will continue this process until six (6) months.
- The ADM, the RD, and the DS examined the process of food preparation and food distribution for all residents on puree diet to ascertain and confirm food items that did not pass IDDSI Level 4 standards would not be given to the residents and will be remade.
- The DON assessed the residents on puree diet for signs and symptoms of respiratory distress and ensured aspiration precautions were maintained for the residents on puree diet. The DON reviewed and revised the care plans as necessary.
- The Speech Language Pathologist (SLP) assessed the residents on pureed diet for signs and symptoms of respiratory distress and aspiration.
- The SLP provided an in-service to the dietary staff and the nursing staff on the risk of eating food that was not properly pureed per physician's order, choking hazards, what signs and symptoms to monitor, and what consistency and texture of a pureed diet should look like.
- The RD provided an in-service and competency test to [NAME] 1, [NAME] 2, DA 1, DA 2, and DA 3 on how to puree foods following the recipes and IDDSI Level 4 standards. The RD provided an in-service to six (6) of seven (7) dietary staff. [NAME] 4 was scheduled to attend an in-service.
- A qualified RD will be supervising the DS for a period of one (1) month or until such time the RD determined the DS to be competent to supervise the workflow of the dietary staff and kitchen. At such time, if it is determined that the DS is not competent, the ADM will replace the DS with a qualified and competent DS.
- A Spanish version of the menu and recipe will be obtained by the ADM as soon as applicable.
- The RD provided another in-service to the licensed nursing staff on testing the puree diet per IDDSI Level 4 standards.
- The DS or licensed nurse will test the pureed foods on the menu per IDDSI Level 4 standards with a fork and spoon tilt test after the in-service training. The in-service training and competency test started. Training would continue until all licensed nursing staff and dietary staff have been completed.
- The assigned designee for testing the puree foods will be the Station 2 charge nurse when the DS is not available such as on weekends, holidays. The 11 p.m. to 7 a.m. shift Station 2 charge nurse will be in-charge for breakfast, the 7 a.m. to 3 p.m. shift Station 2 charge nurse for lunch, and the 3 p.m. to 11 p.m. Station 2 charge nurse for dinner.
- A pureed food adherence tool titled Puree Texture Checklist was used for breakfast to ensure food on the menu are prepared using a blender per IDDSI standards. The Puree Texture Checklist will be used for breakfast, lunch, and dinner including weekends and holidays.
- The RD checked the snacks for the residents on puree diets which included blended yogurt, apple sauce, and pudding. No other snacks would be provided by staff to residents on puree diet except snacks approved by the RD.
- The RD will conduct weekly Quality Assurance (QA) rounds in the kitchen to monitor meal tray accuracy including pureed food texture based on IDDSI Level 4 standards. The results of the audit will be presented to the Quality Assessment and Assurance (QAA) committee monthly and at a minimum of quarterly for further action planning and monitoring as necessary. The benchmark for compliance will be 100 percent (%) for a period of three (3) months.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. Specifically, a trash can in the kitchen was found without a plastic liner, which the Dietary Supervisor acknowledged was necessary to prevent contamination. Additionally, one of the two dumpsters outside the facility was observed to be overflowing and not completely closed, which the Dietary Supervisor and Maintenance Supervisor both stated was unacceptable due to the potential attraction of pests and the spread of germs. The facility's policies and procedures, as well as the Food Code 2022, emphasize the importance of proper trash disposal to prevent contamination and pest attraction. The policies require that trash bins be emptied regularly to avoid overfilling, and that receptacles be covered with tight-fitting lids. The observed deficiencies in trash disposal practices had the potential to attract pests and spread infection among the facility's residents.
Infection Control Deficiency in Scabies Management
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) was competent in implementing the infection control program, specifically in managing a scabies outbreak. Resident 52, who was admitted with diagnoses including unspecified dementia, muscle weakness, and hypertension, was identified as having scabies mites through a diagnostic test. Despite this, the resident was removed from isolation before the completion of treatment or confirmation that they were scabies-free, contrary to the facility's policy. The IP admitted to not knowing the correct duration for scabies isolation and acknowledged that the resident was still undergoing treatment and experiencing symptoms. The facility's policy required maintaining contact precautions until treatment was complete or the resident was confirmed to be scabies-free. However, Resident 52's isolation was discontinued prematurely, and the room lacked necessary transmission-based precautions and personal protective equipment. The IP's lack of adherence to the policy posed a risk of spreading the infestation to other residents and staff. The Director of Nursing emphasized the importance of the IP's competence in infection control to prevent improper isolation and transmission risks. Additionally, the facility failed to report the scabies case to the state agency as required by their policy on unusual occurrence reporting. The IP did not report the incident, mistakenly believing that a single case did not warrant reporting. The facility's policy mandated reporting unusual occurrences that affect the health, safety, or welfare of residents, employees, or visitors to the state agency within 48 hours. The IP's uncertainty about the reporting process further highlighted the deficiency in the facility's infection control practices.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not properly disposing of medications discontinued by the physician for three residents. During an observation, it was found that medications belonging to Residents 25, 63, and 64 were not destroyed as per facility policy. These medications were left in bins beside the refrigerator in the medication room instead of being placed in the incinerator for destruction. The Director of Nursing confirmed that discontinued medications should be disposed of in the incinerator to prevent unauthorized access. Additionally, the facility did not adhere to its policy of labeling multidose medication bottles with the open date. Observations revealed that several medications in the medication carts and medication room were not labeled with the date they were opened. This oversight was acknowledged by the staff, who confirmed that the facility policy requires all opened medication bottles to be dated to ensure proper tracking and usage. Furthermore, the facility failed to maintain accurate records for controlled substances. Specifically, the narcotic sheet for Resident 63's pregabalin was not signed after administration, leading to a discrepancy in the medication count. The staff acknowledged that the narcotic sheet should be signed immediately after removing the medication from the bubble pack to ensure accurate documentation and prevent potential drug diversion.
Deficiency in Kitchen Staff Training and Food Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in food preparation and portion control. Specifically, staff did not follow recipes and portion sizes for both regular and puree diets. For instance, a staff member failed to prepare coffee cake according to the recipe, omitting key ingredients like brown sugar and coffee, which affected the taste and flavor, potentially leading to residents not eating the food. Additionally, the facility did not adhere to the prescribed methods for preparing puree diets. Observations revealed that bread soaked in milk contained whole chunks, scrambled eggs were not smooth, and oatmeal had lumps, all of which were served to residents on puree diets. The staff also used incorrect scoop sizes for portioning, leading to larger portions than intended, which could result in unplanned weight gain. The Director of Food Services admitted that there was no competency evaluation for the staff member responsible for these errors prior to the incident. The facility's policies and procedures required the use of standardized recipes and portion control, but these were not followed, leading to potential nutritional inadequacies for the residents.
Failure to Follow Menu and Portion Sizes
Penalty
Summary
The facility failed to follow the prescribed menu and meet the nutritional needs of 62 out of 63 residents on regular and puree texture diets. On the morning of December 29, 2024, the staff member responsible for meal preparation was unable to locate the menu spreadsheet, which is essential for determining the appropriate food and portion sizes for each diet. The absence of this spreadsheet led to the use of meal tickets that did not specify portion sizes, potentially resulting in inaccurate food servings and unintended weight changes for the residents. Additionally, the facility did not prepare the puree baked Western omelet as required for residents on the puree diet, instead serving plain scrambled eggs that did not meet the necessary texture or nutritional content. This deviation from the menu could lead to residents not receiving the correct number of calories and nutrients, potentially causing weight loss due to the altered taste and missing ingredients. Furthermore, the facility failed to prepare the coffee cake as specified, serving regular cake without the necessary toppings, which could affect the residents' willingness to eat and result in unplanned weight loss. The facility also used incorrect scoop sizes for serving portions, with a #10 scoop used instead of the required #12 scoop for puree eggs and bread soaked in milk. This error in portion control could lead to residents receiving more food than intended, potentially causing unplanned weight gain. The Dietary Supervisor acknowledged these discrepancies and the importance of adhering to the menu and portion sizes to prevent nutritional imbalances among residents.
Failure to Follow Food Preparation Guidelines
Penalty
Summary
The facility failed to prepare food by methods that conserved flavor and appearance during breakfast service. Specifically, a staff member did not follow the recipe for coffee cake, resulting in the preparation of a plain cake instead. The staff member omitted the brown sugar and coffee topping, which affected the taste and flavor of the cake. This deviation from the recipe was acknowledged by the dietary supervisor, who confirmed that the coffee cake recipe did not include coffee as an ingredient and that brown sugar should have been mixed with the wet and dry ingredients. The failure to follow the recipe could lead to residents not eating the food, potentially resulting in unplanned weight loss. Additionally, the facility did not adhere to the specified portion sizes for the baked Western omelet. Instead of cutting the omelet into the prescribed 3x2 1/2 inch servings, a #10 scoop was used, which did not meet the portion size requirements. The dietary supervisor noted that the use of a scoop instead of cutting the omelet affected the presentation, making it less appetizing for residents. This failure to follow the facility's policy and procedure on food preparation could lead to residents not consuming the food, further risking unplanned weight loss.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Expired hotdog and hamburger buns were found in the kitchen refrigerator, and undated foods were stored in the refrigerator. Staff members had placed personal food items in the facility refrigerator, which is against the facility's policy. The Dietary Supervisor and Director of Nursing acknowledged that these practices could pose a risk of contamination and illness to residents. Additionally, the facility did not maintain proper hand hygiene practices. A dietary aide was observed touching a paper towel dispenser button after washing her hands and returning to work without re-washing her hands. This action was contrary to the facility's handwashing procedures and could lead to contamination of food and utensils, potentially causing illness among residents. The facility also failed to maintain cleanliness in food preparation areas. Ice crystals were observed on the walk-in freezer's ceiling, and dust and dirt were found on canned food racks, refrigerator gaskets, and the kitchen hood. A dented can was stored with non-dented cans, and expired sanitizer test strips were in use. These conditions could lead to cross-contamination and foodborne illnesses among residents, as acknowledged by the Dietary Supervisor.
Facility Lacks Designated Medical Director and Documentation of Responsibilities
Penalty
Summary
The facility failed to designate a Medical Director (MD) for a period of 12 months, from December 30, 2023, to December 30, 2024. This deficiency was identified during interviews and record reviews, where it was revealed that the facility did not have a job description or policy outlining the MD's responsibilities in coordinating medical care. The Administrator acknowledged that the facility's license did not list a Medical Director and that an application had not been submitted to the State Agency. Although there was a physician agreement in place since April 1, 2020, it did not specify the MD's role in organizing and coordinating physician services and other professional services related to resident care. Interviews with the MD and the Director of Nursing (DON) indicated that the MD was involved in resident care, attended quality assurance meetings, and provided oversight of clinical practices. However, the lack of formal documentation of the MD's responsibilities could lead to confusion among staff regarding clinical decision-making and accountability. The Administrator admitted uncertainty about how the absence of a job description or policy could impact the quality of care, but recognized that having such documentation could be beneficial.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential inaccuracies in their clinical documentation. For Resident 33, the facility did not accurately document the provision of showers from December 23 to December 29, 2024. The resident, who has Alzheimer's disease and severely impaired cognitive skills, was dependent on staff for activities of daily living, including bathing. Despite the care plan indicating the need for showers twice a week, the documentation showed daily bed baths instead. Additionally, the resident's fingernails were observed to be long and chipped, indicating a lack of proper hygiene care, which was not reported to the charge nurse or documented in the communication binder. In the case of Resident 39, the facility inaccurately documented a bed bath as a shower on December 27, 2024. Resident 39, who has hemiplegia and requires a mechanical lift for showering, reported not being showered for a week due to the unavailability of a sling. CNA 3 confirmed that the resident refused a shower due to the lack of an extra sling and received a bed bath instead. However, the documentation incorrectly indicated that a shower was provided, which was acknowledged as inaccurate by the Director of Nursing. The facility's policy on charting and documentation requires that records be objective, complete, and accurate. However, the discrepancies in documentation for both residents highlight a failure to adhere to these standards. The Director of Staff Development and the Director of Nursing both acknowledged the inaccuracies and the importance of accurate documentation for communication and continuity of care. These failures in documentation could lead to potential risks for the residents, as accurate records are essential for ensuring appropriate care and interventions.
Infection Control Deficiencies in Water Management, Medication Room, and Resident Care
Penalty
Summary
The facility failed to implement effective infection control measures, as evidenced by several deficiencies. Firstly, the facility did not adhere to its water management plan to prevent legionella growth. The Maintenance Supervisor (MS) admitted to not having a standard for legionella prevention and had never conducted a risk assessment as required by the facility's policy. The water temperatures recorded from October to December 2024 were consistently at 110 degrees Fahrenheit, which is within the range prone to legionella growth. The MS also failed to document water temperatures in the shower rooms, which are critical control points for legionella prevention. The Infection Preventionist (IP) and the Director of Nursing (DON) acknowledged the lack of proper monitoring and documentation, which are essential for ensuring resident safety. In another instance, the facility did not maintain a sanitary environment in one of the medication rooms. During an observation, a donut wrapped in a paper towel was found on top of a drainage kit box, which violates the facility's policy that prohibits food in medication rooms. The Licensed Vocational Nurse (LVN) and the DON confirmed that food should not be present in medication rooms to prevent infection. Additionally, the facility failed to maintain appropriate contact isolation for a resident diagnosed with scabies. The resident was initially placed on contact isolation, but it was discontinued before the completion of treatment and without confirming that the resident was scabies-free. The IP and DON acknowledged that the resident should have remained in isolation until treatment was complete or a negative scrape test confirmed the absence of scabies. This oversight posed a risk of spreading the infection to other residents and staff. Furthermore, another resident was observed using a nasal cannula without a labeled date, which is against the facility's policy of changing and dating nasal cannulas weekly to prevent infection. The DON confirmed that the lack of a date on the nasal cannula could lead to infection risks.
Failure to Maintain Resident Dignity and Provide Adequate Care
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents, Resident 33 and Resident 39, as observed during a survey. For Resident 33, a Certified Nursing Assistant (CNA 4) was observed standing over the resident while assisting with feeding during a meal. This action was contrary to the facility's policy, which requires CNAs to sit at eye level with residents to ensure dignity and respect. The Director of Staff Development and the Director of Nursing confirmed that CNAs are expected to sit while assisting residents with meals to maintain their dignity and safety. Resident 33, who was admitted with Alzheimer's disease, major depressive disorder, and bipolar disorder, was dependent on staff for activities of daily living, including eating. Despite the resident's cognitive impairments, the facility's care plan indicated the need for one staff member to assist with eating, which was not adhered to in a manner that respected the resident's dignity. For Resident 39, the facility failed to provide a shower as required by the resident's care plan. Resident 39, who had hemiplegia and hemiparesis following a cerebral infarction, was dependent on staff for showering. The facility lacked sufficient slings for the mechanical lifts needed to shower the resident, resulting in the resident receiving a bed bath instead. The Director of Nursing acknowledged the issue, stating that the lack of slings was a problem and that it was a resident's right to have a shower if requested, as it is part of their dignity.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to inform a resident and their responsible party about the right to formulate an advance directive upon admission. This deficiency was identified during a review of the resident's admission records, which showed that the resident was admitted with diagnoses including pneumonia, muscle weakness, and cerebral palsy. The resident had fluctuating capacity to understand and make decisions due to developmental delay. Despite these conditions, there was no advance directive noted in the resident's medical records, and interviews with facility staff confirmed that no documentation existed to show that an advance directive was offered to the resident or their representative. Interviews with the Medical Records Director, Social Services Director, and Director of Nursing revealed that the facility did not have any documentation indicating that an advance directive was offered to the resident or their representative. The Director of Nursing acknowledged that the Social Services Director should have documented the offer of an advance directive, especially since the resident was under court-ordered conservatorship. The facility's policy requires that residents and their legal representatives be provided with information regarding advance directives upon admission, but this was not adhered to in this case.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to notify the physician that azithromycin, an antibiotic prescribed for a resident with end-stage renal disease and a history of infections, was unavailable for three consecutive days. This resulted in the resident receiving an incomplete course of the medication, as the prescribed doses on specific dates were not administered. The resident was admitted with severe cognitive impairment and was dependent on staff for all activities of daily living, making it crucial for the facility to manage medication administration effectively. The Medication Administration Record indicated that the azithromycin was not given on the specified dates, and the facility's Infection Preventionist confirmed that the medication was not documented as administered. The Director of Staff Development and the Director of Nursing acknowledged that the Licensed Vocational Nurses should have informed the physician about the unavailability of the medication to obtain new orders. The facility's policy required notifying the physician when there was a significant alteration in the resident's medical treatment, which was not followed in this case.
Non-Functional Wall Clock Disrupts Resident's Routine
Penalty
Summary
The facility failed to provide a safe and homelike environment for a resident by not ensuring the resident's wall clock was in working condition. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disorder, generalized muscle weakness, and hypertension, relied on the wall clock to know the time. Observations revealed that the wall clock was stuck at 6:30, which did not reflect the actual time, potentially disrupting the resident's daily routine and scheduled activities. Interviews with staff, including a Certified Nursing Assistant and the Director of Staff Development, confirmed that the wall clock was not functioning and should have been reported to maintenance for repair. The Director of Nursing also acknowledged that the maintenance team should have been notified to address the issue, as knowing the correct time is part of the residents' rights. The facility's policy on providing a homelike environment emphasizes the importance of residents' comfort and personal needs, which was not upheld in this instance.
Deficiency in Personal Hygiene and Grooming Services
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for two residents. Resident 33, who has Alzheimer's disease, major depressive disorder, and bipolar disorder, was found with long and chipped fingernails. Despite being dependent on staff for activities of daily living, including personal hygiene, the resident's nails were not trimmed as required. Certified Nursing Assistant 5 admitted to not trimming the nails due to the resident's tendency to scratch, but failed to report this to the charge nurse or document it in the communication binder. The Director of Staff Development and the Director of Nursing both acknowledged that the resident's nails should have been trimmed as part of their hygiene care. Resident 39, diagnosed with hemiplegia and hemiparesis following a cerebral infarction, did not receive a shower as scheduled. The resident requires a mechanical lift and sling for showering, but the facility lacked sufficient slings, leading to the resident receiving a bed bath instead. Certified Nursing Assistant 3 incorrectly documented that the resident had been showered. The Director of Nursing confirmed the shortage of slings and acknowledged the issue, emphasizing the resident's right to a shower and the potential risk of infection if hygiene needs are not met. The facility's policy on supporting activities of daily living states that residents unable to perform these activities independently should receive necessary services to maintain grooming and personal hygiene. However, the facility's failure to trim Resident 33's nails and provide Resident 39 with a shower as scheduled indicates a deficiency in adhering to this policy, potentially affecting the residents' psychosocial well-being.
Improper LAL Mattress Settings for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services for two residents at risk for developing pressure ulcers by not adhering to the manufacturer's guidelines for low air loss (LAL) mattresses. Resident 14, admitted with diagnoses including pneumonia, muscle weakness, and cerebral palsy, had a fluctuating capacity to understand and make decisions. The resident's LAL mattress was incorrectly set at a level for a person weighing 175 pounds, while the resident weighed only 86 pounds. This discrepancy was observed during a facility visit, and both a registered nurse and the Director of Nursing (DON) confirmed that the mattress should have been set according to the resident's actual weight to prevent skin tissue damage. Similarly, Resident 214, who was admitted with pressure-induced deep tissue damage and other conditions, had an LAL mattress set incorrectly. The resident's care plan specified a mattress setting for a weight range of 90-110 pounds, but the mattress was set for a weight of 164 pounds, while the resident weighed 97 pounds. This incorrect setting was also confirmed by a registered nurse and the DON, who acknowledged that an improper setting could lead to skin breakdown and hinder wound healing. The facility's policy on the prevention of pressure injuries emphasized the importance of selecting appropriate support surfaces based on residents' risk factors and ensuring medical devices are used correctly to minimize tissue damage. However, the failure to set the LAL mattresses according to the residents' weights demonstrated a lack of adherence to these guidelines, potentially compromising the residents' skin integrity and healing process.
Failure to Supervise Smoking and Manage Hazards
Penalty
Summary
The facility failed to provide adequate supervision for Resident 44, who was identified as a smoker requiring supervision. Despite the resident's care plan indicating the need for supervision during smoking activities, observations revealed that Resident 44 was left unsupervised while smoking in the designated area. The resident was seen smoking without a smoking apron, and staff were not present to supervise, contrary to the facility's policy that mandates direct supervision for residents with smoking privileges. Interviews with staff, including the Activity Director and Director of Nursing, confirmed the lack of supervision and acknowledged the potential risks associated with unsupervised smoking. Additionally, the facility did not properly manage and secure cords and cables near Resident 23's bed, posing a potential hazard. An extension cord with power adapters was observed wrapped around the resident's left side bed rail, which the resident had previously requested to be removed. The Director of Nursing acknowledged the presence of the cords and recognized the risk of fire or trip hazards associated with their improper placement. The facility's policy on hazardous areas and equipment emphasizes the need to address such hazards to ensure resident safety. Both deficiencies highlight the facility's failure to adhere to its policies and procedures designed to prevent accidents and ensure a safe environment for residents. The lack of supervision for Resident 44 during smoking and the improper management of cords near Resident 23's bed rail demonstrate lapses in the facility's safety protocols, potentially endangering the residents involved.
Failure to Provide RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours on November 19, 2023, affecting 57 of the 58 residents. A review of the Nursing Staffing Assignment and Sign-In Sheet for that date confirmed that no RN was assigned to work. This deficiency was identified during a record review and interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON). The DSD confirmed the absence of an RN on the specified date, and the DON acknowledged that the facility lacked a policy mandating an RN to work eight hours daily. The Facility Assessment, which outlines the staffing plan, indicated that the facility should provide adequate staffing, including a Nursing Supervisor RN for eight hours during the day shift. The DON emphasized the importance of having an RN to supervise Licensed Vocational Nurses (LVNs), intervene in changes in resident conditions, administer intravenous medications, and support charge nurses. The absence of an RN on the specified date had the potential to delay necessary care and services for the residents.
Failure to Administer Antibiotics as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following the physician's order for antibiotic administration. Resident 214, who was admitted with diagnoses including end-stage renal disease and a history of infections, was prescribed azithromycin to treat pneumonia. The physician's order specified a dosage of 500 mg on the first day followed by 250 mg for the next four days. However, the Medication Administration Record (MAR) indicated that the initial 500 mg dose and the first two 250 mg doses were not administered as prescribed. Interviews and record reviews revealed that the medication was available in the facility's emergency kit, but the nursing staff failed to administer it. The Infection Preventionist confirmed that the medication was not documented as given, indicating it was not administered. The Director of Staff Development and the Director of Nursing acknowledged the error, noting that the delay in administering the antibiotic could worsen the resident's condition. The facility's policy required that medications be administered in a timely manner, but this was not adhered to in this case. Further investigation showed that the pharmacy had delivered the medication, and it was placed in the medication cart. However, the nursing staff did not follow through with the administration. The facility's policy on antibiotic stewardship and medication administration emphasized the importance of timely and accurate medication delivery, which was not followed, leading to the resident receiving an incomplete course of antibiotics.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a deficiency in the assessment process. The resident, who was admitted with diagnoses including pneumonia, generalized muscle weakness, and unsteadiness of feet, was discharged home with home health services. However, the MDS was incorrectly coded as if the resident was discharged to a hospital. This error was identified during a review of the resident's records, which included the Admission Record, History and Physical, physician orders, Discharge Summary, and Nurses' Notes, all indicating the resident was discharged home. The MDS Coordinator acknowledged the mistake during an interview, stating that the discharge assessment was incorrectly coded and should have reflected the resident's actual discharge to home. The Director of Nursing also confirmed that the MDS should be coded accurately to prevent miscommunication and ensure proper care planning. The facility's policy requires interdisciplinary team staff to certify the accuracy of the MDS portions they complete, highlighting the importance of accurate coding in the resident assessment process.
Violation of Resident Room Capacity Requirements
Penalty
Summary
The facility was found to be in violation of the requirement that resident rooms hold no more than four residents. During an observation tour, it was noted that room [ROOM NUMBER] contained five beds, with four residents occupying the room. Despite the presence of five beds, the residents had adequate space to move freely, and the nursing staff had sufficient room to provide care safely. The room was equipped with necessary furniture and resident care equipment, and there were no observed issues with space or clutter. Interviews with staff, including a Certified Nursing Assistant, confirmed that there were no problems with space in room [ROOM NUMBER], and care activities could be performed without issue. The facility had submitted a request for a waiver for the five beds in the room, indicating that each bed allowed for 92.23 square feet of space. The Administrator stated that there were no resident complaints regarding space, and the facility would accommodate any concerns if they arose. The facility's policy on accommodation of needs emphasized maintaining a safe and dignified environment for residents.
Inadequate Implementation of Infection Control Measures
Penalty
Summary
The facility failed to implement its infection control policy by not adhering to Enhanced Barrier Precautions (EBP) for three residents who required such measures due to their medical conditions. These residents had conditions such as pressure ulcers, gastrostomy tubes, and other wounds that necessitated the use of EBP to prevent the spread of multidrug-resistant organisms. Observations revealed that there was no signage or personal protective equipment (PPE) carts outside the rooms of these residents, indicating a lack of compliance with the facility's EBP policy. Additionally, during a COVID-19 outbreak, the facility did not ensure that staff wore appropriate PPE, specifically eye protection, when caring for residents who tested positive for COVID-19. Several Certified Nursing Assistants (CNAs) were observed entering the rooms of COVID-19 positive residents without wearing face shields or goggles, which are required to prevent the spread of the virus. Interviews with staff, including the Infection Preventionist, confirmed that the necessary PPE protocols were not being followed, increasing the risk of transmission. The facility's policies and procedures for both EBP and COVID-19 PPE usage were not adequately implemented, as evidenced by the lack of signage, PPE, and staff adherence to protocols. The Infection Preventionist acknowledged the oversight and the potential for cross-contamination due to the absence of proper infection control measures. This deficiency highlights a significant lapse in the facility's infection prevention and control program, which could lead to increased transmission of infections among residents and staff.
Failure to Document and Offer COVID-19 and Flu Vaccines to Staff
Penalty
Summary
The facility failed to provide documented evidence that staff were educated on the benefits and potential risks associated with the COVID-19 and influenza vaccines. This deficiency was identified for all six sampled staff members during a record review. The records did not indicate that education on the risks and benefits of the vaccinations was provided, nor was there documentation of consent or declination for the COVID-19 or flu vaccines. The Director of Staff Development admitted to only receiving verbal consent and refusal from staff, without proper documentation, which was against the facility's policy. Additionally, the facility did not offer the COVID-19 and flu vaccines to the staff, as required by their policies. The Infection Preventionist confirmed that staff are required to get the flu vaccine annually, and if declined, they must wear a mask. However, there was no documentation of the offer or refusal of the vaccines. The facility's policies clearly state that all staff should be offered the vaccines and provided with education, with documentation maintained in their medical records. The lack of documentation and adherence to these policies had the potential to increase the risk of transmission of infectious diseases among residents and staff.
Delayed Submission of Abuse Report
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely submission of a 5-day report to the State Survey Agency (SSA) following an alleged incident of family-resident financial abuse. The incident was reported to the SSA on June 21, 2024, but the required 5-day report was not submitted until July 3, 2024, which was eight days after the incident. This delay in reporting was identified during an interview with the Administrator, who acknowledged the oversight and confirmed that the report should have been submitted within the stipulated timeframe. The deficiency involved a resident who was admitted to the facility on April 17, 2024, with diagnoses including bipolar disorder, chronic obstructive pulmonary disease, and essential hypertension. The resident's cognitive skills were noted to be intact according to the Minimum Data Set assessment dated April 29, 2024. The failure to submit the report in a timely manner had the potential to result in unidentified abuse within the facility and a failure to protect other residents from similar incidents.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services for a resident by leaving medications unattended at the bedside. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, and essential hypertension, was observed with a medicine cup containing six pills left on the overbed table. A registered nurse admitted to leaving the medications for the resident to take without supervision, acknowledging that this practice was inappropriate and could lead to medication errors. Further review revealed that the resident's hydralazine hydrochloride, a medication for hypertension, was administered three hours and 31 minutes earlier than prescribed. This deviation from the scheduled time could potentially cause the resident's blood pressure to drop lower than usual. The facility's policy on administering medications requires that medications be given in a safe and timely manner, as prescribed, and that nurses should witness residents swallowing their medications. The failure to adhere to these policies resulted in the deficiency noted in the report.
Obstructed Emergency Exit in LTC Facility
Penalty
Summary
The facility failed to maintain one of four means of egress, specifically a designated exit door, free from obstructions. During an observation and interview, it was noted that an emergency exit door located beside a resident room was blocked by a medication cart and a dirty linen bin. A registered nurse stated she was unaware of where the medication cart should be stored when not in use and acknowledged that the items should not block the emergency exit doors. The Minimum Data Set Nurse also confirmed that the medication cart was empty and not in use, and reiterated that emergency exit doors should be clear with an open pathway to the outside of the facility in case of emergency. The facility's policy, dated 9/27/2023, indicated that exits must remain clear of obstructions at all times.
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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