The Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Ana, California.
- Location
- 1800 Old Tustin Avenue, Santa Ana, California 92705
- CMS Provider Number
- 555765
- Inspections on file
- 55
- Latest survey
- March 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Hills Post Acute during CMS and state inspections, most recent first.
Multiple residents with IV access did not receive required weekly dressing changes, and staff failed to consistently measure and document arm circumference and external catheter length during dressing changes. Physician's orders and care plans for IV maintenance were missing or delayed for several residents, and some IV sites were not properly labeled upon insertion. These deficiencies were confirmed through observation, record review, and staff interviews, and were acknowledged by facility staff.
Surveyors found that the kitchen hood was not cleaned as required, kitchen utensils were in poor repair and not properly sanitized, and cutting boards were heavily marred and difficult to clean. Additionally, a chest freezer lacked a thermometer for temperature monitoring, and milk beverages were served above the recommended temperature. These deficiencies were acknowledged by the RD and Assistant DSS during observations and interviews.
Surveyors identified that three residents had incomplete or inaccurate medical records, including missing documentation of medication administration, required monitoring, and an incomplete POLST form. One resident's weekly fluid intake was incorrectly documented as daily totals, and staff confirmed these errors during interviews and record reviews.
Surveyors observed multiple infection control lapses, including a resident's urinal placed next to drinks on a bedside table, an LVN failing to perform hand hygiene or change gloves during GT medication administration, and a nurse not using required PPE while providing GT care to a resident on Enhanced Barrier Precautions for a respiratory MDRO. These actions were confirmed by staff and posed a risk for contamination and infection transmission.
A resident who required a sippy cup for self-feeding, as documented in medical records and physician orders, was not provided with the adaptive equipment during meals. The resident used regular cups instead, and both a CNA and an LVN confirmed that the sippy cup should have been supplied but was not.
Three residents received respiratory care that did not meet facility policy, including one who received oxygen therapy without a physician's order and had unsanitary equipment, and two others whose oxygen tubing and related supplies were not properly labeled or stored. Staff confirmed the lack of labeling and improper storage, and acknowledged these practices did not follow infection control protocols.
Two residents did not receive appropriate dialysis care: one was given antihypertensive medication on dialysis days against physician orders, and another's AV shunt site was not properly monitored or reported to the physician when negative findings were documented. Nursing staff and the DON confirmed that required notifications and assessments were not consistently performed.
The facility did not consistently obtain required nurse signatures on controlled substance logs for two medication carts, resulting in incomplete accountability for narcotic medications. Additionally, a nurse failed to properly administer prescribed eye drops to a resident with cognitive impairment and glaucoma, not following protocol to ensure medication absorption.
Surveyors found that a vial of Lidocaine was removed from an IV emergency kit without documentation in the Emergency Kit Usage Log, and expired Santyl ointments were present on a treatment cart. The IP, DON, and an LVN confirmed these deficiencies, noting that required documentation and removal of expired medications did not occur.
Several residents reported ongoing issues with excessive noise from slamming doors and staff speaking loudly during shift changes, which disrupted their rest. Observations confirmed that doors made loud noises and that staff gatherings contributed to the problem. Additionally, a resident's room was found to have a wall in disrepair, with scratches and chipped paint, which had not been repaired despite the resident spending significant time in the room.
Two residents did not have their care plans updated to reflect current physician orders and changes in condition. One resident's care plan listed an incorrect fluid amount compared to the physician's order, and another resident's care plan was not revised when the behavioral manifestation for antipsychotic medication use changed. These omissions were confirmed by facility staff during record reviews and interviews.
A resident who was fully dependent on staff for ADLs was repeatedly observed with long, sharp fingernails and self-inflicted facial scratches. Staff interviews confirmed that nail care was not provided as required by the care plan, which specifically called for keeping nails short to prevent skin injury. The facility's policy for individualized ADL assistance was not followed, resulting in unmet personal hygiene needs and compromised skin integrity.
A resident with end-stage renal disease and a physician-ordered fluid restriction was not provided the prescribed 360 ml of fluids with each meal, instead only receiving 240 ml. The dietary department's practice did not match the physician's order, and there was no documentation of refusal or physician notification about the discrepancy, as confirmed by the resident and the RD.
A resident with a recent pneumonia diagnosis was observed receiving continuous oxygen therapy without a physician's order or a comprehensive care plan in place. Both an LVN and the DON confirmed that the care plan for oxygen use had not been initiated after the resident's readmission.
A resident with documented dislikes for certain foods was repeatedly served those items despite clear notations on her care plan and diet card. The resident expressed frustration and did not eat her meal, and a CNA confirmed the tray should not have included the disliked foods.
A resident with dysphagia and other medical conditions was given regular peanut butter sandwiches instead of a prescribed pureed diet, leading to a choking incident and subsequent death. The healthcare assistant was unaware of the dietary restrictions, and the facility staff confirmed the inconsistency with the diet orders.
A long-term care facility failed to safeguard controlled medications for nine residents, resulting in the diversion of significant quantities of tramadol, hydrocodone-acetaminophen, and Oxycontin. The facility's medication logs were falsified to show that medications were transferred to the DON, but signatures were forged, and the medications were missing. The facility's narcotic count process did not detect the diversion, as the logs falsely indicated the medications were in the DON's possession.
A resident experienced an unwitnessed fall resulting in a head injury, but the facility failed to document the necessary post-fall assessment details as per their policy. Despite the resident's report of significant pain and visible injury, the medical records lacked comprehensive documentation of the skin and wound condition. The DON confirmed the absence of required documentation.
The facility failed to ensure complete and accurate medical records for three residents. A resident's MAR lacked documentation of blood sugar levels and medication administration on specific dates. Another resident's MAR was missing similar documentation, and a third resident's MAR lacked nurse initials for medication administration. The DON confirmed these findings, highlighting the expectation for immediate documentation post-medication administration.
The facility failed to properly manage and document controlled substances, resulting in missing oxycodone medications for a resident. The investigation revealed inconsistencies in the Medication Administration Record (MAR) and Controlled Drug record, as well as missing signatures on shift count sheets for multiple medication carts. These lapses were acknowledged by the DON and nursing staff.
Failure to Ensure Safe and Appropriate IV Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for the safe and appropriate administration and maintenance of IV fluids and access devices for multiple residents. For several residents with PICC lines or midline catheters, the facility did not ensure that dressing changes were completed weekly as required, nor did they consistently measure and document arm circumference and external catheter length during dressing changes. In some cases, such as with one resident, the care plan for IV use was not developed in a timely manner, and documentation was bypassed by staff entering 'N/A' instead of actual measurements. Additionally, the facility did not always obtain physician's orders for the care and maintenance of IV lines, nor did they develop care plans for residents with IV access. For example, one resident received IV hydration therapy without a corresponding physician's order for maintenance, and there was no documentation of site assessment or a care plan addressing the IV site. Another resident had a peripheral IV site that was not labeled with the date, time, or initials upon insertion, and there was no physician's order or care plan for the maintenance of the IV site as required by facility policy. Observations and interviews confirmed that these lapses in care and documentation were acknowledged by facility staff, including the MDS Coordinator, RNs, and the DON. The failures included not following facility policies for IV site labeling, not performing or documenting required assessments and measurements, and not initiating or updating care plans in a timely manner. These deficiencies were identified through direct observation, medical record review, and staff interviews, and had the potential to delay the identification of catheter-related complications for the affected residents.
Multiple Food Safety and Sanitation Failures in Kitchen Operations
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food safety and sanitation. During an initial kitchen tour, the hood over the stove was found to have black, dirt residue, contrary to the facility's policy requiring biweekly cleaning and USDA Food Code standards. The kitchen staff acknowledged that the hood was only cleaned monthly, and both the Registered Dietitian (RD) and Assistant Dietary Services Supervisor (DSS) recognized this as an infection control and fire hazard issue. Additionally, several kitchen utensils, including slotted scoops, spatulas, and serving spoons, were observed to have partially melted handles, discoloration, and were in poor repair, which the RD and Assistant DSS confirmed should have been replaced according to policy and food code requirements. Further observations revealed that multiple utensils and kitchenware, such as knives, scoops, and serving spoons, were dirty, with dry, crusted residue, cloudy film, and watermarks present. The RD and Assistant DSS acknowledged these items had not been properly washed, violating both facility policy and food code standards for cleanliness. Cutting boards in the kitchen were also found to be heavily marred, fuzzy, and with deep grooves, making them difficult to clean and sanitize. The RD stated the boards had been changed the previous month, but the Assistant DSS agreed they should have been replaced due to infection control concerns. Additional deficiencies included the absence of a thermometer in the chest freezer used for ice cream storage, despite facility policy requiring two thermometers per freezer and food code guidance on proper temperature monitoring. During meal service, milk beverages were found to be above the recommended temperature, with one instance measuring 43 degrees Fahrenheit and another at 49.1 degrees Fahrenheit, exceeding the facility's policy and food code requirements for cold food holding. These findings were verified by the RD and DSS during observation and interview.
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as evidenced by missing or incomplete documentation in medication administration records (MAR), physician orders, and required forms. For one resident, the MAR did not show administration of prescribed medications such as Protonix and Humalog insulin, nor did it document completion of a tuberculin test or required monitoring activities, including hours of sleep, non-pharmacological interventions, side effects of hypnotics, signs and symptoms of bleeding related to anticoagulant use, and pain level assessments for specific shifts. The LVN confirmed that these omissions meant the care or monitoring was not performed or not documented as required. Another resident's Physician Orders for Life-Sustaining Treatment (POLST) form was found to be incomplete, lacking the physician's name, telephone number, license number, signature, and date for a period of six months. Both the Social Services Designee and the DON acknowledged that the POLST should have been fully completed according to requirements. Additionally, the facility did not accurately calculate and document weekly fluid intake totals for a third resident who was on a physician-ordered fluid restriction and required weekly evaluation of intake and output. The documentation reflected daily, rather than weekly, fluid intake amounts, which was verified as inaccurate by the DON. These documentation failures were confirmed through interviews and concurrent record reviews with facility staff.
Infection Control Lapses in Resident Care and GT Procedures
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices as evidenced by multiple observed deficiencies. In one instance, a resident's urinal containing approximately 200 ml of urine was placed on a bedside table next to a water pitcher and two cups of juice, creating a potential for contamination of the drinks. The MDS Coordinator confirmed the placement and acknowledged the risk of contamination. Additionally, staff did not adhere to hand hygiene protocols during gastrostomy tube (GT) care. An LVN was observed administering medication via GT without performing hand hygiene or changing gloves after touching the privacy curtain, despite facility policy requiring handwashing before handling GTs. Furthermore, a nurse failed to follow Enhanced Barrier Precautions (EBP) for a resident with a respiratory MDRO and an indwelling medical device, as she did not don a gown and mask while providing GT care, even though signage and care plans indicated EBP was required. These lapses were verified by staff during interviews.
Failure to Provide Required Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment, specifically a sippy cup, to a resident who required it to maintain independence in self-feeding. Medical records, including a nutrition evaluation and physician order, indicated the resident should have a sippy cup for meals. The resident's diet card also specified the need for adaptive equipment at all meals. During a mealtime observation, the resident was seen using regular cups for both milk and juice, and a CNA confirmed that the sippy cup was not provided as required. The CNA stated that the kitchen should have supplied the sippy cup, and an LVN verified that the resident should have received it, confirming the deficiency.
Failure to Provide Safe and Sanitary Respiratory Care
Penalty
Summary
The facility failed to provide safe and sanitary respiratory care for three residents who required oxygen therapy. One resident received oxygen therapy without a physician's order, and the oxygen tubing and nasal cannula for this resident were found lying on the floor, not maintained in a sanitary manner. The resident had a recent history of pneumonia and was readmitted from an acute care hospital, but there was no current physician order for oxygen therapy, as confirmed by both observation and staff review of the medical record. Another resident was observed using oxygen tubing that was not labeled with the date it was first used or changed, and the tubing was not stored in a sanitary manner, being left on the bed and not placed in a plastic bag as required by facility policy. Staff interviews confirmed that the tubing should have been labeled and stored properly to prevent contamination, and that the tubing was being changed every 72 hours, although the infection preventionist later stated the change interval was weekly. The tubing was replaced after the deficiency was identified. A third resident's oxygen tubing and humidifier bottle were also not labeled with the date they were last changed, contrary to facility policy. Staff verified that labeling was necessary to ensure timely changes and prevent infection. The Director of Nursing confirmed the importance of dating these items for infection control. These findings were based on direct observation, staff interviews, and review of facility policies and medical records.
Failure to Provide Appropriate Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide necessary care and services for two residents requiring dialysis. For one resident, who was scheduled for dialysis three times per week, physician orders specified that antihypertensive medications should be withheld on dialysis days. Despite these orders, the medication Benazepril hydrochloride was administered on several dialysis days, as confirmed by both the Medication Administration Record (MAR) and the Director of Nursing (DON). This occurred even after the physician's orders were updated to clarify when the medication should be held. For another resident with an arteriovenous (AV) shunt in the left upper arm, the facility did not consistently assess and monitor the dialysis access site as required. The facility's policy and physician orders required that the AV shunt be checked for bruit and thrill every shift, and that the site be monitored for redness, bleeding, skin breakdown, and edema. Documentation in the MAR showed multiple instances where the AV shunt was assessed as negative for thrill and bruit, and positive for signs of redness, bleeding, skin breakdown, or edema. However, there was no evidence that the physician was notified of these findings, despite facility policy and physician orders requiring immediate notification for such changes. Interviews with nursing staff confirmed that the absence of bruit and thrill, as well as the presence of redness, bleeding, skin breakdown, or edema, should have prompted physician notification. The DON and other staff acknowledged that these findings represented a change in condition and that the physician should have been informed, but this did not occur according to the documentation reviewed.
Failure to Account for Controlled Medications and Improper Eye Drop Administration
Penalty
Summary
The facility failed to ensure proper accounting and safeguarding of controlled medications by not consistently obtaining signatures from incoming and outgoing licensed nurses on the Controlled Substance Logs for two medication carts. Multiple instances were identified where nurses' signatures were missing for various shifts, as verified by facility staff and the Director of Nursing. The facility's policy requires a physical inventory and documentation of controlled medications at each shift change, but this procedure was not consistently followed, creating gaps in medication accountability. Additionally, the facility did not ensure proper administration of an eye drop medication for a resident with moderate cognitive impairment and a diagnosis of mild open-angle glaucoma. During a medication administration observation, the nurse did not compress the resident's tear duct or ensure the resident's eyes remained closed for the required time after instilling the eye drops, as outlined in facility policy. The nurse left the room before confirming the medication was properly absorbed, and the resident was observed opening and wiping his eyes shortly after administration.
Failure to Document Emergency Kit Medication Use and Remove Expired Medications
Penalty
Summary
The facility failed to ensure proper documentation and storage of medications as required by its own policies and professional standards. During an inspection of the medication room's IV emergency kit, it was observed that a vial of Lidocaine was missing from the kit, and there was no documentation in the Emergency Kit Usage Log regarding its removal, the resident it was administered to, or the date it was taken. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the nurse who removed the medication did not document the usage as required by facility policy. Additionally, expired Santyl collagenase ointments were found on Treatment Cart 2 during an inspection. The ointments had expiration dates that had already passed, and the presence of these expired medications was verified by an LVN, who acknowledged that expired medications or medical supplies should be disposed of. The DON was informed of these findings and acknowledged the presence of expired medications on the treatment cart.
Failure to Maintain Comfortable Sound Levels and Room Condition
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for several residents, as evidenced by excessive noise levels and physical disrepair in a resident's room. Multiple residents expressed concerns about loud noises caused by staff slamming kitchen and dining room doors, as well as staff speaking loudly in the hallways, particularly during shift changes at night. These concerns were consistently reported during resident council meetings and individual interviews, with residents stating that the noise disrupted their rest and that the issue persisted despite being brought to the facility's attention. Observations confirmed that the dining room door made a loud noise when closed, and both the Administrator and Maintenance Director acknowledged the problem during on-site checks. Residents reported that the noise was especially problematic during the 2300 hours shift change, when staff would gather and socialize in the hallway, further increasing the noise level. Some residents also noted that they had not been offered alternative room placements in response to their complaints about the noise. Additionally, one resident's room was found to be in disrepair, with scratches and chipped paint on the wall adjacent to the bed. The resident indicated that while some repairs had been made to other parts of the room, the damaged wall near the bed, where the resident spent significant time, had not yet been addressed. The Administrator confirmed the condition of the room and acknowledged the outstanding repairs.
Failure to Revise Care Plans Following Physician Orders and Changes in Condition
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised in accordance with physician orders and changes in resident conditions for two residents. For one resident, the care plan indicated that 240 ml of fluid should be provided with each meal, while the physician's order specified 360 ml per meal as part of a fluid restriction protocol. This discrepancy was confirmed during a review with the Registered Dietitian, who acknowledged that the care plan did not reflect the current physician's order. For another resident, the care plan addressing psychotropic medication use was not updated when there was a change in the manifestation of the resident's behavior. The physician's order was revised to monitor episodes of psychosis manifested by seeing objects that were not there, but the care plan continued to reference only persecutory delusions. Both the MDS Coordinator and the DON confirmed that the care plan was not revised to reflect the updated behavioral symptoms as required.
Failure to Provide Adequate Nail Care Resulting in Self-Inflicted Injuries
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADL), including personal hygiene and grooming, did not receive adequate nail care. The resident was observed multiple times with long and sharp fingernails, which resulted in self-inflicted scratches on the face. Staff interviews confirmed that the resident required total assistance with ADLs and could not perform personal hygiene independently. The care plan for the resident specifically included an intervention to keep fingernails short due to a history of self-inflicted skin impairment, but this intervention was not consistently implemented. Observations and interviews with CNAs and an LVN revealed that the resident's fingernails had not been trimmed as required, and staff could not recall the last time nail care was provided. The resident was repeatedly seen scratching his face, and staff acknowledged that the long fingernails contributed to the skin injuries. The facility's policy required staff to provide ADL assistance according to individualized care plans, but this was not followed for the resident in question, resulting in unmet personal hygiene needs and skin integrity issues.
Failure to Provide Prescribed Fluid Amounts with Meals
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease and a physician-ordered fluid restriction of 2000 ml per 24 hours did not receive the prescribed amount of fluids with meals. The physician's order specified that the dietary department should provide 360 ml of fluids with each meal (breakfast, lunch, and dinner), totaling 1080 ml per day from dietary sources. However, the resident was only provided with 240 ml of fluid (a carton of Nepro) at each meal, which was consistent with a lower fluid restriction than ordered. There was no documentation indicating that the resident refused the additional fluids or that the physician was notified about the discrepancy. The issue was identified through observation, interviews, and medical record review. The resident confirmed only receiving 240 ml of fluid with each meal and expressed a preference for a variety of fluids, including water, juice, and hot chocolate. The registered dietitian (RD) verified that the dietary department was not following the physician's order and that the resident had not received the ordered amount of fluids since at least a specific date. The RD also confirmed that the kitchen's diet order did not match the physician's order, and there was no documentation of any refusal or physician notification regarding the missed fluids.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive care plan for a resident who was receiving oxygen therapy. The resident, who had been diagnosed with pneumonia and was recently readmitted from an acute care hospital, was observed lying in bed with an oxygen concentrator set to deliver continuous oxygen at 2 liters per minute. The oxygen tubing and nasal cannula were attached, and the resident had been receiving this therapy since readmission. During interviews and medical record reviews with both an LVN and the DON, it was confirmed that there was no physician's order for the oxygen therapy and no care plan had been initiated to address the resident's use of oxygen. The DON acknowledged that a care plan should have been started at the time the resident began receiving oxygen therapy after readmission, but this was not done.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's documented food preferences, resulting in the resident being served items she had specifically identified as dislikes. The resident's care plan and nutrition evaluation clearly listed several foods she did not want, including bacon, pork, mushrooms, spinach, olives, cabbage, and shredded carrots. Despite these documented preferences, the resident was observed being served cabbage and carrots for lunch, which were noted as dislikes on her diet card. During interviews and observations, the resident expressed frustration about receiving unwanted food items, and a CNA confirmed that the lunch tray should not have included cabbage and chopped carrots. The resident did not eat her lunch and requested an alternative meal, further verifying that her preferences were not being honored as required by her care plan and dietary documentation.
Failure to Provide Appropriate Dietary Texture Leads to Resident's Choking Incident
Penalty
Summary
The facility failed to provide a resident with the appropriate dietary texture as ordered by the physician, which put the resident at risk for choking. The resident, who had diagnoses including dysphagia, acute respiratory failure, epilepsy, and autism, was on a fortified, pureed diet with nectar thick liquids. Despite this, the resident was given regular peanut butter and jelly sandwiches, which were not consistent with the prescribed pureed diet. The facility's documents clearly indicated that peanut butter sandwiches were not allowed for residents on a pureed diet. The incident occurred when a healthcare assistant (HA) provided the resident with regular texture sandwiches, unaware of the resident's dietary restrictions. The HA stated that the resident frequently requested and consumed these sandwiches, and there was no communication regarding the resident's specific diet orders. The resident experienced a choking episode, followed by seizure-like activity, and was found unresponsive with food in their mouth. Despite efforts to perform the Heimlich maneuver and initiate CPR, the resident expired. Interviews with facility staff, including the Administrator and Director of Nursing (DON), confirmed the inconsistency with the resident's diet orders.
Controlled Medication Diversion in LTC Facility
Penalty
Summary
The facility failed to provide necessary pharmacy services to safeguard controlled medications for nine of 11 sampled residents. This deficiency was identified through interviews, medical record reviews, and facility document reviews. The missing medications included significant quantities of tramadol, hydrocodone-acetaminophen, and Oxycontin, which were not accounted for in the medication cart's locked narcotic drawer. The facility's policies and procedures required controlled substances to be handled, stored, and documented according to federal and state laws, but these protocols were not followed, leading to the diversion of medications. The investigation revealed that the controlled medication logs for the affected residents showed discrepancies. For instance, the logs indicated that medications were transferred to the Director of Nursing (DON) for destruction, but the signatures on these logs were forged. The missing medications were from residents who either had large amounts of controlled medications on hand, took pain medication infrequently, or were transferred out of the facility. The facility's narcotic count, conducted at each shift change, failed to detect the diversion because the logs falsely indicated that the medications were in the possession of the DON. Interviews with the DON and Administrator confirmed that the controlled medications were supposed to be transferred to the DON's locked cabinets when discontinued or when residents were transferred. However, the perpetrator forged the signatures of the DON and a witnessing nurse on the controlled medication logs, making it appear as though the medications were properly transferred. This failure in the facility's medication management system resulted in the unaccounted loss of controlled substances, highlighting a significant breach in the facility's responsibility to safeguard medications.
Failure to Document Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to maintain their highest practicable well-being following an unwitnessed fall. The resident, who had the capacity to understand and make decisions, experienced a fall resulting in a head injury. Despite the facility's policy requiring a physical assessment and documentation in the Nursing Progress Notes after a fall, there was a lack of detailed documentation regarding the resident's skin condition and the description of the hematoma on the right frontal temporal region. The resident reported a pain level of 8 out of 10 and had a visible bump with a scab on the head. Although the resident was transferred to an acute care hospital and later returned to the facility, the medical records lacked comprehensive documentation of the skin and wound condition. The Director of Nursing confirmed the absence of necessary documentation, acknowledging that the staff should have documented the description of the hematoma as per the facility's policy.
Incomplete Medical Record Documentation for Residents
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for three of eight sampled residents. For Resident 2, the licensed nurse did not document blood sugar levels, levothyroxine administration, and the amount of regular insulin administered in the Medication Administration Record (MAR) on two specific dates. This lack of documentation was confirmed during an interview with the Director of Nursing (DON), who stated that the expectation was for nurses to document medication administration immediately after it occurred. Similarly, for Resident 3, the MAR lacked documentation of blood sugar levels, the amount of insulin administered, and the nurse's initials on the same two dates. The DON verified these findings during a review and interview, reiterating the expectation for immediate documentation post-medication administration. For Resident 8, the MAR was missing the nurse's initials for medication administration on two separate dates. The medications involved were for the treatment of Parkinson's disease. The DON confirmed these omissions during a review and interview, acknowledging the expectation for timely documentation. These documentation failures had the potential to impact the residents' care needs due to incomplete and inaccurate medical information.
Failure to Properly Manage and Document Controlled Substances
Penalty
Summary
The facility failed to provide the necessary pharmacy services for a resident, specifically in the management and documentation of controlled substances. The facility did not ensure that the resident's oxycodone medications were stored properly, resulting in missing medications. Additionally, the facility did not ensure that the Controlled Drug record and the Medication Administration Record (MAR) documentation for the resident's oxycodone matched. This discrepancy was confirmed through interviews with the Director of Nursing (DON), Registered Nurse (RN), and Licensed Vocational Nurses (LVNs), who acknowledged the missing medications and documentation inconsistencies. The facility's policies and procedures (P&P) required that controlled substances be received, stored, and documented by licensed personnel. However, the investigation revealed that the resident's oxycodone medications were not properly stored or accounted for. RN 1 admitted to receiving the medications but failed to inform anyone or properly store them, leading to the medications being unaccounted for. Further review showed that the MARs did not reflect the administration of the medications on specific dates, despite being signed out in the Controlled Drug record. Additionally, the facility failed to conduct proper inventory checks of all narcotics during shift changes. The investigation found multiple instances of missing signatures on the shift count sheets for Medication Carts 1, 2, 3, and 5, indicating that the required physical inventory of controlled substances was not consistently performed. This lapse in procedure was verified by the DON and Clinical Resource nurse, who acknowledged the missing documentation and the potential for medication diversion due to these failures.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
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