The Meadows On Sunset Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 5154 Sunset Blvd, Los Angeles, California 90027
- CMS Provider Number
- 056056
- Inspections on file
- 83
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at The Meadows On Sunset Post Acute during CMS and state inspections, most recent first.
Surveyors found that bathroom call lights were not functioning in three residents’ rooms. One resident with CHF, chronic kidney disease, muscle weakness, and lack of coordination, and another with peripheral vascular disease and muscle spasms, both cognitively intact and needing staff assistance or supervision for toileting-related tasks, could not reliably activate the bathroom call light indicators outside their rooms. A third cognitively intact resident with heart failure, anxiety disorder, muscle weakness, and hip pain, who required moderate assistance with toileting and transfers, also had a nonfunctional bathroom call light. A CNA reported a prior resident complaint about a malfunctioning call light and could not recall reporting it, while the Environmental Director acknowledged no documented system-wide functional checks and suggested a loose wiring connection as a potential cause. The DON and Environmental Director stated that all rooms should have functional call lights and that nonfunctional bathroom call lights could delay care and increase fall risk, contrary to facility policy requiring accessible and properly reported call system issues.
A resident with dementia, CKD stage 4, and dependence on renal dialysis was readmitted after a change in dialysis access from an AV fistula to a left upper chest port catheter. Despite severely impaired cognition and dependence on staff for most ADLs, the care plan was not updated to include person-centered interventions, measurable objectives, or timetables for care and monitoring of the new port catheter. An RN and the DON both acknowledged that the care plan failed to address the accurate dialysis access site and that it was not complete or person-centered, contrary to the facility’s Comprehensive Care Plans policy requiring comprehensive care plans to meet identified medical and psychosocial needs.
Surveyors found that emergency medication kits were not consistently checked and contained expired medication, and that medication disposition procedures were not followed. An IM e-kit contained expired bacteriostatic water, and staff could not produce e-kit logs for any of the three nurse stations or show that the 15 e-kits were checked each shift. A resident’s medications remained stored in a medication room long after discharge, exceeding the facility’s 90-day destruction timeframe. Medication disposition logs at two nurse stations showed drugs documented as destroyed without a second nurse witness signature, and some medications were recorded as discarded in a trash bin instead of an approved waste management system, contrary to facility policy.
A resident with multiple fractures and cognitive capacity experienced a fall, but staff did not complete a post-fall assessment, notify the physician, or initiate a Change of Condition form as required. The facility also failed to obtain physician orders for the resident's wrist splint care and did not coordinate therapy sessions around the resident's medical appointments, resulting in missed therapy without documented rescheduling attempts.
A resident with multiple medical conditions and intact cognitive function reported seeing cockroaches in her bathroom on several occasions, but staff failed to document or investigate her complaints according to facility grievance policy. Interviews with staff confirmed that the grievance process was not initiated, and the concern was not recorded in the grievance log.
A resident with multiple medical conditions and intact cognitive function was discharged without a care plan for discharge, a completed Discharge Transition Plan, or proper delivery of the Notice of Transfer or Discharge. The resident was asked to sign a blank form, did not receive the completed document, and later discovered a form had been signed by staff without her knowledge or consent. Facility policy requiring timely and accurate discharge documentation and notification was not followed.
A resident with multiple fractures and a right wrist splint was admitted without a care plan addressing discharge planning or the management of the wrist splint. Despite being cognitively intact and able to communicate, the care plan only addressed fall risk and recent surgeries, omitting required interventions for discharge and splint care as outlined in facility policy. Staff confirmed these omissions during interviews and record reviews.
Facility staff failed to maintain accurate and complete medical records for a resident by allowing staff to sign a Notice of Transfer or Discharge form in place of the resident without proper notation or consent, and by documenting conflicting information regarding the resident's fall history. The DON confirmed discrepancies in signatures and documentation, and facility policies require clear, accurate, and complete records.
Two residents did not receive their prescribed calcium carbonate tablets on multiple occasions because the medication was not available in the medication cart. Despite facility policy requiring medications to be administered as ordered and documented, there was no evidence that the physician was notified or that an order to hold the medication was obtained, resulting in missed doses for both residents.
A resident with multiple medical conditions and moderate cognitive impairment experienced episodes of blood in the stool, leading to orders for STAT laboratory tests. After the resident refused a CBC blood draw, staff did not fully document the refusal, failed to follow facility policy for refusals, and did not update or create a care plan to address the situation.
A resident with a scheduled dialysis regimen was transported to the wrong dialysis center, resulting in a delayed and shortened dialysis session. Licensed nurses did not communicate the transport error, the reduced treatment time, or notify the MD, and key staff were unaware of the incident. Facility policies on patient identification and communication with the dialysis center were not followed.
Nursing staff failed to follow facility policy by leaving insulin syringes and medications unattended in a resident's room. On more than one occasion, insulin syringes and solutions were placed on the resident's bed and wheelchair and left without supervision, resulting in an accidental needle stick to a CNA. The resident involved had diabetes, chronic kidney disease, and major depressive disorder, and was assessed as cognitively intact.
The facility served meals to most residents in plastic containers with plastic utensils, resulting in cold and unappetizing food. Multiple residents with chronic conditions expressed frustration and reported that their complaints were not addressed by dietary staff or administration. Staff acknowledged that the use of disposable containers, due to a broken elevator, negatively affected food temperature and presentation, contrary to facility policy on resident dignity.
Due to a prolonged elevator outage, staff delivered meals using stairs and served food in disposable plastic containers, resulting in meals that were cold and unappetizing. Multiple residents, including those with hypertension and diabetes, reported dissatisfaction with the temperature and presentation of their food. Staff confirmed that the use of plastic containers did not retain heat, and the Dietary Supervisor noted this was not standard practice except in emergencies.
Surveyors observed several infection control breaches, including a CNA storing a personal cup in a clean linen cart and drinking in hallways, staff returning linen from a resident's room to a clean linen cart, failure to use gowns during care for a resident on Enhanced Barrier Precautions, improper PPE use in a contact isolation room, and undated respiratory equipment found on the floor. These actions were inconsistent with facility policies and infection prevention standards.
A resident with a physician's order for a renal diet without onions was served a meal containing onions, despite clear documentation of this preference on the meal ticket. Both the IPN and DON confirmed the error and acknowledged the importance of following dietary orders to meet the resident's nutritional needs, as required by facility policy.
A CNA in an LTC facility administered nystatin powder to a resident, following instructions from an LVN, despite not being trained or licensed to do so. The resident, who had multiple diagnoses and required assistance, was prescribed the medication for a fungal rash. Facility staff confirmed that medication administration is outside the CNA's scope of practice, and policies require licensed personnel to administer medications.
A CNA in an LTC facility administered nystatin powder to a resident without being licensed or trained to do so, following instructions from an LVN. The resident, who had conditions like osteomyelitis and peripheral vascular disease, required moderate assistance. Interviews with facility staff confirmed that medication administration is outside a CNA's scope of practice, and facility policies mandate that only licensed personnel administer medications.
A resident's medical records contained inaccurate documentation regarding the time of physician notification. The facility's system defaulted to 12 a.m. if staff did not manually enter the time, leading to discrepancies. The DON confirmed the inaccuracy, highlighting a failure to adhere to the facility's policy on timely and accurate documentation.
A facility failed to maintain an effective infection control program when a CNA did not follow Enhanced Barrier Precautions (EBP) for a resident with multi-drug-resistant organisms (MDROs). The CNA did not wear a gown while providing care and neglected hand hygiene after glove removal, contrary to facility policies. The resident had a history of gallstones with acute cholecystitis and required EBP due to MDROs.
The facility failed to obtain necessary physician's orders, informed consent, and restraint assessments for placing beds against walls for six residents, which restricted their freedom of movement and posed safety risks. Staff interviews confirmed the need for proper documentation and assessment, which was not followed.
The facility's nursing staff failed to rotate injection sites for insulin and heparin for four residents, leading to potential risks of lipodystrophy and bruising. Despite facility policies and guidelines emphasizing the importance of site rotation, records showed repeated use of the same sites. Interviews with staff confirmed the oversight and acknowledged the associated risks.
The facility failed to maintain a safe environment for residents, with deficiencies including improper medication storage at a resident's bedside, obstructed fall mats, a wet floor hazard, and unsecured smoking materials. These issues were confirmed by staff and violated facility policies, posing risks of injury and adverse effects.
The facility failed to ensure proper accountability of Controlled Substances (CS) by not including verifying signatures of the DON or an RN on accountability logs. During a review, it was found that two logs for CSs awaiting disposal lacked necessary signatures. The DON admitted to not consistently signing and dating the logs upon receipt from LVNs, despite understanding the importance of CS accountability. This failure increased the risk of CS diversion and accidental exposure to harmful medications.
A facility experienced a medication error rate of 14.81% due to errors affecting two residents. One resident did not receive prescribed psyllium husk powder and was given incorrect calcium without vitamin D. Another resident received incorrect multivitamin and calcium doses. The errors were acknowledged by the LVN and confirmed by the DON.
The facility failed to ensure residents were free from significant medication errors, including not rotating injection sites for insulin and heparin, administering expired insulin, and not administering Tacrolimus at scheduled times. These actions were contrary to standard practices and facility policies, potentially compromising resident health.
The facility failed to manage expired medications, including insulin and Aplisol, leading to their administration to residents. Open insulin pens were stored beyond recommended periods, and an expired emergency kit was found. The DON acknowledged the oversight, which posed risks to resident safety.
The facility failed to properly dispose of garbage, as observed with overflowing dumpsters in the parking lot. Interviews with staff confirmed that dumpsters should be closed to prevent pests and infection, aligning with the facility's waste management policy. This posed a potential risk to the health and safety of all 138 residents.
The facility failed to maintain an effective infection prevention and control program. The Housekeeping Supervisor placed dirty pillows on clean linens, risking contamination. Additionally, a resident's floor mat was damaged, exposing foam that could absorb dirt and liquids, posing an infection risk. These actions were contrary to the facility's infection control policies.
A facility failed to maintain a resident's dignity by not ensuring privacy for a confused resident who frequently removed her hospital gown. The resident, with conditions including dementia and major depressive disorder, was found undressed in bed with the curtain open, visible to staff and visitors. Staff interviews confirmed awareness of the need for privacy, but the facility did not adhere to its policy on resident rights, which emphasized safeguarding personal dignity.
A resident's floor mat, intended as a fall precaution, was found damaged with exposed foam, compromising the safety and cleanliness of their environment. Despite the facility's policy to maintain a safe and homelike setting, staff failed to notify maintenance for replacement, affecting the resident's well-being.
A facility failed to accurately code the PASARR for a resident admitted with major depressive disorder, schizophrenia, and anxiety disorder. The PASARR incorrectly indicated no mental disorder, potentially affecting care needs. The ADON confirmed the error, noting the PASARR should reflect the resident's medical condition. Facility policy required accurate PASARR completion prior to admission.
A facility failed to include oxygen use in a resident's baseline care plan, despite a physician's order for continuous oxygen due to COPD. The baseline care plan, required within 48 hours of admission, omitted this critical information, potentially delaying appropriate care.
A facility failed to implement comprehensive care plans for two residents, leading to deficiencies in care. One resident's smoking materials were not stored as per the care plan, and their bed was placed against the wall without a care plan, physician's order, or informed consent. Another resident was prescribed ciprofloxacin without a care plan to monitor for side effects or effectiveness. These oversights were confirmed through observations and staff interviews.
A resident with a urinary catheter was at risk for UTIs due to improper care. The catheter tubing had a loop, impeding urine flow, and lacked a securement device, contrary to facility policy. This was confirmed by a nurse and the DON, who acknowledged the importance of proper catheter positioning and securement to prevent UTIs.
The facility failed to provide appropriate care for two residents receiving enteral feeding. One resident's feeding formula bag was labeled with an incorrect administration rate, and the bags were prepared too early, risking expired formula use. Another resident's feeding tube was left uncapped when disconnected, increasing infection risk. Both residents had impaired cognition and required enteral feeding due to medical conditions.
A resident with multiple medical conditions did not receive safe IV fluid administration due to the facility's failure to clarify the need for a PIVC with the physician, change the dressing, assess the site for infection, and implement a care plan. The PIVC lacked a sanitizing cap, and there was no physician's order for its use, as confirmed by facility staff and the DON.
A facility failed to assess a newly hired RN's competency in foley catheter care, as required by policy. The RN's file lacked documentation of a completed skills assessment, which is crucial for ensuring safe care for residents with indwelling urinary catheters. Interviews with the DSD and DON confirmed the oversight, highlighting a gap in the facility's adherence to its competency assessment procedures.
A facility failed to consistently arrange hospice services for a resident with conditions like hemiplegia and cerebral infarction. Hospice Provider 1 did not provide necessary nursing and visitation notes, and scheduled visits were missed. The Social Services Director and Medical Records Director confirmed the lack of documentation, which was required by the facility's policy and agreement with the hospice provider.
A resident at the facility did not receive the 2024/2025 COVID-19 booster vaccine, and their vaccination status was not documented. The resident had consented to the vaccine, but the Infection Preventionist did not follow up or document the administration. The facility's policy for vaccine administration, including obtaining a physician's order and updating records, was not followed.
A facility failed to accurately code the MDS for a resident's discharge, indicating a hospital discharge instead of a transfer to a skilled nursing facility. The error was identified through a review of the resident's records, including a physician order and social services note, which confirmed the transfer to the SNF. The MDSC and DON acknowledged the coding error, emphasizing the importance of accurate MDS coding for billing and discharge follow-up.
A facility failed to provide a dignity bag for a resident's urinary drainage bag, compromising the resident's dignity. The resident, with quadriplegia and major depressive disorder, had a care plan that included a privacy bag for their catheter. However, during an observation, it was noted that the dignity bag was not in use, which was confirmed by a CNA and acknowledged by the facility's Administrator.
A quadriplegic resident in an LTC facility did not receive necessary grooming and personal hygiene services, resulting in long and curving fingernails and toenails. Despite a physician's order for podiatry consults, the resident had not seen a podiatrist and had not had their nails trimmed for about a month. Staff interviews confirmed the oversight, with the administrator unable to verify the last nail trimming. The facility's policy on ADLs was not followed, as the resident's grooming needs were neglected.
A resident with quadriplegia and other conditions was found to have an inaccessible call light, which was positioned behind the bed, making it difficult for the resident to request assistance. The facility's policy requires call lights to be within reach, but this was not adhered to, posing a risk for delayed care.
A resident experienced discomfort due to their room temperature being 88°F, exceeding the facility's acceptable range of 71-81°F. The resident, with multiple health conditions, reported the vent was not working, relying on an open screen door for air. The Maintenance Supervisor confirmed the high temperature and identified low freon in the air conditioning unit as the issue, admitting to only checking temperatures in the morning. The Director of Nursing noted this practice failed to capture temperature changes throughout the day, affecting resident comfort.
A resident dependent on staff for personal hygiene and diagnosed with muscle weakness, morbid obesity, and paraplegia fell and died due to the facility's failure to implement a comprehensive care plan. The care plan did not align with the resident's MDS, which required a two-person assist, and failed to specify the need to change the mattress setting to static mode during care. The CNA did not request assistance or adjust the mattress, leading to the resident's fall and subsequent death.
A resident with muscle weakness, morbid obesity, and paraplegia required two-person assistance for personal hygiene but was cared for by a single CNA, leading to a fatal fall. The resident's mattress was not set to static mode, contributing to the instability during care. Discrepancies in the care plan and failure to follow proper procedures resulted in the accident.
Two residents experienced a lack of a homelike environment due to peeling and cracked walls with plaster debris in their room. The facility had not completed repairs, affecting the residents' comfort. One resident, with dementia and impaired cognitive skills, and another, with COPD and intact cognitive skills, were involved. The issue was acknowledged by an LVN and the DON.
The facility failed to ensure proper use and functioning of a low air loss mattress (LALM) for a resident with a stage 3 sacral pressure ulcer. The LALM was found to be non-functional, and excessive layers of linen were used, contrary to guidelines. This compromised the pressure-relieving benefits of the LALM, increasing the risk of pressure ulcer development and delaying wound healing.
Nonfunctional Bathroom Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that bathroom call lights were functional in three residents’ rooms, as required by facility policy. For one resident with CHF, chronic kidney disease, muscle weakness, and lack of coordination, records showed intact cognition and a need for maximal assistance with lower body dressing, moderate assistance with toileting hygiene, and supervision with toilet transfers. During observation with a CNA in this resident’s room, pulling the bathroom call light cord did not activate the call light indicator outside the room. The CNA reported that the resident had complained the previous day that the bathroom call light was not working, and that when the CNA checked it then, the light indicator flashed but there was no audible sound; the CNA could not recall if she had reported this malfunction to other staff. A second resident, admitted with peripheral vascular disease, myalgia, and muscle spasms, had intact cognition and required supervision for toileting hygiene and lower body dressing, and was always continent of bowel. During observation in this resident’s room, when the CNA activated the bathroom call light, the call light indicator outside the room did not activate. The CNA stated that the call light indicator was not functioning and that the resident would not be able to call for assistance from the bathroom. A third resident, with diagnoses including heart failure, anxiety disorder, muscle weakness, and left hip pain, had intact cognition and required moderate assistance with toileting hygiene and toilet transfers, and was always continent of bowel and bladder. During observation with the Environmental Director in this resident’s room, pulling the bathroom call light cord did not activate the call light indicator outside the room. In an interview, the Environmental Director stated there was no documented evidence that the call light system, including bathroom switches, was assessed for functionality, and reported there was a loose connection in the system wiring that potentially caused the malfunctioning bathroom call lights. The Environmental Director and the DON both stated that all resident rooms should have functioning call light systems and that failure to have functional bathroom call lights could potentially delay care and increase fall risk. Review of the facility’s policy on call lights indicated that the call system must be accessible at each toilet and bath or shower facility and that staff will report problems with call lights or the call system to the supervisor and/or maintenance director.
Failure to Care Plan for New Dialysis Port Catheter
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables to address a resident’s left upper chest port catheter used for renal dialysis. The resident was originally admitted with diagnoses including dementia, dependence on renal dialysis, and stage four chronic kidney disease, and was later readmitted after a hospitalization during which the dialysis access was changed from an arteriovenous fistula to a left upper chest port catheter. The resident’s history and physical documented fluctuating capacity to understand and make decisions, and the Minimum Data Set showed severely impaired cognitive functioning and dependence on staff for eating, oral care, toileting hygiene, showers, personal hygiene, and dressing. During concurrent interview and record review, RN 1 confirmed that the resident’s care plan did not include any plan for care and monitoring of the left upper chest port catheter and had not been updated upon readmission to reflect the new dialysis access site. RN 1 stated that the care plan should have been updated to address the accurate dialysis access site to provide proper monitoring. The DON also stated that the care plan should have been developed upon admission to address the new renal dialysis access site and how to manage and care for it, and acknowledged that the resident’s care plan was not person-centered and complete because it lacked a plan for the dialysis access site. The facility’s policy on Comprehensive Care Plans required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs, including services to attain or maintain the resident’s highest practicable well-being.
Failure to Maintain E-Kits and Proper Medication Disposal Procedures
Penalty
Summary
Surveyors identified a failure to maintain pharmaceutical services and emergency medication kits in accordance with facility policy and pharmacy agreements. At nurse station 2, an IM emergency kit contained a vial of bacteriostatic water 30 ml in slot 20 that had expired on 11/1/2025 and remained in the kit for 75 days past expiration. RN 1, who opened the locked medication room, acknowledged she had not checked the e-kit and stated expired medications could be contaminated and lose effectiveness. Across nurse stations 1, 2, and 3, RN 1 was unable to locate any e-kit logs, and LVN 1 stated there were no e-kit logs in the facility and that he did not consistently perform visual checks on the e-kits at nurse stations 2 and 3. The facility did not provide documentation that the 15 e-kits in the facility were checked every shift as required by the DON’s stated process. The survey also found failures in the disposition and documentation of resident medications. Resident 4 was admitted with diagnoses including nontraumatic intracerebral hemorrhage, cerebral edema, and atelectasis, and expired on 7/28/2025. On 1/14/2026, RN 1 located a white paper bag containing Resident 4’s medications on the top shelf of a cabinet in the locked medication room at nurse station 2. RN 1 stated that medications for discharged residents should be disposed of and documented on the Medication Disposition Record and Pass Log, but she could not locate these logs for nurse station 2. The DON later stated that medications of discharged residents should be destroyed within 90 days of discharge, while Resident 4’s medications remained in the facility for 179 days after discharge. Record reviews of Medication Disposition Record and Pass Logs at nurse stations 1 and 3 revealed additional deficiencies in medication destruction practices. At nurse station 3, the log dated 10/13/2025 showed two medications documented as disposed of in waste management without a second licensed nurse’s signature as witness, contrary to facility policy requiring two licensed nurses to witness destruction of non-controlled medications. At nurse station 1, the log dated 10/19/2025 showed five medications documented as disposed of in a trash bin, which the DON stated was not an approved method of medication disposition, and these entries also lacked a second nurse’s witness signature. The DON confirmed that the facility failed to follow its process for proper medication disposal and that e-kits were expected to be checked every shift to ensure emergency medications were not expired and kits were intact.
Failure to Provide Post-Fall Assessment, Splint Care Orders, and Therapy Coordination
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who was admitted with multiple diagnoses, including muscle weakness, polyneuropathy, and fractures of the right lower leg and right hand. The resident, who was cognitively intact and able to communicate needs, experienced a fall in the bathroom after being startled by cockroaches. Following the fall, facility staff did not initiate a Change of Condition (COC) form, notify the physician, or complete a post-fall assessment as required by facility policy. There was no documentation of a comprehensive assessment, physician notification, or monitoring for post-fall complications, despite staff interviews confirming these actions should have occurred. Additionally, the facility did not obtain physician orders for the care of the resident's right wrist and distal forearm splint, which had been applied during a prior hospital stay. The absence of such orders meant that staff lacked guidance on proper splint management, as confirmed by both the Assistant Director of Rehabilitation and the Director of Nursing. Facility policy required that care for prosthetic and orthotic devices be consistent with professional standards and individualized care plans, but there was no evidence that these standards were met for the resident's splint. The facility also failed to coordinate and schedule occupational and physical therapy sessions around the resident's outpatient medical appointments. As a result, the resident missed therapy sessions on days when she was out of the facility for medical appointments, and there was no documentation of attempts to reschedule or provide therapy at alternative times. The lack of coordination was acknowledged by both the rehabilitation staff and the Director of Nursing, who noted that therapy staff should have communicated with the resident and made multiple attempts to ensure therapy was provided.
Failure to Investigate and Address Resident Grievance Regarding Pest Infestation
Penalty
Summary
The facility failed to promptly address and investigate grievances reported by a resident who was admitted with multiple diagnoses, including muscle weakness, polyneuropathy, and fractures. The resident, who was cognitively intact and able to communicate clearly, reported seeing cockroaches in her bathroom on several occasions shortly after admission. Despite making multiple complaints to facility staff, her concerns were not addressed, and no grievance form was initiated as required by facility policy. Interviews with staff, including a registered nurse, the Social Services Director, and the Director of Nursing, confirmed that the resident's complaints were not documented or investigated according to the facility's grievance procedures. The facility's grievance log did not show any record of the resident's concern, and staff acknowledged that the grievance process should have been initiated to ensure the resident's concerns were properly addressed. The failure to follow the established grievance policy resulted in the resident's right to voice grievances without discrimination or reprisal not being honored.
Failure to Provide Required Discharge Planning and Notification
Penalty
Summary
The facility failed to follow its own Discharge Planning Process policy for a resident by not initiating a discharge care plan upon admission, not providing a completed Discharge Transition Plan prior to discharge, and not giving the required Notice of Transfer or Discharge form to the resident before discharge. The resident was admitted with multiple diagnoses, including muscle weakness, polyneuropathy, and fractures, and was assessed as having intact cognitive function and the ability to make decisions. Despite this, the care plan did not include a discharge plan from the time of admission, and the Discharge Plan Documentation form was not completed before the resident left the facility. Interviews and record reviews revealed that the resident was approached by a nurse with a blank Notice of Transfer or Discharge form and requested to sign it. The resident declined to sign until she could review the completed form, but the nurse did not return with it. After discharge, the resident found a signed Notice of Transfer or Discharge form in her packet, but stated she did not sign it and was not given the opportunity to review or discuss its contents. The DON confirmed that the signature on the form did not match the resident's known signature and appeared to have been signed by facility staff without proper notation or explanation. Facility policy required that discharge planning begin upon admission and that residents be provided with a Discharge Transition Plan and Notice of Transfer or Discharge, including information about their rights and the reason for discharge. The DON acknowledged that these steps were not followed, and that documentation practices did not meet the facility's standards for accuracy and transparency. The failure to provide the required documentation and notification meant the resident was not properly informed of her discharge or her rights.
Failure to Develop and Implement Complete Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that included measurable objectives and timetables to meet all of a resident's needs. Specifically, upon admission, the care plan did not address discharge planning for a resident who had multiple diagnoses, including muscle weakness, polyneuropathy, unspecified fractures of the right lower leg and right hand, and was using a right wrist and distal forearm splint. The resident was cognitively intact, able to communicate needs, and required supervision for some activities of daily living, but was otherwise independent with personal hygiene and used a crutch for mobility. Record reviews and staff interviews revealed that the care plan initiated at admission focused on fall risk and recent surgical interventions but omitted both discharge planning and interventions related to the resident's right wrist splint. The Director of Nursing (DON) confirmed that discharge planning was not initiated as required by facility policy, which mandates that discharge planning begin upon admission and be incorporated into the person-centered care plan process. The DON acknowledged that this omission could result in the resident's discharge goals not being identified or met. Additionally, the care plan did not address the presence of the right wrist and distal forearm splint, despite documentation in hospital and occupational therapy records. Staff interviews confirmed that the care plan should have included interventions for the splint to guide staff in supporting the resident's healing process and preventing complications. Facility policy requires that care plans address all identified needs with measurable objectives and timeframes, but this was not followed in the resident's case.
Failure to Maintain Accurate Medical Records and Proper Discharge Documentation
Penalty
Summary
Facility staff failed to maintain accurate and complete medical records for a resident, specifically regarding the Notice of Transfer or Discharge form. The resident, who was cognitively intact and able to make decisions, reported that a registered nurse (RN) initially presented a blank discharge notice for signature, which the resident declined to sign until she could review the completed form. The RN left with the form and did not return, and the resident later discovered a signed discharge notice in her discharge packet after leaving the facility. The resident stated she did not sign the form and was not given the opportunity to review or discuss its contents prior to discharge. The Director of Nursing (DON) confirmed that the signature on the discharge notice did not match the resident's known signature and appeared to have been signed by facility staff without any notation indicating it was not the resident's signature or that verbal consent was obtained. Additionally, there were inconsistencies in the resident's fall risk documentation. The initial fall risk assessment, completed by a registered nurse upon admission, was not dated, and there was conflicting information between the fall risk assessment and the nursing documentation regarding whether the resident had experienced a fall in the months prior to admission. The DON acknowledged the discrepancy and noted that accurate and complete documentation is necessary for proper care planning, particularly for fall prevention interventions. Facility policies reviewed indicated that nursing documentation should be clear, accurate, and reflective of the care provided, and that falsification or improper correction of records is not permitted. The policies also required that documentation be complete, relevant, and signed by the person making the entry, with the date and time recorded. The failure to follow these standards resulted in incomplete and inaccurate records for the resident, including a falsified discharge notice and contradictory fall risk information.
Failure to Administer Physician-Ordered Calcium Carbonate Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that two residents received their prescribed calcium carbonate oral tablets as ordered by their physicians. For both residents, physician orders specified daily or twice-daily administration of calcium carbonate for conditions such as osteoporosis and supplementation. However, medication administration records and interviews revealed that the medication was not available in the medication cart on multiple occasions, resulting in missed doses over the course of a week for each resident. For the first resident, who had diagnoses including chronic kidney disease, type 2 diabetes mellitus, and muscle weakness, the calcium carbonate was not administered on several specified dates. Although the attending physician was reportedly notified and ordered the medication to be held until available, there was no documented evidence of this notification or order in the resident's records. The facility's own policy required medications to be administered as ordered and for any administration to be documented immediately on the medication administration record (MAR), but this was not followed. Similarly, the second resident, with diagnoses including acute kidney failure, type 2 diabetes mellitus, and gastro-esophageal reflux disease, did not receive the ordered calcium carbonate on multiple dates due to unavailability. Again, there was no documented evidence that the physician was notified or that an order to hold the medication was obtained. The facility's policy and procedure for medication administration, which mandates adherence to physician orders and proper documentation, was not followed in these instances.
Failure to Update Care Plan After Resident Refusal of Blood Draw
Penalty
Summary
A deficiency occurred when the facility failed to develop and update a comprehensive, person-centered care plan for a resident who refused a blood draw for a complete blood count (CBC) test. The resident, admitted with diagnoses including metabolic encephalopathy, altered mental status, type 2 diabetes mellitus, and essential hypertension, was noted to be moderately impaired in thought process and required substantial assistance with activities of daily living. The resident experienced episodes of blood in the stool, prompting orders for STAT laboratory tests, including a CBC and occult blood test. Despite the physician and nurse practitioner being notified and orders being placed, the resident refused the CBC blood draw. Multiple staff members, including RNs and laboratory staff, attempted to encourage the resident to comply, but the refusal persisted. Documentation of the refusal, the attempts to obtain the sample, and communication with the medical team were either incomplete or missing. Staff interviews revealed that required steps per facility policy—such as offering the procedure three times, explaining risks and benefits, notifying the physician, and documenting all actions—were not fully carried out or recorded in the resident's medical record. Further review confirmed that no care plan was developed to address the resident's refusal of the CBC blood draw. Both nursing staff and the Director of Nursing acknowledged that a care plan should have been created to identify interventions for the refusal and to monitor the resident's condition. The facility's policy required a baseline care plan for each resident, but this was not implemented in this case.
Failure to Ensure Proper Communication and Transport for Dialysis Care
Penalty
Summary
Licensed nurses failed to follow professional standards of practice for a resident requiring dialysis by not ensuring accurate communication with transport services regarding the correct dialysis center. On one occasion, the resident was transported to the wrong dialysis center, resulting in a delayed start to the dialysis treatment and a reduction in treatment time from three hours to two hours. The facility's records indicated that the resident had a scheduled dialysis regimen, and the error in transportation led to a shortened session. Additionally, there was a lack of communication among licensed nurses about the resident's late transport and decreased dialysis treatment duration. The attending physician was not notified of the shortened dialysis session. Interviews with staff confirmed that key personnel, including the Assistant Director of Nursing, were not informed about the incident or the resident's altered treatment. The facility's policies required the use of at least two patient identifiers and ongoing communication with the dialysis center, but these procedures were not followed in this case.
Unattended Insulin Syringes and Medications Left in Resident Room
Penalty
Summary
Facility staff failed to ensure that medications, specifically insulin syringes and solutions, were not left unattended in a resident's room. On multiple occasions, nursing staff placed insulin syringes and medications on the resident's bed and wheelchair and then left the room, leaving the medications unattended. This was observed both during a surveyor's visit and confirmed through staff interviews. The unattended medications included Novolog and Novolin R insulin solutions, which were prepared for a resident with type 2 diabetes mellitus, chronic kidney disease, and major depressive disorder. The resident was assessed as having intact cognitive skills and the capacity to make decisions. The facility's own policies required that medications be administered at the time they are prepared and not left unattended unless specifically authorized for bedside storage. Despite this, staff admitted to leaving insulin syringes and medications unattended, and one incident resulted in a certified nursing assistant being accidentally poked by a syringe left on the resident's wheelchair. Staff interviews confirmed awareness that medications should not be left unattended, and the facility's policies were not followed in these instances.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain or enhance residents' dignity and individuality by serving meals to 151 out of 158 sampled residents in plastic containers with plastic utensils. Multiple residents reported that the food was cold, unappetizing, and difficult to eat from the plastic containers. Residents expressed frustration and dissatisfaction, stating that their concerns were not addressed by the dietary supervisor or administration. Observations confirmed that food temperatures were significantly lower when served to residents compared to the temperatures recorded at the service line, and staff acknowledged that the plastic containers did not retain heat effectively. Interviews with residents and staff revealed ongoing complaints about the quality and presentation of meals, with residents stating that the use of disposable containers was not appropriate for their home environment. The facility's use of disposable containers was attributed to a non-functioning elevator, requiring staff to pass trays via stairs. Despite this, the facility's own policy emphasized the importance of treating residents with respect and dignity and providing a homelike environment, which was not upheld in this situation.
Failure to Serve Food at Safe and Appetizing Temperatures Due to Elevator Outage
Penalty
Summary
The facility failed to prepare and serve food in a manner that conserved temperature, flavor, and appearance, resulting in residents receiving meals that were not palatable, attractive, or at a safe and appetizing temperature. Due to an inoperable elevator, staff distributed food using stairs and served meals in plastic containers, which did not retain heat effectively. Multiple residents reported that their food and beverages, such as coffee, were cold and unappetizing, and staff interviews confirmed that the use of disposable containers contributed to the food being barely warm and not presentable. The Dietary Supervisor acknowledged that the use of plastic containers was only intended for emergencies and that it negatively impacted the dining experience. The deficiency affected a large number of residents, including those on regular, therapeutic, and puree diets. Residents with medical conditions such as hypertension and diabetes expressed dissatisfaction with the food temperature and presentation. Staff interviews and record reviews revealed that the elevator repair was delayed due to payment disputes with the elevator company, resulting in prolonged use of stairs and disposable containers for meal delivery. Facility policy required food to be prepared in accordance with the FDA Food Code, but observations and interviews indicated that this standard was not met during the period in question.
Multiple Infection Control Breaches Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices. Certified Nursing Assistant (CNA) 1 was seen drinking from a personal cup in the hallway and storing it inside a clean linen cart, despite acknowledging that this practice was not permitted due to contamination risks. CNA 1 continued to store the cup in the dirty linen cart after being observed. Additionally, CNA 2 was observed returning clean linen from a resident's bed to a clean linen cart, believing it was acceptable because the linen was in a plastic bag, but later confirmed with the Infection Preventionist that this practice was not allowed due to cross-contamination concerns. Enhanced Barrier Precautions (EBP) were not implemented as required for a resident with wound care needs. CNA 7 was observed not wearing a gown while providing care and changing bed sheets for a resident on EBP, despite being aware that a gown should be worn to prevent the spread of bacteria. Furthermore, staff failed to wear appropriate Personal Protective Equipment (PPE) when entering a contact isolation room, and gloves were worn in the hallway, contrary to facility policy and infection control standards. Additional deficiencies included the failure to date a nasal cannula and humidifier for a resident, with the nasal cannula found on the floor and both items undated. The Registered Nurse (RN) acknowledged that these items must be dated to track when they were last changed to prevent infection. Facility policies reviewed confirmed the requirements for proper linen handling, PPE use, and equipment dating, all of which were not followed as observed during the survey.
Failure to Honor Dietary Preferences for a Resident
Penalty
Summary
A deficiency occurred when a resident with a physician's order specifying a renal diet with no onions was served a meal containing onions. The resident's admission record indicated a diagnosis of hypertension, and the Minimum Data Set showed intact cognition and a need for assistance during eating. Despite clear documentation in the physician's order and on the meal ticket that onions were not to be included, the resident's meal tray was observed to contain salisbury steak with brown gravy and slices of onions. During the observation, the Infection Preventionist Nurse confirmed that the meal ticket indicated no onions and acknowledged that the resident should not have received onions, as the resident did not like them and would likely not eat the meal. The DON also reviewed the physician's order and stated the importance of not serving onions to the resident. The facility's policy required that residents be offered food options that meet their nutritional needs and preferences, but this was not followed in this instance.
Unlicensed Medication Administration by CNA
Penalty
Summary
The facility failed to ensure that medication was administered by licensed staff, resulting in a deficiency related to medication administration for a resident. The incident involved a resident who was admitted with diagnoses including acute hematogenous osteomyelitis, unspecified peripheral vascular disease, and generalized muscle weakness. The resident was cognitively intact and required moderate assistance for daily activities. A physician's order prescribed nystatin powder to be applied topically to the resident's abdominal area. A Certified Nursing Assistant (CNA) was instructed by a Licensed Vocational Nurse (LVN) to administer the nystatin powder to the resident, despite the CNA not being trained or licensed to administer medication. The CNA followed the instruction and applied the medication, acknowledging that she was not aware of the medication's effects or side effects. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that medication administration is outside the scope of practice for CNAs and that they are not competent or trained for such tasks. The facility's policies and procedures clearly state that medications should only be administered by licensed personnel who are legally authorized to do so. The CNA's job description did not include medication administration, and the facility's policy on staffing emphasized the need for nursing staff to have the appropriate skills and competencies. The failure to adhere to these guidelines resulted in a potential medication error, highlighting a deficiency in ensuring that only licensed staff administer medications.
Unlicensed Medication Administration by CNA
Penalty
Summary
The facility failed to provide pharmaceutical services by not ensuring that a licensed staff member administered medication to a resident. This deficiency was identified during a review of the records and interviews with staff members. The incident involved a resident who was admitted with diagnoses including acute hematogenous osteomyelitis, unspecified peripheral vascular disease, and generalized muscle weakness. The resident was cognitively intact and required moderate assistance for daily activities. The deficiency occurred when a Certified Nursing Assistant (CNA) was instructed by a Licensed Vocational Nurse (LVN) to administer nystatin powder, a medication for fungal infections, to the resident's lower abdomen. The CNA, who was not trained or licensed to administer medication, followed the instruction and applied the medication. During interviews, the CNA acknowledged the mistake, stating that she was not aware of the medication's effects or side effects and should not have followed the LVN's instructions. Further interviews with the facility's Assistant Director of Nursing, Director of Staff Development, and Director of Nursing confirmed that medication administration is not within a CNA's scope of practice. The facility's policies and procedures also indicated that only licensed personnel are authorized to administer medications. The CNA's job description did not include medication administration, highlighting a clear breach of protocol and competency requirements.
Inaccurate Documentation of Physician Notification
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, leading to potential confusion in care. The resident was admitted with diagnoses including acute hematogenous osteomyelitis, unspecified peripheral vascular disease, and generalized muscle weakness. A review of the resident's medical records revealed discrepancies in the documentation of physician notification times. Specifically, the SBAR communication form indicated that the physician was notified at 12 a.m., which was inconsistent with the actual time of notification as stated by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The DON acknowledged that the documentation was inaccurate and explained that if staff did not manually enter the time of notification, the system defaulted to 12 a.m. This oversight occurred because staff failed to manually document the time they notified the physician, resulting in inaccurate records. The facility's policy on nursing documentation emphasized the importance of timely and accurate documentation, which was not adhered to in this instance.
Infection Control Breach Due to Non-Adherence to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA 1) who did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident diagnosed with multi-drug-resistant organisms (MDROs). During an observation, CNA 1 was seen not wearing a gown while replacing the resident's blanket, despite the resident being on EBP. Additionally, CNA 1 did not perform hand hygiene after removing gloves and before handling clean linen, which is a critical step in preventing the spread of infections. The resident involved had a history of gallstones with acute cholecystitis and was readmitted to the facility with a requirement for EBP due to MDROs. The facility's policies on hand hygiene and EBP, which were last reviewed in January 2025, clearly state the necessity of wearing gowns during direct patient care for residents on EBP and performing hand hygiene before and after glove use. The Director of Nursing confirmed the importance of these practices to prevent infection spread, highlighting the deficiency in the facility's adherence to its own infection control protocols.
Failure to Obtain Proper Authorization for Bed Placement Against Wall
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, specifically regarding the placement of beds against walls without proper authorization and assessment. This deficiency was identified for six residents, where the facility did not obtain a physician's order, informed consent, or conduct a restraint assessment for the use of bed placement against the wall. The absence of these critical steps potentially restricted residents' freedom of movement and posed risks such as entrapment and physical harm. For Resident 137, the facility's records showed no physician's order, informed consent, or restraint assessment for the bed placement against the wall, despite the resident's inability to make decisions. Observations confirmed the bed was placed against the wall, creating a potential risk for entrapment. Interviews with staff, including an LVN and RN, confirmed that placing the bed against the wall was considered a restraint and required proper documentation and assessment to ensure safety. Similar deficiencies were noted for Residents 61, 131, 123, 132, and 42. Each resident's bed was placed against the wall without the necessary physician's order, informed consent, or restraint assessment. Staff interviews consistently indicated that the bed placement was intended to prevent falls but acknowledged it restricted residents' movement and required proper authorization and assessment. The facility's policy on restraints emphasized the need for evaluation and consent before applying any restraint, which was not adhered to in these cases.
Failure to Rotate Injection Sites for Insulin and Heparin
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards of care by not rotating the subcutaneous administration sites for insulin and heparin for four residents. This failure was identified during interviews and record reviews, which revealed that the same injection sites were repeatedly used for administering these medications. The facility's policy and procedure for insulin administration, as well as the manufacturer's guidelines for both insulin and heparin, clearly state the necessity of rotating injection sites to prevent adverse effects such as lipodystrophy, bruising, and localized cutaneous amyloidosis. Resident 29, who was admitted with diagnoses including type 2 diabetes mellitus, acute kidney failure, and acute osteomyelitis, was found to have insulin and heparin administered repeatedly in the same areas. The resident's care plan indicated the use of hypoglycemic and anticoagulant medications, but the administration records showed a lack of site rotation. Interviews with the RN and DON confirmed the oversight and acknowledged the potential risks associated with not rotating injection sites. Similarly, Residents 42, 402, and 134, all with diagnoses of diabetes and receiving insulin, experienced the same deficiency. Their medication administration records indicated repeated use of the same injection sites, contrary to the facility's policies and the manufacturer's guidelines. Interviews with nursing staff and the DON reiterated the importance of site rotation to prevent complications, yet the records showed consistent non-compliance with this standard practice.
Deficiencies in Resident Safety and Medication Management
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents. For one resident, medications including triamcinolone acetonide cream, travatan, bisacodyl, bromonidine tartrate, and dorzolamide HCl timolol maleate were found at the bedside without any orders or self-administration assessment. This posed a risk of overdose or access by other residents, as confirmed by the CNA and RN involved. The facility's policy requires that medications not authorized for bedside storage be reported and removed, which was not adhered to in this case. Another deficiency involved the improper use of fall mats for two residents. In one instance, a side table was placed on top of a fall mat, which could cause injury if the resident fell onto it. The LVN and DON confirmed that fall mats should be free of obstructions to prevent injury. Similarly, another resident's overbed table was placed on a floor mat, making it unstable and posing a fall risk. The facility's policy and the manufacturer's guidelines for floor mats were not followed, as they require the mats to be free of objects to reduce fall impact. Additionally, a resident was found standing over a wet floor due to a urine spill, increasing the risk of slipping and falling. The CNA and RN acknowledged that the floor should be dry and clutter-free to prevent falls. Furthermore, smoking materials were improperly stored at a resident's bedside, contrary to the facility's policy that requires such materials to be stored securely by staff. The DON confirmed that smoking materials should not be kept at the bedside to prevent fire hazards and accidental harm to other residents.
Failure in Controlled Substances Accountability
Penalty
Summary
The facility failed to ensure proper accountability and control of Controlled Substances (CS) by not including verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) on the Antibiotic or Controlled Drug Record accountability logs. This deficiency was identified during an interview and record review conducted in the DON's office, where two accountability logs for CSs awaiting disposal lacked the necessary signatures. The DON acknowledged the absence of signatures and admitted to not consistently signing and dating the logs upon receipt of the CSs from Licensed Vocational Nurses (LVNs), despite understanding the importance of CS accountability. The facility's policy and procedures, last reviewed on December 4, 2024, require compliance with all laws and regulations related to the handling, storage, disposal, and documentation of Controlled Medications (CM). The policy specifies that the nurse administering the medication is responsible for recording details such as the name, strength, dose, time, method of administration, quantity remaining, and their signature. The failure to adhere to these procedures increased the risk of CS diversion and accidental exposure to harmful medications for all residents in the facility.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 14.81% due to four medication errors out of 27 opportunities. These errors affected two residents, identified as Resident 71 and Resident 88, during medication administration observations. The errors involved incorrect administration of medications, which were not in accordance with the physician's orders. Resident 71, who was admitted with diagnoses including difficulty in walking, reduced mobility, and gastrointestinal issues, did not receive the prescribed psyllium husk powder and was given an incorrect dose of oyster shell calcium without vitamin D. The Licensed Vocational Nurse (LVN) responsible for administering the medication acknowledged the error, noting the potential harm from not receiving vitamin D and psyllium husk powder as prescribed. Resident 88, admitted with a fracture of the left femur and iron deficiency, received a multivitamin with minerals and an incorrect dose of calcium with vitamin D, contrary to the physician's orders. The LVN admitted to administering the wrong medications and failing to clarify the unclear order for calcium with vitamin D. The Director of Nursing confirmed these errors and emphasized the importance of following physician orders and facility guidelines for medication administration.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances of improper medication administration and management. Specifically, the facility did not rotate subcutaneous injection sites for insulin and heparin for several residents, including Residents 29, 42, 134, and 402. This failure to rotate injection sites could lead to complications such as lipodystrophy and bruising. The report details that insulin and heparin were repeatedly administered in the same areas, contrary to standard medical practices and the facility's policies. Additionally, the facility administered expired insulin to Residents 63, 71, and 141. The expired insulin was given over several days by different licensed nursing staff, despite the manufacturer's guidelines and facility policies that require expired medications to be removed and replaced. The report highlights that the expired insulin was stored improperly and administered, which could compromise the medication's effectiveness and potentially harm the residents. Furthermore, the facility failed to administer Tacrolimus Oral capsules to Resident 495 at the scheduled times, which is critical for preventing kidney transplant rejection. The medication was consistently given outside the prescribed time window, and the resident had to remind staff to administer it. This deviation from the prescribed schedule could lead to serious health complications for the resident. The report indicates that these practices were not in accordance with the facility's policies and procedures, leading to significant medication errors.
Expired Medications Not Properly Managed
Penalty
Summary
The facility failed to properly manage and discard expired medications, specifically insulin and Aplisol, as well as an emergency medication kit. During an observation, it was found that two open Lantus Solostar insulin pens for two residents were stored at room temperature beyond the manufacturer's recommended 28-day period. Additionally, an open Humulin 70/30 Kwikpen for another resident was also stored at room temperature beyond the recommended 10-day period. These expired medications were not removed from the medication cart, leading to their administration to residents beyond their effective dates. In the medication room, an open Aplisol vial was found stored in the refrigerator beyond the manufacturer's recommended 30-day period. Furthermore, an unopened emergency medication kit was found to be expired. The facility's policies and procedures require that expired medications be removed from use and stored separately for disposal, which was not adhered to in these instances. The Director of Nursing acknowledged the oversight and the potential harm that could result from administering expired medications. The Licensed Vocational Nurse (LVN) involved confirmed that several doses of expired insulin were administered to residents, which could lead to ineffective blood sugar control and potential health complications. The facility's failure to adhere to its own policies and procedures regarding medication storage and expiration checks contributed to these deficiencies, posing a risk to resident safety and well-being.
Improper Garbage Disposal in Facility Parking Lot
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during multiple inspections of the facility's parking lot. On several occasions, the lids of the black dumpster bins were left open with bags of garbage stacked over the openings, preventing the lids from closing completely. This was observed on two consecutive days, indicating a consistent issue with waste management practices at the facility. Interviews with the Housekeeping Supervisor, Maintenance Supervisor, and Director of Nursing confirmed that the dumpsters should be kept closed to prevent attracting pests and spreading infection. The facility's policy and procedure on waste management, last reviewed in December 2024, also indicated that all waste should be disposed of according to state and federal regulations, which includes keeping the dumpsters closed. The failure to adhere to these practices posed a potential risk to the health and safety of all 138 residents in the facility.
Infection Control Deficiencies in Laundry and Resident Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents. Firstly, during a tour of the facility's laundry area, the Housekeeping Supervisor (HSKS) was observed placing two pillows from the ground onto clean linens. This action was acknowledged by the Laundry Attendant (LA) and the HSKS as inappropriate, as the pillows were considered dirty after touching the floor, potentially contaminating the clean blanket they were placed on. The Director of Nursing (DON) confirmed that this practice could lead to cross-contamination and the spread of infectious agents. Secondly, the facility did not ensure that a resident's floor mat was maintained in a sanitary condition. Resident 402, who had been admitted with diagnoses including type 2 diabetes mellitus and required assistance with activities of daily living, had a floor mat next to their bed that was damaged, with the foam exposed. Both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) verified the damage and acknowledged that the exposed foam could absorb dirt and liquids, posing an infection control issue. The DON stated that damaged floor mats should be replaced to prevent such risks. The facility's policies and procedures for handling soiled and clean linens, as well as its Infection Prevention and Control Program, were reviewed. These documents outlined the importance of maintaining a safe and sanitary environment to prevent the spread of infections. However, the observed practices in the laundry area and the condition of the resident's floor mat indicated a failure to adhere to these policies, potentially compromising the health and safety of residents and staff.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence by not ensuring privacy for a confused resident who frequently removed her hospital gown. The resident, who was admitted with diagnoses including metabolic encephalopathy, dementia, and major depressive disorder, was observed lying undressed in bed, covered only by a thin white sheet, with the curtain open, making her visible to staff and visitors. Despite the resident's care plan specifying the need for privacy and comfort, staff did not consistently ensure the resident was dressed or that the curtains were drawn to maintain her dignity. Interviews with facility staff, including a Licensed Vocational Nurse, a Certified Nursing Assistant, a Registered Nurse, and the Director of Nursing, confirmed that the staff recognized the need to provide privacy and dignity to the resident, even though she was confused. The Director of Nursing acknowledged that leaving the curtains open and the resident undressed was a dignity issue and that the resident should not have been wearing a hospital gown in the facility as it did not promote a home-like environment. The facility's policy on resident rights emphasized the importance of safeguarding personal dignity and providing a homelike environment, which was not adhered to in this instance.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for a resident, identified as Resident 402, by not ensuring that the resident's floor mat was in good condition. The floor mat, which was intended to serve as a landing pad and fall precaution, had a tear on the top cover with the foam exposed. This issue was observed during a survey, and both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) confirmed the damage. The CNA and LVN stated that the maintenance department should have been notified to replace the damaged mat, as it compromised the safety and cleanliness of the resident's environment. Resident 402 was admitted to the facility with diagnoses including type 2 diabetes mellitus, abnormalities of gait and mobility, and generalized muscle weakness. The resident required substantial assistance with activities of daily living and had intact cognition, allowing them to understand and make decisions. The facility's policy emphasized the importance of maintaining a safe, clean, and homelike environment, which was not upheld in this instance, as the damaged floor mat posed a potential risk to the resident's well-being.
Inaccurate PASARR Coding for Resident with Mental Disorders
Penalty
Summary
The facility failed to accurately code the Preadmission Screening and Resident Review (PASARR) for a resident, identified as Resident 103, who was admitted with diagnoses including major depressive disorder, schizophrenia, and anxiety disorder. The PASARR, completed after admission, incorrectly indicated that the resident did not have a diagnosis of a mental disorder. This discrepancy was identified during a review of the resident's admission records and PASARR documentation. The Assistant Director of Nursing (ADON) confirmed that the PASARR Level 1 Screening was not completed accurately prior to the resident's admission, which could potentially result in the resident's medical and nursing care needs not being met. The facility's policy and procedure for PASARR completion, last reviewed shortly before the incident, stated that the Administrator would designate either the Admissions Director or social worker to ensure the PASARR is completed for all potential residents. The policy also required that if a referral indicated any mental illness or intellectual disability, the PASARR must be completed prior to admission. However, in this case, the PASARR was not accurately coded to reflect the resident's current medical condition, including their mental illness or mood disorder, as verified by the ADON during the interview and record review.
Failure to Include Oxygen Use in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan addressing the use of oxygen for a resident who was reviewed for respiratory care. The resident, who was originally admitted on 10/15/2024 and readmitted later, had diagnoses including chronic obstructive pulmonary disease (COPD), urinary tract infection, and generalized muscle weakness. Despite having a physician's order for continuous oxygen at 1-2 liters per minute via nasal cannula to maintain oxygen saturation at or above 90%, the baseline care plan dated 12/14/2024 did not include instructions for the use of oxygen. During an interview and record review, a registered nurse confirmed that the baseline care plan did not address the resident's oxygen use. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, including necessary healthcare information based on admission and physician orders. The absence of this information in the baseline care plan could lead to a delay in providing appropriate care and treatment specific to the resident's needs.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 137 and Resident 128, leading to deficiencies in care. For Resident 137, the facility did not implement the care plan for storing the resident's smoking materials, as observed when the resident's cigarettes and lighter were found on the nightstand instead of being stored by staff as per the care plan. Additionally, the facility did not develop a care plan for the placement of Resident 137's bed against the wall, which was considered a restraint. This lack of a care plan was noted during observations and interviews with staff, who confirmed that a physician's order, informed consent, and restraint assessment were necessary but not obtained. Resident 137 was admitted with diagnoses including altered mental status, generalized muscle weakness, lack of coordination, and unsteadiness on his feet. The resident required varying levels of assistance with daily activities and was sometimes able to make himself understood. Despite these needs, the facility did not ensure the safe storage of smoking materials or address the potential risks associated with the bed placement, which could limit the resident's movement and pose a safety hazard. For Resident 128, the facility failed to develop and implement a care plan for the use of ciprofloxacin, an antibiotic prescribed for an infection. The absence of a care plan meant that there were no documented interventions to monitor for side effects or the effectiveness of the antibiotic treatment. This oversight was confirmed during interviews with the Infection Preventionist and the Director of Nursing, who acknowledged the importance of having a care plan to guide the care of residents on antibiotics. Without such a plan, there was a potential risk of not identifying adverse effects or the need for a change in medication.
Inadequate Urinary Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a potential risk of urinary tract infections (UTIs). The resident, who was readmitted to the facility with a history of chronic obstructive pulmonary disease and UTIs, was observed with a urinary catheter that had a loop in the tubing while hanging on the side of the bed. This observation was confirmed by a registered nurse, who acknowledged that the catheter tubing should not have a loop, as it could impede urine flow and potentially lead to UTIs. Additionally, the catheter was not secured with a securement device, which is a standard practice to prevent accidental pulling or trauma. The Director of Nursing confirmed that the facility's policy requires the use of a catheter securement device and that the catheter tubing should be free from kinks or loops, with the drainage bag placed below the bladder and off the floor. The facility's policy and procedure document also emphasized these requirements. The failure to adhere to these standards placed the resident at risk for recurrent UTIs due to the improper positioning and lack of securement of the urinary catheter.
Deficiencies in Enteral Feeding Care
Penalty
Summary
The facility failed to ensure appropriate care and services for residents receiving enteral feeding, leading to potential complications. For Resident 52, the facility did not ensure that the enteral feeding formula bag indicated the correct administration rate as prescribed by the physician. The bag was labeled with an incorrect rate of 55 ml/hr instead of the prescribed 60 ml/hr, which could result in the resident not receiving the correct amount of nutrition. Additionally, the enteral feeding formula bag and water flush bag were primed and hung well before the start of infusion, which could lead to the formula expiring prematurely and causing gastrointestinal issues. Resident 52, who was admitted with diagnoses including anoxic brain damage and gastrostomy, had severely impaired cognition and required maximal assistance with daily activities. The facility's failure to adhere to the prescribed feeding schedule and administration rate placed the resident at risk for weight loss and malnutrition. The Director of Nursing confirmed that the bags should not be prepared more than four hours before use to prevent the formula from expiring early, which could lead to stomach pain and diarrhea. For Resident 104, the facility did not cover the feeding tube tip with a cap when it was disconnected, increasing the risk of gastrointestinal infection. Resident 104, who had diagnoses including sepsis and ileus, had impaired cognition and required enteral feeding. The feeding tube was observed hanging without a cap, contrary to the facility's policy, which mandates covering the tube tip to prevent infection. The Director of Nursing acknowledged that the feeding tube should be capped when disconnected to prevent exposure to harmful organisms.
Failure in Safe Administration of IV Fluids
Penalty
Summary
The facility failed to ensure the safe administration of parenteral fluids for a resident, identified as Resident 132, by not adhering to professional standards of practice. The resident was admitted with conditions including cellulitis, a cutaneous abscess, and acute embolism and thrombosis of deep veins. Despite these conditions, the facility did not clarify with the primary physician whether the peripheral intravenous catheter (PIVC) was still necessary, nor did they have a physician's order for its use in the facility. During an observation, it was noted that the PIVC dressing was not changed as required, and the injection port lacked a sanitizing cap, which is essential to prevent infection. The facility's staff, including a Licensed Vocational Nurse and a Registered Nurse, acknowledged these oversights, stating that the dressing change should occur weekly and that a sanitizing cap should be present. Additionally, there was no assessment of the PIVC site for signs of infiltration or infection, which is crucial for the resident's safety. Furthermore, the facility did not develop or implement a care plan for the PIVC, which is a critical component of ensuring safe treatment and preventing infection. The Director of Nursing confirmed these deficiencies, emphasizing the importance of having a physician's order, regular site assessments, and a comprehensive care plan. The facility's policies and procedures, which were reviewed, also highlighted the need for these practices, yet they were not followed in this case.
Failure to Assess RN Competency in Foley Catheter Care
Penalty
Summary
The facility failed to evaluate and assess a registered nurse (RN) for specific clinical competency and skills related to the care of residents with indwelling urinary catheters (foley catheters). This deficiency was identified during a review of the RN's employee file, which revealed no documented evidence of a completed clinical skills competency assessment for foley catheter care. The RN was newly hired and had been working at the facility for a few months without this critical assessment, which is necessary to ensure safe and effective care for residents with foley catheters. During interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), it was confirmed that the facility's policy requires a competency assessment for foley catheter care as part of the orientation for licensed nurses. However, the DSD was unsure if this assessment was mandatory, and the DON confirmed that the assessment was not completed for the RN in question. The facility's policy emphasizes the importance of providing nursing staff with the appropriate skills and competency necessary to care for residents, and the lack of this assessment could potentially lead to complications for residents with foley catheters.
Failure to Arrange Consistent Hospice Services
Penalty
Summary
The facility failed to consistently arrange for hospice services for a resident, identified as Resident 11, who was admitted with conditions including hemiplegia, hemiparesis, and cerebral infarction. The resident was under the care of Hospice Provider 1 (HP 1) for routine hospice services. However, the facility did not ensure that the hospice staff, including the registered nurse (RN), licensed vocational nurse (LVN), and hospice aide (HA), provided necessary nursing and visitation notes to the facility. Additionally, the calendar of visits from HP 1 was not consistently provided, which could have led to a delay or lack of necessary hospice care. The Social Services Director (SSD) confirmed that the RN and HA from HP 1 did not visit Resident 11 as scheduled on specific dates, and their notes were not included in the resident's clinical record. The SSD, who was responsible for coordinating with hospice providers, verified that the RN and HA visits were not documented as required, and the Medical Records Director (MRD) also confirmed that HP 1 did not provide or place progress notes in the hospice binder. The MRD mentioned that the notes could be scanned and uploaded to the electronic health record (EHR), but this was not done, leaving the staff unaware of the care provided to the resident. The Director of Nursing (DON) stated that the hospice providers should follow the scheduled visits and document any changes. The facility's policy and procedure required the administrator to ensure hospice services met professional standards and that communication between the facility and hospice provider was documented. The agreement with HP 1 specified that all required documentation should be submitted within five days of service, but this was not adhered to, resulting in a lack of documentation and potential delay in care for Resident 11.
Failure to Administer and Document COVID-19 Booster Vaccine
Penalty
Summary
The facility failed to ensure that the 2024/2025 COVID-19 booster vaccine was administered to Resident 77 and that the vaccination status was documented in the resident's clinical record. Resident 77, who was admitted to the facility with conditions including acute pyelonephritis, diabetes mellitus, and congestive heart failure, had consented to receive the COVID-19 vaccine. However, the consent form was incomplete and did not indicate the resident's COVID-19 vaccination history or eligibility for the booster. The Infection Preventionist (IP) was responsible for documenting the resident's vaccination status and ensuring the administration of the vaccine. Despite a visiting clinic being scheduled to administer the vaccine, there was no physician's order, and the vaccine was not documented as administered in the Medication Administration Record (MAR) or the Immunization Report. The IP did not follow up to clarify the resident's vaccine status or document whether the vaccine was received or refused. Interviews with the Administrator and Director of Nursing revealed that the facility's policy and procedures for vaccine administration were not followed. The IP did not ensure that Resident 77 received the vaccine or document the resident's status, despite the resident expressing a desire to receive the vaccine. The facility's policy required obtaining a physician's order, administering the vaccine, and documenting the vaccination status, which was not adhered to in this case.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident by incorrectly coding the Minimum Data Set (MDS) to indicate that the resident was discharged to a hospital instead of a skilled nursing facility (SNF). This error was identified during a review of the resident's records, which included an admission record, physician order, and social services progress note. The resident, who was admitted with diagnoses such as primary osteoarthritis of the right hip and idiopathic aseptic necrosis of the right femur, was actually transferred to SNF 1, as indicated by the physician order and social services note. However, the MDS inaccurately reflected a discharge to a hospital. The Minimum Data Set Coordinator (MDSC) acknowledged the coding error during an interview, stating that the MDS should accurately reflect the resident's discharge status as it is part of the medical record and is transmitted to the state. The Director of Nursing (DON) also confirmed that the MDS coding is crucial for billing purposes and ensuring proper discharge follow-up. The facility's failure to accurately code the MDS for the resident's discharge status was a deviation from the guidance provided in the CMS RAI Version 3.0 Manual, which specifies that the discharge status should document the actual location to which a resident is discharged.
Failure to Provide Dignity Bag for Resident's Urinary Drainage
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 3, was treated with dignity and care in a manner that promotes the maintenance or enhancement of their quality of life. Specifically, the facility did not provide a dignity bag for Resident 3's urinary drainage bag, which is used to collect urine from a urinary catheter. This oversight was observed during a visit, where a Certified Nursing Assistant (CNA) confirmed the absence of a dignity bag and acknowledged its importance in maintaining the resident's dignity. Resident 3 was admitted to the facility with diagnoses including quadriplegia, major depressive disorder, and muscle weakness. The resident's care plan, developed shortly after admission, included the provision of a privacy bag for the catheter. However, during an observation, it was noted that the dignity bag was not in use. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not adhered to in this instance, as confirmed by the facility's Administrator.
Failure to Maintain Resident's Grooming and Hygiene
Penalty
Summary
The facility failed to provide necessary grooming and personal hygiene services to a quadriplegic resident who was entirely dependent on staff for care. The resident, admitted with diagnoses including quadriplegia, major depressive disorder, and muscle weakness, had long and curving fingernails and toenails that needed trimming. Despite a physician's order for podiatry consults, the resident reported not having seen a podiatrist and had not had their nails trimmed for about a month. This oversight was confirmed during an observation and interview with a CNA, who noted the potential for the resident to harm themselves due to the long nails. Further interviews with the treatment nurse and the administrator revealed that the facility's staff, including CNAs and LVNs, were capable of performing nail trimming for non-diabetic residents. However, the resident's toenails were described as thick and requiring a podiatrist's attention. The administrator could not verify when the last nail trimming occurred, acknowledging that the nails were longer than recommended. The facility's policy on Activities of Daily Living emphasized the need for care to maintain or improve residents' ADL abilities, which was not adhered to in this case.
Inaccessible Call Light for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure that a call light was within reach for one of the sampled residents, identified as Resident 3. Resident 3 was admitted with diagnoses including quadriplegia, major depressive disorder, and muscle weakness, and was dependent on assistance for various activities of daily living. During an observation and interview, it was noted that the call light was positioned behind Resident 3's bed, making it inaccessible for the resident to call for assistance. Certified Nursing Assistant 1 confirmed that Resident 3 would not be able to reach the call light, which posed a risk for falls or the inability to get help when needed. Resident 3 expressed that although he could use the call light with his left hand, he faced difficulties when it was not within reach, necessitating him to ask for it. The facility's policy on call lights, last reviewed in February 2023, mandates that all patients should have a call light or alternative communication device within their reach at all times when unattended. The Administrator acknowledged the importance of having the call light within reach to ensure residents' needs are met promptly, recognizing the potential for delays in care due to this oversight.
Failure to Maintain Safe and Comfortable Room Temperature
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the room temperature being measured at 88 degrees Fahrenheit, which is above the acceptable range of 71 to 81 degrees Fahrenheit. The resident, who has been diagnosed with type 2 diabetes mellitus, obstructive sleep apnea, dysphagia, and muscle weakness, expressed discomfort due to the high temperature and stated that the vent in the room was not working. The resident relied on keeping the screen door open for air circulation, as closing it would make the room unbearably hot. The Maintenance Supervisor (MS) confirmed the high temperature reading and acknowledged that the air conditioning unit was low on freon, which was necessary for proper cooling. The MS admitted to only checking the temperature in the morning, which did not account for temperature changes throughout the day. The Director of Nursing (DON) also noted that monitoring temperatures only in the morning would not accurately reflect the conditions later in the day, potentially affecting residents' comfort. The facility's policy requires maintaining a temperature range of 71 to 81 degrees Fahrenheit to ensure a comfortable environment for residents.
Failure to Implement Comprehensive Care Plan Leads to Resident's Death
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was dependent on staff for personal hygiene and diagnosed with muscle weakness, morbid obesity, and paraplegia. The care plan did not align with the resident's Minimum Data Set (MDS), which indicated the need for staff assistance in personal hygiene, toileting hygiene, and rolling left and right. Additionally, the care plan failed to specify the need to change the resident's Med Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress setting from the physician's order to static mode during care. As a result of these deficiencies, the resident fell while a Certified Nursing Assistant (CNA) was providing care without assistance from another staff member. The resident sustained a laceration to the left eyebrow and was found with approximately 1 liter of blood next to her head. Despite emergency intervention, the resident was pronounced dead by paramedics at the facility. Interviews and record reviews revealed that the CNA did not request assistance from another staff member before performing care and did not change the pressure on the resident's low air loss mattress. The care plan inaccurately indicated a one-person assist, contrary to the MDS, which required a two-person assist. This discrepancy placed the resident at risk of improper care, contributing to the fatal incident.
Failure to Provide Adequate Assistance and Mattress Setting Leads to Resident's Fatal Fall
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for personal hygiene due to muscle weakness, morbid obesity, and paraplegia, was free from accidents. The resident required two-person assistance for care, but a Certified Nursing Assistant (CNA) provided care alone, without assistance from another staff member. During this care, the resident fell from the bed, which was elevated to a height of approximately three feet, resulting in a fatal injury. The resident was on a Med Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress, which was not set to static mode as required during care. The CNA did not request assistance to change the mattress setting, as she was instructed not to alter it. This failure to adjust the mattress setting contributed to the resident's fall, as the mattress continued to alternate pressure, making it unstable for care activities. Interviews with staff revealed discrepancies in the resident's care plan, which inaccurately indicated a one-person assist instead of the required two-person assist. The care plan did not align with the Minimum Data Set (MDS) assessment, which highlighted the resident's need for additional assistance. This misalignment in documentation and failure to adhere to proper care procedures directly led to the resident's accident and subsequent death.
Facility Fails to Maintain Homelike Environment Due to Wall Damage
Penalty
Summary
The facility failed to provide a homelike environment for two residents by not maintaining the walls in their room, which were observed to be peeling and cracked, with plaster debris on the floor. This deficiency was identified during an observation and interview with a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the potential impact on the residents' comfort and homelike feeling. Resident 1, admitted with dementia, unsteadiness on feet, and essential hypertension, had moderately impaired cognitive skills and lacked decision-making capacity. Resident 2, admitted with chronic obstructive pulmonary disease, unsteadiness on feet, and a pressure ulcer, had intact cognitive skills and was independent in using a manual wheelchair. Resident 2 expressed dissatisfaction with the unfinished wall repairs, indicating that the facility had previously started but not completed the work.
Failure to Ensure Proper Use and Functioning of Low Air Loss Mattress
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. Specifically, the facility did not ensure that the low air loss mattress (LALM) was turned on and functioning properly. During an observation, it was found that the LALM control unit was not powered on, and it required intervention from the housekeeping supervisor to restore power. This failure to maintain the LALM in working condition could have contributed to the development or worsening of pressure ulcers for the resident, who was already at risk due to their medical conditions, including diabetes mellitus and essential hypertension. Additionally, the facility did not adhere to the manufacturer's guidelines for the LALM by placing only one sheet of linen over the mattress top cover. Instead, there were six layers of linen, including a fitted sheet, a folded sheet, and a chux pad, between the resident and the LALM. This excessive layering was confirmed by a certified nursing assistant and was acknowledged as inappropriate by multiple staff members, including the Director of Staff Development and a licensed vocational nurse. The improper use of linens could have negated the pressure-relieving benefits of the LALM, thereby increasing the risk of pressure ulcer development and delaying wound healing. The resident involved had a stage 3 sacral pressure ulcer and required moderate assistance from staff for transfers. The resident was frequently incontinent of bladder functions and always incontinent of bowel functions, further increasing the risk of pressure ulcers. Despite the physician's order for the LALM to be checked every shift, the facility failed to ensure its proper functioning and appropriate use, leading to a deficiency in the standard of care provided to the resident.
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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