The Rehabilitation Center Of Bakersfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 2211 Mount Vernon Avenue, Bakersfield, California 93306
- CMS Provider Number
- 555256
- Inspections on file
- 86
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at The Rehabilitation Center Of Bakersfield during CMS and state inspections, most recent first.
A resident with hypertension and coronary artery disease, care planned for blood pressure monitoring and listed as DNR, did not have current vital signs documented for several days. On one shift, a CNA attempted four times to obtain the resident’s BP with an electronic vitals tower, received only error indications, did not use a manual BP cuff, and later informed an LVN that the readings could not be obtained. The LVN acknowledged plans to recheck the BP manually but did not assess the resident’s vital signs before going to lunch and did not report the equipment issue. Later that evening, the resident was found unresponsive in bed, and the DON, MD, and family were notified. The DON stated that per facility policy, unsuccessful CNA attempts should have been followed by a nurse assessment and use of a manual BP monitor when there is a change in condition.
A resident was served lunch with meat and green beans at 100°F, which did not meet the facility's required serving temperature of greater than 140°F for hot foods. The salad was also above the required cold holding temperature. The resident, who had moderate cognitive impairment, reported the food was not hot enough, and the facility's policy confirmed the temperature standards were not met.
Two residents reported receiving late meals that were not at safe or appetizing temperatures, with observations confirming that both hot and cold foods were served outside required temperature ranges. The dietary supervisor acknowledged ongoing complaints about late meal service, and a review of food temperature logs revealed numerous missing entries for required temperature checks before meal distribution.
A resident did not receive a lunch meal tray, while their roommate did. Despite all lunch trays being distributed and returned to the kitchen, none of the CNAs delivered a meal tray to the resident. The DON confirmed the resident should have received a meal. The facility's policy requires providing meals that meet nutritional standards.
The facility experienced a medication error rate of 12.82%, exceeding the acceptable threshold of 5%. Errors included administering incorrect medications, late administration, and incomplete medication delivery via G-tube. These issues were due to non-compliance with the facility's medication administration policies.
The facility failed to implement infection control practices, including the absence of Enhanced Barrier Precautions signage and PPE for a resident with a gastrostomy tube, a structural hole between clean and dirty utility rooms, and a janitorial cart without a lid on its trash bin. These issues were confirmed by staff and contradicted the facility's policies.
A resident reported missing personal belongings, including a gold box, which were not documented on her Inventory of Personal Effects (IPE). The facility failed to review and update the IPE during the resident's quarterly care plan conference, as required by their policy. This oversight hindered the verification and potential replacement of the missing items.
The facility did not notify the ombudsman of the transfers of two residents to the hospital, as required by their policy. During a survey, it was found that the MDSC and SSA could not provide documentation of such notifications, which are necessary to ensure residents have an advocate for their transfer and discharge rights.
A facility failed to document a verbal order for Glucagon in a resident's medical record, leading to an incomplete record. Additionally, an LVN administered an incorrect dose of a nutritional supplement to another resident, contrary to the prescribed dosage in the MAR.
A facility failed to follow a resident's RNA therapeutic program as per physician's orders, leading to inconsistent therapy sessions. The RNA was often reassigned, resulting in missed exercises, and failed to complete required weekly summaries to monitor the resident's progress. The facility's policy emphasized the need for documentation, which was not adhered to.
The facility failed to conduct an annual performance evaluation for a Supervisor Licensed (SL) employee, as required by its compliance policy. Despite being hired in December 2023, the SL's personnel file lacked any performance evaluation. The DON and DSD confirmed the necessity of annual evaluations, which are meant to ensure adherence to the facility's compliance program.
A facility failed to provide an adaptive call light for a resident with physical limitations, resulting in unmet needs. The resident, who had contractures in one hand and a limp arm, was unable to use the standard call light and resorted to whistling for assistance. A CNA confirmed the resident's inability to use the call light, and the DON acknowledged that the resident should have had an adaptive call light, as per facility policy.
A resident reported abuse allegations, but the facility failed to follow its grievance process. The resident was not informed of the investigation's outcome, and the grievance report was incomplete. The Administrator confirmed the oversight, which was against the facility's policy requiring a completed investigation report within five business days.
A facility did not follow its abuse investigation policy when a resident alleged physical abuse by a CNA. The DON, responsible for the investigation, failed to interview other residents cared for by the accused CNA, as required by the policy. The SSA and CM were not involved in the investigation, and the Administrator confirmed that the DON was solely responsible. The facility's policy mandates thorough investigations, including interviewing other residents.
The facility failed to involve a resident's conservator in the care conference and did not include individualized goals for another resident's restorative mobility in their care plan. The first resident, with severe cognitive impairment, had no documentation of conservator participation, while the second resident's care plan lacked interventions for upper extremity strengthening.
The facility failed to follow prescribed menus for two residents, resulting in smaller portion sizes than required. A resident on a large portion diet received fewer breakfast items than specified, and another resident on a renal diet received less corn than indicated. Staff interviews confirmed the discrepancies, and the facility's policy emphasized adherence to the written menu to meet nutritional needs.
The facility failed to document food temperatures for meals served, as confirmed by the Dietary Supervisor. This oversight was contrary to the facility's policy, which mandates recording temperatures to ensure food safety, potentially leading to foodborne illnesses.
A resident with cognitive impairments was subjected to disrespectful treatment by a CNA, who yelled at the resident and used dismissive language. The incident was witnessed by a marketer and confirmed through an investigation, revealing a failure to adhere to the facility's policy on treating residents with respect and dignity.
A resident with cognitive impairments reported missing money and giving money to a staff member for personal use. Despite multiple withdrawals from the resident's trust account, the facility delayed investigating the issue and failed to protect the resident from potential financial exploitation. The Activity Director denied taking money, but a written statement indicated a problem with their tire, which the resident mentioned as a reason for giving money.
A resident with dementia and bipolar disorder experienced multiple unwitnessed falls over five months due to the facility's failure to complete Post Fall Evaluations and update care plans as per their Fall Management Program. The resident sustained a femoral fracture requiring surgery after one fall. The Director of Nursing confirmed that care plans were not revised following specific incidents, contrary to facility policy.
A resident was found with discoloration and swelling on the right eye, but the injury was not reported or investigated by the facility staff. Interviews revealed that the injury was observed by a CNA and two LVNs, but not communicated to the DON or Administrator. The facility's policy requires prompt investigation of unexplained injuries, which was not followed in this case, leading to a deficiency.
A resident with severe cognitive impairments experienced a fall, but the facility did not follow its Fall Management Program. The necessary post-fall protocol, including neurological checks, fall risk assessment, and care plan updates, was not implemented. The facility's policy requires specific actions after a fall, which were not adhered to, resulting in a deficiency.
The facility failed to administer incentive spirometry (ISP) as ordered by the MD for three residents. Despite having intact cognition, two residents confirmed they had not used ISP since admission, and no ISP devices were observed in their areas. The DON confirmed that ISP was not administered to a third resident as well, despite orders. The facility's digital system auto-populated ISP orders for new admissions, but these were not executed, violating the facility's ISP policy.
A facility failed to accurately document ISP treatment for three residents, leading to falsified medical records. Despite MD orders for ISP every shift, the treatment was not provided, and MARs falsely indicated it was given. Interviews revealed ISP equipment was unavailable for months, yet documentation continued inaccurately. The DON confirmed the discrepancy and lack of policy availability.
A facility failed to follow its abuse prevention policy when a resident was not assessed for emotional distress after a family member confessed to financial abuse. Despite the resident's upset state, there was no documentation of assessment by licensed nurses or Social Services, as required by the care plan and facility policy.
A facility failed to complete an investigation of a financial abuse incident involving a resident within the required five working days. The resident's family member was suspected of taking money from the resident's account, which was confirmed through bank footage. The administrator did not follow up on the investigation timely, and the Social Services Director was unaware of the requirement to complete the five-day summary, resulting in a nine-day delay.
The facility failed to inform three residents about lab orders, compromising their dignity and privacy. A resident felt humiliated when CNAs entered her room without explanation to request a urine sample. Another resident, a dialysis patient, was asked for a urine sample despite not producing urine for years. CNAs were instructed by an LVN to collect samples but were not informed of the reasons. The facility's policy on resident rights was not followed.
The facility failed to consistently document and administer medications and treatments for three residents, as evidenced by multiple omissions in the Medication Administration Record (MAR). This included failures to change IV tubing, administer medications, flush PICC lines, and monitor for complications, potentially compromising treatment effectiveness.
A resident's urinary catheter collection bag was found on the floor, not in a dignity bag, contrary to the facility's policy and CDC guidelines. This failure in catheter care was confirmed by a CNA and could lead to catheter-associated UTIs.
The facility failed to verify the qualifications of the DON, as the application lacked education and employment history details. The background check was completed post-hire, violating the facility's policy. This oversight could compromise resident safety due to unverified qualifications.
The facility did not follow its 'Abuse-Prevention, Screening, & Training Program' policy by failing to complete the required two reference checks for a newly hired LVN. Only one reference check was conducted, despite the LVN having two previous employers and three personal references. This failure had the potential to expose residents to possible abuse.
A facility failed to follow its 'Abuse Reporting' policy when a CNA allegedly pulled a resident's pubic hairs. Although the CNA was suspended and an investigation began, the incident was not reported to the California Department of Public Health within the required timeframe. This delay in reporting was confirmed by the Regional Quality Assurances Consultant and had the potential to place all residents at risk.
A medication cart was found unlocked and unattended at a nurses' station, with a resident who had severely impaired cognition nearby. The facility's policy requires medications to be securely stored and accessible only to authorized personnel, which was not followed in this case.
A resident experienced delayed care and unnecessary nerve pain due to the facility's failure to administer medications as ordered and in a timely manner. The resident's morning medications, including those for neuropathy, were not given, and a pain-relief patch was repeatedly administered late. Interviews and record reviews confirmed these deficiencies, highlighting a significant oversight in medication management.
A facility failed to implement proper infection control practices, leading to a mix-up of Albuterol inhalers between two residents, one of whom was on COVID-19 isolation. The inhalers were not labeled correctly, resulting in cross-contamination. Additionally, a CNA did not follow hand hygiene protocols after handling items from an isolation room, increasing the risk of infection spread. These actions violated the facility's policies on medication administration and hand hygiene.
A resident with anxiety, depression, and PTSD did not receive her prescribed psychotropic medications upon admission to the facility. The facility's nursing staff failed to reconcile the resident's medication list from the acute hospital, resulting in the omission of Ecitalopram from her medication administration record. This oversight led to increased anxiety and difficulty coping with stressors for the resident.
A resident's mail was found in another resident's possession, leading to a potential privacy violation. The facility lacked a process to track mail delivery, and the mail was not held for the resident who was hospitalized. The facility's policy requires mail delivery within 24 hours.
A resident, who was legally blind and required assistance for eating and drinking, was found without fluids within reach, risking dehydration. A CNA confirmed the resident's water pitcher was out of reach, contrary to the facility's hydration policy, which mandates accessible fluids unless medically contraindicated.
A resident, who is legally blind and dependent on staff for daily activities, was found to have an inaccessible call light clipped against the wall and out of reach. The resident expressed difficulty in locating the call light, which is essential for requesting assistance. A CNA confirmed the issue, and the facility's policy requires call lights to be within reach, which was not adhered to in this case.
A resident at high risk for pressure injuries developed multiple injuries due to the facility's failure to implement a comprehensive care plan. The resident, with severe cognitive and physical impairments, was not repositioned regularly, and their nutritional needs were not adequately met, resulting in significant weight loss. The facility's policy on pressure injury prevention was not followed, leading to the development of deep tissue injuries and unstageable pressure injuries.
A resident in a LTC facility experienced a significant weight loss of 24.5 pounds over two months due to the facility's failure to provide prescribed nutrition. The resident, who was dependent on staff for eating and had severe cognitive impairment, did not receive meal trays consistently, as confirmed by a CNA and the DON. Despite having a care plan and recommendations for enteral feedings, the facility did not adequately monitor or document the resident's nutritional intake.
A facility failed to ensure a resident received prescribed nutrients, risking unmet care needs and weight loss. The resident was to receive a standard diet, pureed snacks, and G-tube feedings, but documentation for meals and snacks was missing. Facility policies required immediate documentation of food intake and medication administration, which was not followed, leading to the deficiency.
A facility failed to conduct quarterly fall risk evaluations for a resident with a history of seizures, leading to a potential risk of falls. The resident experienced a seizure and fell, resulting in a fractured midfoot. Despite the resident's condition, the facility did not complete the required evaluations, as confirmed by the DON.
A resident with a seizure disorder went out on pass unaccompanied and experienced a seizure and fall, resulting in a foot fracture. The facility failed to follow its policy requiring a physician's order specifying the duration and accompaniment for out on pass activities. Despite the resident's history of seizures during passes, the necessary details were missing from the physician's order, compromising the resident's safety.
A resident was transferred to the hospital due to a significant change in condition, but the facility failed to notify the family. The LVN attempted to contact the family without success and did not pass on the responsibility to the next shift, leaving the family uninformed. The resident lacked the capacity to make healthcare decisions, highlighting the importance of family notification.
A resident with dementia and other mental health conditions suffered second-degree burns after being allowed to smoke unsupervised with oxygen in a designated smoking area. Despite care plan requirements for supervision, the resident was left alone, leading to the incident. Facility policies on smoking safety and oxygen use were not adequately followed, contributing to the accident.
The facility failed to ensure accurate Smoking and Safety (SS) Evaluations and complete smoking care plans for several residents. The SS evaluations lacked documentation on residents' abilities to handle smoking materials safely, and care plans did not address cigarette and lighter storage or supervision needs. Discrepancies were also found between SS assessments and care plans, with the DON confirming these issues.
A resident's family member filed a grievance after multiple attempts to schedule a care plan meeting with the physician present were unsuccessful. The facility canceled a scheduled meeting without notification and failed to have a physician present for subsequent meetings, leading to their cancellation. The Director of Nursing acknowledged the miscommunication and the frustration it caused the complainant.
The facility failed to complete activity assessments for two residents as required by policy, leading to the potential for their activity needs not being met. The Activities Director confirmed that the most recent assessments for both residents were outdated, and subsequent quarterly assessments were not conducted.
A terminally ill resident experienced unmanaged moderate to severe pain due to the facility's failure to re-assess pain and administer prescribed medications. Despite having orders for acetaminophen and morphine sulfate, the resident's pain complaints were not addressed, and breakthrough pain medications were not given. The facility did not follow its policy for pain assessment and re-evaluation, resulting in prolonged pain for the resident.
Failure to Obtain Complete Vital Signs After Unsuccessful Machine Readings
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality when complete vital signs were not obtained for a resident with significant cardiac history after multiple unsuccessful attempts. The resident had diagnoses of essential hypertension and atherosclerotic heart disease of native coronary artery without angina and was care planned for coronary artery disease with an intervention to monitor blood pressure and notify the physician of abnormal readings. The resident was also documented as DNR. The Weights and Vitals Summary showed the resident’s last recorded vital signs were taken several days before the incident, despite the care plan requirement to monitor blood pressure. On the day of the incident, a CNA attempted to obtain the resident’s blood pressure at approximately 3 p.m. using a vitals machine tower and was unable to get a reading after four attempts. The CNA reported that the machine displayed three horizontal lines on the first two attempts and “ERR” on the third and fourth attempts, and did not attempt to use a manual blood pressure monitor. The CNA did not report any broken vitals machine tower to maintenance, and the Maintenance Supervisor later stated that none of the eight vitals machine towers had been identified as broken prior to his quarterly checks. The facility’s Owner’s Manual for the touchscreen vital signs monitor indicated that certain error codes required the monitor not be used and that service be contacted, and the DON explained that three horizontal lines meant the machine was trying to obtain a reading and “ERR” meant the cuff was not properly attached and the machine was not pumping air. The CNA notified an LVN at approximately 5:30 p.m. that she was unable to obtain the resident’s blood pressure using the vitals machine. The LVN stated she intended to use a manual blood pressure monitor because the machine’s cuff sometimes did not work, but she did not notify anyone that the vitals machine was not working and did not complete the vital sign assessment before going to lunch. When the LVN returned from lunch around 7 p.m., she was informed the resident was unresponsive; the LVN found the resident pale, cold, and without signs of life. An alert note documented that at 7:15 p.m. the resident was found unresponsive in bed and that the DON, physician, and family were notified. The DON later stated that if a CNA was unable to obtain vital signs, the nurse should have checked the vital signs and the CNA should have attempted to use a manual blood pressure monitor, consistent with the facility’s policies on change in condition and obtaining vital signs, which require reporting changes to a licensed nurse and having the nurse assess and determine appropriate interventions, including vital signs when there is a change in condition.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature for one of three sampled residents. During an observation and interview, the Dietary Supervisor measured the temperature of the meat on a resident's lunch tray and found it to be 100°F, which was below the facility's policy requirement of greater than 140°F for meat and entrees. The green beans on a test tray were also measured at 100°F, and the salad at 50°F, which did not meet the policy requirement of less than 41°F for hazardous salads and desserts. The resident, who had a BIMS score of 12 indicating moderate cognitive impairment, stated that the food was not hot enough to his liking. The facility's policy and procedure for food temperatures was reviewed and confirmed these temperature standards.
Failure to Serve Meals at Safe and Palatable Temperatures and Maintain Temperature Documentation
Penalty
Summary
The facility failed to serve food and beverages to residents at appropriate, palatable temperatures and within scheduled meal times. Two residents reported that their meals were often delivered late, resulting in hot foods being served cold and cold foods being served warm or hot. One resident specifically mentioned that coffee was sometimes cold upon delivery, and another stated that milk was served warm. Observations confirmed that lunch was served late, and food temperatures taken at the time of service were outside the facility's policy standards, with hot foods below the required temperature and cold foods above the safe threshold. Interviews with the Dietary Supervisor Assistant revealed awareness of ongoing complaints about late meal service, particularly over the weekend. The facility's policy outlined specific meal service times and temperature requirements for various food items, but these standards were not consistently met. The last lunch tray on the day of observation showed multiple items not meeting the required temperatures, such as sweet potato fries and roast beef sandwich being served below 140°F, and milk, chocolate milk, and coleslaw being served above 41°F. A review of the Food Temperature Log for June showed numerous missing entries for required food and beverage temperature checks prior to meal distribution. The log lacked documentation for various meal components across multiple days, including main entrees, substitutes, milk, juice, and desserts. The Dietary Supervisor Assistant confirmed that temperatures should be recorded before serving meals and that the log should be reviewed daily to ensure compliance, as per facility policy.
Failure to Provide Meal Tray to Resident
Penalty
Summary
The facility failed to provide a lunch meal tray to one of the six sampled residents, identified as Resident 1. During an observation at 1 p.m., Resident 1's roommate received his meal tray, but Resident 1 did not. Approximately 34 minutes later, it was confirmed that Resident 1 still had not received a meal tray. Licensed Vocational Nurse (LVN) 1 confirmed that all lunch trays had been distributed and returned to the kitchen, but none of the Certified Nursing Assistants (CNAs) had delivered a meal tray to Resident 1. Interviews with CNA 2, who was assigned to Resident 1, and CNA 1 confirmed that neither had provided a meal tray to Resident 1. The Director of Nursing (DON) acknowledged that Resident 1 should have been provided a meal tray. The facility's policy and procedure on menus, dated April 1, 2014, indicated that the facility is responsible for providing meals that meet the nutritional requirements set by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences, including planning for three meals and an evening snack.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12.82% error rate for three of six sampled residents. This was identified during observations, interviews, and record reviews. For one resident, a Licensed Vocational Nurse (LVN) administered Mucus Relief instead of the prescribed Mucinex Allergy due to stock issues and failed to administer Fluticasone as documented. Another resident received Naproxen and Simethicone past the scheduled administration time. Additionally, a third resident did not receive all prescribed medications via their gastrostomy tube, as one crushed medication was left unadministered. The facility's policy and procedures for medication administration, dated January 2012, were not adhered to. The policy requires medications to be administered by a licensed nurse within one hour of the scheduled time, ensuring the right medication and time are observed. The documentation of medication administration was also found lacking, as the time and dose were not accurately recorded. These lapses in following the established procedures contributed to the medication errors observed during the survey.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances. For one resident, identified as Resident 18, who was on Enhanced Barrier Precautions (EBP) due to a gastrostomy tube and risk of multidrug-resistant organism infections, there was no EBP signage or personal protective equipment (PPE) supplies outside the resident's room. This was contrary to the facility's policy, which required a brown bin with PPE and signage to be placed outside the room to alert staff of the necessary precautions. The Infection Prevention Nurse confirmed the absence of these supplies during an interview. Additionally, there was a structural issue in the facility where a hole was found between the clean and dirty utility rooms, which could compromise infection control. The clean utility room contained an ice machine used for residents, while the dirty utility room housed biohazard bins and soiled materials. The Director of Maintenance confirmed the presence and dimensions of the hole. Furthermore, a janitorial cart was observed without a lid on its trash bin, which was acknowledged by both the Housekeeping Supervisor and the janitor as not meeting the facility's housekeeping policy requirements.
Failure to Update Resident's Personal Property Inventory
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the management of personal property for a resident, identified as Resident 13. During an interview, Resident 13 reported missing personal belongings, including a gold box shaped like an egg, which she had received as a Christmas gift. The facility's Inventory of Personal Effects (IPE) form for Resident 13, last updated on 7/23/23, did not accurately reflect her current personal belongings, listing only a white fan, mattress, 32-inch television, and a dresser. The IPE did not include the missing items, which hindered the facility's ability to verify and potentially replace them. The Social Services Assistant (SSA) confirmed that the facility's policy requires the Interdisciplinary Team (IDT) to review and update the resident's inventory for accuracy during quarterly care plan conferences. However, during Resident 13's quarterly care plan conference on 10/22/24, the IPE was not reviewed or updated. The SSA acknowledged that the facility should have updated the IPE at that time, as per their policy. This oversight resulted in the inability to verify missing items and the potential for those items not being replaced, as they were not documented on the IPE.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Notice of Transfer/Discharge' by not notifying the ombudsman of the transfer of two residents, Resident 24 and Resident 69, to the hospital. During interviews and record reviews, it was revealed that the Minimum Data Set Coordinator (MDSC) and Social Services Assistant (SSA) were unable to provide documentation indicating that the ombudsman was notified of these transfers. Specifically, Resident 24 was transferred to the hospital on October 2, 2024, and Resident 69 on March 31, 2024, without the required notification to the ombudsman. The facility's policy, dated 2017, mandates that before a transfer or discharge occurs, the resident, responsible party, and ombudsman must be notified, and this must be documented in the resident's clinical record. The failure to notify the ombudsman as per the policy potentially deprived the residents of having an advocate to review their admission, transfer, and discharge rights and options. This oversight was identified during a survey conducted on January 9, 2025, through interviews with the MDSC and SSA, who confirmed the absence of the necessary documentation for both residents.
Failure to Document Verbal Order and Administer Correct Medication Dosage
Penalty
Summary
The facility failed to ensure that a verbal order for a medication was properly documented in the medical record for a resident. During an interview and record review, it was found that a Licensed Vocational Nurse (LVN) administered Glucagon to a resident who was experiencing low blood sugar, based on a verbal order from the resident's doctor. However, the LVN did not enter this verbal order into the medical record, resulting in an incomplete record. The facility's policy requires that telephone orders be documented with specific details, but this was not followed in this instance. Additionally, the facility did not adhere to its medication administration policy when an LVN administered an incorrect dose of a nutritional supplement to another resident. The LVN gave 200 ml of Med Plus 2.0, while the Medication Administration Record (MAR) indicated that only 120 ml should be administered. This discrepancy was confirmed during an interview and record review, highlighting a failure to comply with prescribed dosage guidelines as outlined in the facility's policy.
Failure to Follow RNA Program and Document Progress
Penalty
Summary
The facility failed to adhere to the physician's orders for a Restorative Nursing Assistant (RNA) therapeutic program for a resident, identified as Resident 64. The orders specified that the resident was to receive RNA therapy five times a week, including exercises using a rickshaw, active range of motion (AROM) for lower extremities, and a leg ergometer. However, the resident reported that the RNA was often reassigned to work as a Certified Nursing Assistant (CNA), resulting in missed exercise sessions. The electronic medical record (eMR) tasks confirmed that the resident's therapy sessions were inconsistent, with several instances marked as 'Not Applicable,' indicating that the therapy was not provided on those days. Additionally, the RNA failed to complete the required weekly summaries for the resident's RNA program, which are essential for monitoring the resident's progress towards regaining independence in daily activities. The Director of Nursing (DON) acknowledged that the RNA weekly summaries were not being completed as required. The facility's policy and procedure for the Restorative Nursing Program emphasized the importance of documenting measurable objectives, interventions, and the frequency of the RNA program, which were not adhered to in this case.
Failure to Conduct Annual Performance Evaluation for Supervisor Licensed Employee
Penalty
Summary
The facility failed to ensure that a Supervisor Licensed (SL) employee had an annual performance evaluation completed, which is a requirement for maintaining compliance with the facility's policies. During an interview, the Director of Nursing (DON) confirmed that all employees must have annual performance evaluations. A review of SL 3's personnel file revealed that despite being hired on December 24, 2023, there was no record of a performance evaluation. The Director of Staff Development (DSD) acknowledged that SL 3 should have had an annual performance evaluation. The facility's policy, titled 'Compliance as a Component of Employee Performance,' mandates that employee performance evaluations include adherence to the compliance program, which was not adhered to in this case.
Failure to Provide Adaptive Call Light for Dependent Resident
Penalty
Summary
The facility failed to provide an adaptive call light for a dependent resident, identified as Resident 80, who had physical limitations. During an observation and interview, it was noted that the call light was wrapped around the right upper side rail, and Resident 80, who had contractures in his right hand and a limp left arm, stated he could not use the call light and instead whistled to call for assistance. A Certified Nursing Assistant confirmed that Resident 80 would not be able to use the call light as it was positioned. The Director of Nursing acknowledged that all residents should have accessible call lights and mentioned that the facility had house-shaped call lights designed for dependent residents, which Resident 80 should have had. The facility's policy indicated that adaptive call bells should be provided according to residents' needs.
Failure to Follow Grievance Process for Abuse Allegation
Penalty
Summary
The facility failed to adhere to its grievance process for a resident who reported abuse allegations. The resident filed a grievance with the Social Service Assistant, but the facility did not follow up with the resident regarding the grievance. The Resident Grievance/Complaint Investigation Report (RGCIR) for this grievance was incomplete, with several sections left blank, including the response to the grievance, confirmation of the grievance, and notification to the concerned party. During a review of the facility's policy and procedure on grievances, it was noted that the Administrator, who is the Grievance Official, is responsible for overseeing the grievance process and ensuring that grievances are tracked to their conclusion. The policy requires a completed investigation report within five business days, but this was not done in this case. The Administrator confirmed that the RGCIR was not completed and that the resident was not informed of the investigation's outcome or any corrective actions.
Failure to Follow Abuse Investigation Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Abuse Investigation and Reporting' concerning an allegation of physical abuse involving a resident. The Director of Nursing (DON) 2 was responsible for investigating the allegations against a Certified Nursing Assistant (CNA) but did not interview other residents who received care from the accused CNA, as required by the facility's policy. Interviews with the Social Services Assistant (SSA) and Case Manager (CM) revealed that they were not involved in the investigation, contrary to the stated responsibilities. The Administrator confirmed that DON 2 was solely responsible for the investigation and was not involved herself. The facility's policy, revised in December 2016, mandates that all reports of abuse be thoroughly investigated by facility management, including interviewing other residents cared for by the accused employee.
Deficiencies in Care Planning and Conservator Involvement
Penalty
Summary
The facility failed to adhere to its policy and procedure for Comprehensive Person-Centered Care Planning for two residents. For the first resident, the facility did not ensure the participation of the resident's conservator in the care conference. The resident, diagnosed with dementia and severe cognitive impairment, was unable to make healthcare decisions independently. Despite this, there was no documentation indicating the conservator's attendance at the care conference, which is a requirement according to the facility's policy. For the second resident, the facility did not include individualized goals and interventions for restorative mobility in the comprehensive care plan. The care plan lacked specific interventions for strengthening the resident's upper extremities, which is necessary for the resident's mobility and function potential. The facility's policy requires that all goals, objectives, and interventions from the baseline care plan be included in the comprehensive care plan, and that the care plan be updated with any changes to the Restorative Nursing Program.
Failure to Follow Prescribed Menus for Residents
Penalty
Summary
The facility failed to ensure that menus were followed for two residents, resulting in them receiving smaller portion sizes than prescribed. Resident 1, who was on a regular-large portion diet, reported receiving only one egg and one piece of bread for breakfast, contrary to the facility's Winter Menus, which specified two fried eggs and two slices of wheat toast, among other items. This discrepancy was confirmed by a Certified Nursing Assistant and a staff member, who acknowledged that the portions served did not align with the menu requirements. Additionally, during the lunch meal service, Resident 2, who was on a renal diet, received a smaller portion of corn than specified. The facility's Winter Menus indicated that residents on a renal diet should receive a #8 scoop of corn, but a staff member used a #12 scoop instead. The Registered Dietitian and Certified Dietary Manager both confirmed that the kitchen staff should adhere to the spreadsheet, which calculates the necessary nutrients for residents. The facility's policy and procedure on menus emphasized the importance of adhering to the written menu to meet the nutritional needs of residents.
Failure to Document Food Temperatures
Penalty
Summary
The facility failed to ensure that food prepared and served was in accordance with professional standards for food service safety, which had the potential to cause foodborne illnesses among residents. During a review of the facility's menu for specific dates, it was noted that meals such as French toast with breakfast meats and a dinner of crispy fish fillet with sides were served. However, during an observation in the facility's kitchen, it was found that food temperatures were not documented for these meals, which is a critical step in ensuring food safety. The Dietary Supervisor confirmed that the meals were prepared and served in the facility's kitchen, but acknowledged that no food temperatures were recorded for the breakfast and dinner services on the specified dates. The facility's policy and procedure for food temperatures, which requires recording temperatures at the beginning of the tray line and ensuring foods are served at proper temperatures, was not followed. This lack of documentation and adherence to the policy indicates a failure in maintaining food safety standards.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by an incident involving a Certified Nursing Assistant (CNA 3) and Resident 2. Resident 2, who was admitted with conditions including hemiplegia, hemiparesis, aphasia, and anxiety disorder, was unable to complete a mental status interview due to cognitive impairments. During an incident, CNA 3 was overheard yelling at Resident 2, telling them to stop yelling and using the phrase 'Earth to [Resident 2]' in a loud voice. This behavior was confirmed by a marketer who witnessed the event and heard the exchange from her office. The facility's investigation revealed that CNA 3 admitted to the behavior and showed no remorse, questioning the decision to suspend her due to staffing issues. The facility's policy on Resident Rights, which emphasizes treating residents with kindness, respect, and dignity, was not adhered to in this instance. The deficiency was identified through interviews and record reviews, highlighting a failure to uphold the resident's right to be treated with respect and dignity, potentially causing emotional distress to Resident 2.
Failure to Investigate and Protect Resident from Financial Exploitation
Penalty
Summary
The facility failed to timely investigate and protect a resident when the resident reported missing money and giving money to a staff member. The resident, who had a history of dementia, bipolar disorder, and schizophrenia, reported missing money and stated that they had given money to a staff member, the Activity Director, for personal use. The resident's cognitive impairment was noted with a BIMS score indicating moderately impaired cognition. Interviews and record reviews revealed that the resident had made multiple withdrawals from their trust account for personal needs, with significant amounts withdrawn over a few months. The Licensed Vocational Nurse filed a grievance on behalf of the resident, noting that the resident was looking to give money to the Activity Director, which should not have been happening. The Activity Director denied taking money from the resident, although a written statement later indicated a problem with their tire, which the resident had mentioned as a reason for giving money. The Director of Nursing acknowledged that the grievance should have been reported as financial abuse, as there was missing money and the resident was giving money to a staff member. The investigation was delayed, starting over two months after the initial report, and no protection was provided to the resident during this time. The facility's policy on abuse prevention and management was not followed, as there was no timely investigation or intervention to protect the resident from potential exploitation.
Failure to Follow Fall Management Program Leads to Multiple Falls
Penalty
Summary
The facility failed to adhere to its Fall Management Program policy and procedure for a resident, resulting in multiple falls over a five-month period. The resident, who was admitted with diagnoses including dementia and bipolar disorder, experienced several unwitnessed falls. The facility did not complete the Post Fall Evaluation (PEE) forms for these incidents, leaving sections such as Fall Details, Contributing Factors, Medication Changes, Physical Findings, MDS, Care Planning, and Clinical Suggestions blank. This lack of documentation hindered the identification of possible causes of the falls and the development of strategies to prevent future incidents. The resident's care plan was not updated following the falls on specific dates, despite the facility's policy requiring such updates. The Director of Nursing confirmed that care plans were not developed after the falls on three occasions. The resident's care plan, which focused on high fall risk due to dementia, gait instability, and a history of recurrent falls, was not revised to address the specific incidents, contrary to the facility's policy. The resident sustained a left intertrochanteric femoral fracture requiring surgical repair after one of the falls. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed that the post-fall evaluations were intended to inform care plan updates to prevent future falls. However, the evaluations were not completed, and the care plans were not revised, contributing to the resident's repeated falls and subsequent injury.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and investigate an injury of unknown origin for one of the residents. The incident involved a resident who was noted to have discoloration and swelling on the right eye, as documented in the SBAR communication tool on 10/9/24. Interviews with staff, including a CNA and two LVNs, revealed that the injury was observed but not reported to the Director of Nursing (DON) or the Administrator. The LVNs acknowledged that such injuries should be investigated, as they could potentially indicate abuse. However, the Director of Staff Development (DSD) confirmed that there was no documentation explaining the cause of the injury in the resident's medical record. The Administrator stated that she was not informed about the resident's eye discoloration and swelling, and therefore, no investigation was conducted. The facility's policy and procedure for injuries of unknown origin require that all unexplained injuries be promptly and thoroughly investigated to protect resident safety. The policy defines an injury of unknown source as one that is not observed by any person or cannot be explained by the resident, and is suspicious due to its extent or location. The failure to adhere to this policy resulted in a deficiency, as the injury was neither reported nor investigated, potentially compromising the resident's health and safety.
Failure to Implement Fall Management Protocol
Penalty
Summary
The facility failed to adhere to its Fall Management Program policy and procedure for a resident who experienced a fall. The resident, who had severe cognitive impairments and required substantial assistance with mobility, was found crawling on the floor by a CNA. Despite the incident being classified as a fall, the facility did not implement the necessary post-fall protocol. This included the absence of neurological checks, a fall risk assessment, a post-fall assessment, and an update to the resident's fall care plan. The facility's policy mandates specific actions following a fall, such as conducting a post-fall evaluation, updating the care plan, and performing neurological checks for unwitnessed falls or those with potential head injuries. Additionally, the policy requires notifying the DON, the resident's physician, and responsible party, as well as conducting a Post-Fall Huddle and documenting the incident for IDT review. These steps were not followed, leading to a deficiency in the facility's management of the resident's fall incident.
Failure to Administer Incentive Spirometry as Ordered
Penalty
Summary
The facility failed to follow Medical Doctor (MD) orders for incentive spirometry (ISP) for three residents, resulting in orders not being followed. Resident 1 had an MD order for ISP to be administered every shift until a specified date, but during an observation, no ISP device was present in the resident's area, and the resident confirmed not having used ISP since admission. Similarly, Resident 2 had an MD order for ISP every shift, but no device was observed, and the resident confirmed non-use. Both residents had intact cognition scores, indicating they were capable of understanding and following ISP instructions if provided. Resident 3 also had an MD order for ISP every shift with no end date, but the Director of Nursing (DON) confirmed that the resident was not receiving ISP as ordered. The DON reviewed the Medication Administration Records (MAR) for all three residents and confirmed the absence of ISP administration. The facility's digital system was auto-populating ISP orders for new admissions, but the orders were not being executed. The facility's policy on ISP, which outlines its purpose and proper utilization, was not adhered to, leading to the deficiency.
Falsification of ISP Documentation in LTC Facility
Penalty
Summary
The facility failed to accurately document the provision of incentive spirometry (ISP) for three residents, resulting in falsification of medical records. The deficiency was identified through observations, interviews, and record reviews. Residents had medical doctor orders for ISP to be administered every shift, but the treatment was not provided. Despite this, the Medication Administration Records (MAR) indicated that the ISP was given, which was confirmed to be false by multiple facility nurses during interviews. Resident 1, Resident 2, and Resident 3 were all affected by this deficiency. Resident 1 and Resident 2 had intact cognition as indicated by their Brief Interview for Mental Status (BIMS) scores. During interviews, both residents confirmed they had not received ISP treatment, although their MARs falsely documented otherwise. The Director of Nursing (DON) acknowledged that the facility's digital system was auto-populating ISP orders for new admissions, which contributed to the inaccurate documentation. Interviews with several facility nurses revealed that ISP equipment had not been available for at least three months, yet the MARs continued to reflect that the treatment was administered. Nurses admitted to documenting ISP as given or refused, despite not having the equipment to provide the treatment. The DON confirmed that the documentation did not reflect the actual care provided and that the facility's policy and procedure for nursing documentation were not available upon request.
Failure to Assess Resident for Emotional Distress After Abuse Incident
Penalty
Summary
The facility failed to adhere to its policy and procedure on abuse prevention and management when a resident was not assessed for signs of emotional distress following a reported abuse incident. The incident involved a resident whose family member confessed to taking money from her account without permission. Despite the resident expressing upset feelings about the situation, there was no documentation of any assessment for emotional distress by the licensed nurses or the Social Services Director (SSD). Interviews with the Licensed Vocational Nurse (LVN), SSD, and Acting Director of Nursing (ADON) confirmed the lack of monitoring for emotional distress. The resident's care plan indicated a risk for psychosocial distress due to the alleged financial abuse and included interventions such as notifying the Medical Director of signs of emotional distress and having Social Services monitor the resident daily for three days. However, these interventions were not documented as being carried out, which was a deviation from the facility's policy titled 'Abuse Prevention and Management.'
Delayed Investigation of Financial Abuse Incident
Penalty
Summary
The facility failed to complete an investigation of an abuse incident within the required five working days for a resident. The incident involved a financial abuse allegation where the resident's family member was suspected of taking money from the resident's account. The resident's daughter discovered the issue when she found the account balance was zero and confirmed through bank camera footage that the family member was responsible. The family member admitted to taking the money and apologized. Despite the facility's policy requiring a written report of the investigation results to be submitted to the California Department of Public Health within five working days, the administrator did not follow up on the investigation in a timely manner. The administrator was waiting for the Social Services Director to provide the investigation's conclusion, but the Social Services Director was unaware of the requirement to complete the five-day summary. As a result, the investigation summary was completed nine days overdue, contrary to the facility's policy.
Failure to Inform Residents of Lab Orders
Penalty
Summary
The facility failed to ensure that three residents were informed in advance about laboratory orders, which compromised their dignity and privacy. Resident 1 reported feeling humiliated when three CNAs entered her room without prior explanation and requested a urine sample. She initially refused to provide the sample until an RN later explained the reason for the test. Resident 3 experienced a similar situation, where CNAs requested a urine sample without prior notice, and he only complied after receiving an explanation from an RN. Resident 2, a dialysis patient who had not produced urine for five years, was also approached by CNAs for a urine sample, which she could not provide. The CNAs involved stated that they were instructed by an LVN to collect the urine samples, but they were not informed of the reasons for the tests. The LVN claimed she would typically explain the need for lab tests to residents and would not ask CNAs to collect samples without assistance. The RN involved stated she was directed by the Director of Nursing to obtain urine samples and had placed the orders, asking LVNs to collect them. The facility's policy on resident rights emphasizes treating residents with respect and dignity, including maintaining their privacy and confidentiality, which was not adhered to in these instances.
Failure to Document and Administer Medications and Treatments
Penalty
Summary
The facility failed to consistently carry out physicians' orders for three residents, leading to potential adverse outcomes. For Resident 4, the Medication Administration Record (MAR) showed multiple instances where intravenous (IV) tubing for protonix was not documented as changed, and pantoprazole was not documented as administered. Additionally, the flushing of the PICC line was not documented on several occasions. These omissions in documentation suggest that the necessary medical procedures may not have been performed, compromising the effectiveness of the treatment. Resident 5's MAR also revealed significant documentation gaps. The dressing and cap change for the PICC line was not documented as completed, and the IV tubing for vancomycin was not documented as changed on multiple dates. Furthermore, the administration of vancomycin was not documented on several occasions, and the flushing of the PICC line was not recorded. Monitoring of the PICC line for signs of complications was also not documented, indicating a lack of adherence to the prescribed care plan. For Resident 6, the MAR indicated that the flushing of the central line was not documented as administered on two occasions. Additionally, monitoring of the central line for redness, swelling, bleeding, or pain was not documented as completed on two shifts. These documentation lapses suggest that the facility did not consistently follow its own policies and procedures for medication administration and monitoring, as confirmed by the Director of Nursing.
Improper Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, as observed during a survey. The resident's urinary catheter collection bag was found lying on the floor outside their room, not placed in a dignity bag, which was confirmed by a Certified Nursing Assistant (CNA). This action was contrary to the facility's policy and procedure for catheter care, which mandates that catheter tubing, bags, or spigots should not touch the floor to prevent catheter-associated urinary tract infections (UTIs). The facility's policy also aligns with the CDC guidelines, which emphasize maintaining unobstructed urine flow and keeping the collecting bag below the bladder level without resting it on the floor.
Incomplete Verification of DON's Qualifications
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) possessed the necessary skills and qualifications to ensure residents' safety. During an interview and record review, it was found that the DON's application was incomplete, lacking details about education, previous employment, and references. The Administrator admitted that the normal procedures for verifying the qualifications of employees were not followed, as the DON's background check was completed after the date of hire, contrary to the facility's policy. The facility's Employee Handbook and the Director of Nursing Services Job Description both require that background checks and verification of credentials be completed before hiring. However, these procedures were not adhered to in the case of the DON. The facility's policy on abuse prevention also mandates obtaining at least two reference checks from previous employers, which was not done. This oversight in the hiring process had the potential to compromise the safety and care of the residents due to the lack of verification of the DON's qualifications.
Failure to Complete Required Reference Checks for LVN
Penalty
Summary
The facility failed to adhere to its own policy and procedure titled 'Abuse-Prevention, Screening, & Training Program' by not completing the required reference checks for a newly hired Licensed Vocational Nurse (LVN 4). According to the facility's policy, at least two reference checks from previous or current employers must be obtained prior to hiring an applicant. However, during a review of LVN 4's employment application and verification documents, it was confirmed that only one reference check was completed, despite LVN 4 having two previous employers and three personal references listed. This oversight had the potential to expose the facility's residents to possible abuse.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Abuse Reporting' concerning a reported incident involving a resident. The incident involved a Certified Nursing Assistant (CNA) allegedly pulling a handful of pubic hairs from a resident. This incident was documented in the Resident Grievance/Complaint Investigation Report dated August 29, 2024. Despite the initiation of an investigation and the suspension of the CNA involved, the facility did not report the allegations to the California Department of Public Health in a timely manner. During an interview with the Regional Quality Assurances Consultant (RQAC) on September 5, 2024, it was confirmed that the allegations were not reported promptly as required by state and federal regulations. The facility's policy, revised on January 8, 2014, mandates that known or suspected instances of physical abuse must be reported to the proper authorities within 24 hours if the event does not result in serious bodily injury. This includes making a telephone report to local law enforcement and a written report to the local Ombudsman, the California Department of Public Health, and local law enforcement. The delay in reporting had the potential to place all residents at risk for abuse.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that medication carts were secured and accessible only to licensed nursing staff, as observed with one of six sampled medication carts. During an observation at the nurses' station, a medication cart was found unlocked with no licensed nurse in sight, and a resident in a wheelchair was directly in front of the cart. The resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The facility's policy stated that medications should be stored safely and securely, accessible only to authorized personnel, but this was not adhered to in this instance.
Medication Administration Failures
Penalty
Summary
The facility failed to adhere to its own medication administration policy, resulting in a delay in care and unnecessary nerve pain for a resident. On a specific day, the resident was unable to receive her morning medications, which included essential treatments for neuropathy and other conditions. Despite the resident's efforts to locate a nurse, the medications were not administered, and the nurse's notes indicated that the medical doctor was aware of the situation. This lapse in medication administration was confirmed through interviews and record reviews, highlighting a significant oversight in the facility's medication management process. Additionally, the facility did not administer medications in a timely manner, as evidenced by the late administration of a pain-relief patch on multiple occasions. The facility's policy allows for medications to be given one hour before or after the scheduled time, but records showed that the patch was administered several hours late on numerous dates. Interviews with nursing staff and the Director of Nursing confirmed these delays, with some nurses reportedly documenting the administration later than it occurred. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed and documenting them immediately after administration. However, the repeated failure to follow these guidelines resulted in delayed care for the resident, particularly concerning the administration of a pain-relief patch. The Director of Nursing acknowledged the issue, confirming that medications should be documented right after they are given, which was not consistently practiced in this case.
Infection Control Lapses in Medication Handling and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by the sharing of medication between two residents. Resident 1, who was on isolation due to a COVID-19 infection, was given an Albuterol inhaler that was not properly labeled, leading to a mix-up with Resident 2's inhaler. Both residents had different colored inhalers, but the containers were not marked with their names, only the boxes they came in. This mix-up was confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the cross-contamination and the need for a system to identify individual inhalers. Additionally, a Certified Nursing Assistant (CNA) failed to follow hand hygiene protocols, which are crucial for preventing the spread of infections. The CNA was observed taking a water pitcher from Resident 1's isolation room without washing her hands and then entering Resident 3's room to assist with lunch. This action was in direct violation of the facility's hand hygiene policy, which requires handwashing before and after entering resident rooms, especially when dealing with residents in isolation. The facility's policies on medication administration and hand hygiene were not adhered to, leading to potential risks of infection spread among residents. The DON confirmed the expectations for staff to conduct hand hygiene before and after entering resident rooms, highlighting the importance of these practices in preventing infection transmission. The failure to label medications correctly and maintain hand hygiene standards contributed to the deficiencies observed during the survey.
Failure to Administer Psychotropic Medications as Ordered
Penalty
Summary
The facility failed to provide psychotropic medications as ordered upon admission for a resident diagnosed with generalized anxiety, depression, and PTSD. The resident, who had been on antidepressant medication for six years, did not receive her prescribed medications, Ecitalopram and Lorazepam, since her admission. This resulted in the resident experiencing increased anxiety and difficulty coping with stressors, as observed during an interview where she appeared teary-eyed and expressed her distress. The Director of Nursing (DON) confirmed that the resident was supposed to continue her medications from the acute hospital, where she was on Ecitalopram 20 mg daily and Lorazepam 0.5 mg every six hours as needed. However, the facility's registered nurses failed to reconcile the acute hospital's medication list with the facility's list, leading to the omission of Ecitalopram in the resident's medication administration record. The DON acknowledged that the morning nursing shifts are responsible for ensuring medication orders are correct upon admission, and the interdisciplinary team (IDT) reviews psychotropic medications and consents. The facility's policies on medication administration and behavior management emphasize the accurate administration of medications and the provision of necessary behavioral healthcare. Despite these policies, the resident did not receive her prescribed medications, which could negatively impact her psychological well-being. The DON verified that the resident had consent for both medications, but the facility's IDT meeting regarding her psychotropic medications was not properly conducted.
Failure to Protect Resident Mail Privacy
Penalty
Summary
The facility failed to protect the privacy of a resident's mail, leading to a potential violation of residents' rights. During an observation, a letter addressed to Resident 2 was found in a large clear plastic container of multicolored beads belonging to Resident 1, who is legally blind. Resident 1, who uses the beads for making bracelets and necklaces, stated he could feel the letter but did not know to whom it belonged. Certified Nursing Assistant (CNA) 1 confirmed the letter was addressed to Resident 2 and stated that Resident 2 could not have placed it there as he had been hospitalized for several days. The Activities Assistant (AA) responsible for distributing mail stated she did not know how Resident 2's mail ended up with Resident 1, especially since Resident 2 was in the hospital and Resident 1 did not have mail that day. The facility lacked a process to track mail delivery and receipt, as confirmed by the Administrator, who stated that mail for residents not in the facility should be held by the front office. The facility's policy on resident mail, dated 1/1/12, requires mail to be delivered to residents within 24 hours of delivery to the premises.
Failure to Provide Accessible Fluids for Resident
Penalty
Summary
The facility failed to provide fluids within reach for a resident, which had the potential to lead to dehydration. The resident, who was legally blind and required assistance for eating and drinking, was observed without any fluids or a pitcher of water within reach. A maroon-colored pitcher filled with water was placed on a dresser on the left side of the resident's bed, out of reach. The resident expressed thirst and requested something to drink during the observation. A Certified Nursing Assistant (CNA) confirmed that the pitcher was the resident's water and acknowledged it was out of reach. The CNA stated that the resident was not on any fluid restrictions and should have access to water at any time. The facility's policy on hydration, dated November 2015, indicated that CNAs should ensure each resident has a pitcher of fresh, cool water and a clean glass bedside unless medically contraindicated. The administrator also confirmed that residents' water or fluids should be within their reach.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 1, who was legally blind and dependent on staff for various activities of daily living, including toileting and bathing. During an observation and interview, it was noted that Resident 1's call light was clipped against the wall and hanging down toward the floor, making it inaccessible. Resident 1 expressed difficulty in locating the call light, which he relied on to request assistance from staff. A Certified Nursing Assistant (CNA) confirmed that the call light was not within reach and suggested that it might have been moved during room cleaning. The facility's policy, dated 1/1/12, mandates that call cords be placed within the resident's reach to facilitate prompt communication with nursing staff. The administrator also acknowledged that call lights should be accessible to residents, highlighting a lapse in adherence to the facility's procedures.
Failure to Implement Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident identified as high risk for developing pressure injuries. This resident, who was admitted with conditions including hemiplegia, hemiparesis, severe protein calorie malnutrition, and cognitive impairments, developed multiple pressure injuries while under the facility's care. Observations revealed that the resident was left in the same position for extended periods without being turned or repositioned, which is a critical intervention for preventing pressure injuries. The resident's care plan was not updated to address the risk of pressure injuries, despite the resident's high-risk status as indicated by a Braden Scale score of 12. The facility's Director of Nursing confirmed that the care plans were deactivated when the resident was sent to an acute hospital, and no new care plan was developed upon the resident's return. Additionally, the resident experienced significant weight loss, and there was a lack of documentation indicating that the resident received the prescribed meals and nutritional support, including enteral feedings. The facility's policy on pressure injury prevention requires the development of individualized care plans for residents at risk, including interventions such as repositioning, heel protection, and monitoring food and fluid intake. However, these interventions were not effectively implemented or documented for the resident, leading to the development of deep tissue injuries and unstageable pressure injuries on the resident's left foot, right heel, and coccyx.
Failure to Provide Prescribed Nutrition Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident received the prescribed nutrition necessary to meet their nutritional needs and maintain a desirable weight. This deficiency was identified through observation, interviews, and record reviews. The resident, who was dependent on staff for eating and had a severely impaired cognitive status, experienced a significant weight loss of 24.5 pounds, equating to 17.3% of their body weight over two months. The resident's care plan included goals for maintaining adequate nutritional status and consuming a certain percentage of meals daily, but these goals were not met. Observations revealed that the resident was not provided with meal trays on multiple occasions, and there was a lack of documentation indicating that meals were provided. A Certified Nursing Assistant (CNA) confirmed that the resident did not receive a lunch meal tray on a specific day and mentioned that no one covered the resident's care during meal service or breaks. The Director of Nursing (DON) confirmed that there was no documentation for 65 out of 177 meals, indicating a failure to provide the necessary nutrition consistently. The resident's medical history included conditions such as hemiplegia, hemiparesis, severe protein-calorie malnutrition, and nutritional deficiency, which required assistance with personal care and feeding. Despite recommendations for enteral feedings and a fortified diet to address significant weight loss, the facility did not adequately monitor and document the resident's nutritional intake. The facility's policy on evaluating weight and nutritional status emphasized the importance of maintaining acceptable nutritional parameters, but the facility failed to implement interventions consistent with the resident's needs and goals.
Failure to Document and Provide Prescribed Nutrients
Penalty
Summary
The facility failed to ensure that a resident received the prescribed nutrients, which had the potential for unmet care needs and weight loss. During an interview and record review with the Director of Nursing (DON), it was found that the resident was supposed to receive a standard portion diet and a 4 oz pureed snack daily, as well as G-tube bolus feeding twice daily between meals. However, there was no documentation for seven meals and 13 snacks, indicating they were not provided. Additionally, the resident's Medication Administration Record (MAR) showed that enteral feeding orders were not documented as provided on multiple occasions. The facility's policy and procedure for food and fluid percentage documentation required CNAs to record the percentage of all food and fluid intake in the resident's ADL flowsheet after each meal. The policy for medication administration required licensed nurses to document the time and dose of the drug or treatment administered. The DON confirmed that the expectation was for documentation to be done immediately, and if it was not documented, it was considered not done. This lack of documentation and adherence to policies contributed to the deficiency in providing the resident with the necessary nutrition.
Failure to Conduct Quarterly Fall Risk Evaluations
Penalty
Summary
The facility failed to adhere to its Fall Management Program policy by not completing quarterly fall risk evaluations for a resident, which could have potentially led to fall incidents. The resident, who has a history of seizures and takes medication for it, experienced a seizure while out on pass and fell, resulting in a fractured midfoot. Despite the resident's known condition and previous seizures during passes, the facility did not conduct the required fall risk evaluations in January and April 2024, as confirmed by the Director of Nursing. The resident's last fall risk evaluation was conducted in April 2023, indicating a low fall risk score. However, the resident's Minimum Data Set assessment in May 2024 showed that walking was not attempted due to medical or safety concerns. The facility's policy mandates that fall risk evaluations be conducted quarterly, annually, or when there is a significant change in condition, but this was not followed, as evidenced by the missing evaluations. This oversight was identified during a review of the facility's policy and procedure, which aims to provide a safe environment and minimize fall-related complications.
Failure to Implement Out on Pass Policy for Resident with Seizure Disorder
Penalty
Summary
The facility failed to implement its policy and procedure for managing a resident's out on pass (OOP) status, resulting in an incomplete physician order for a resident with a seizure disorder. The resident, who had a history of seizures and muscle weakness, went out on pass and experienced a seizure and fall, leading to a fracture of the right fifth metatarsal. The resident reported these incidents upon returning to the facility, but the physician order did not specify whether the resident should be accompanied or the duration of the pass, as required by the facility's policy. The resident's care plan indicated seizure precautions, including not leaving the resident alone during a seizure and protecting them from injury. However, the resident had been going out on pass unaccompanied since February, despite having seizures during these outings and notifying the facility. The facility's Director of Nursing (DON) confirmed that the physician's order for the resident's out on pass did not include necessary details such as the length of time or whether the resident should be accompanied, which was a deviation from the facility's policy. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), revealed that the resident was considered alert and oriented, and thus responsible for himself while out on pass. However, the facility's policy required specific physician orders for such passes, which were not present in this case. The lack of adherence to the policy potentially compromised the resident's safety, as evidenced by the resident's fall and subsequent fracture while out on pass.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding Change of Condition Notification, as evidenced by the lack of notification to the responsible party about a change in condition for one of the sampled residents. Specifically, Resident 1 experienced a significant change in condition, being unable to be aroused and lethargic, which necessitated a transfer to the hospital for further evaluation. Despite this critical change, the facility did not successfully inform the resident's family member, who was the responsible party. The deficiency occurred when the Licensed Vocational Nurse (LVN) attempted to contact the family member but received no response. The LVN did not pass on the responsibility to the next shift, resulting in the family not being informed of the resident's transfer to the hospital. This oversight was contrary to the facility's policy, which mandates timely notification of the resident's attending physician and legal representative or appropriate family member in such situations. Additionally, Resident 1's medical records indicated that they did not have the capacity to understand choices and make healthcare decisions, further emphasizing the importance of notifying the family.
Resident Suffers Burns Due to Unsupervised Smoking with Oxygen
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, resulting in a resident sustaining second-degree burns to the face. The resident, who has a history of dementia, bipolar disorder, schizophrenia, and tobacco use, was allowed to smoke unsupervised while using oxygen. Despite the care plan indicating the need for supervision while smoking, the resident was left alone on the smoking patio, leading to the incident. The resident's care plan included instructions for smoking safety and supervision, but these were not adequately implemented. The resident was known to be non-compliant with the facility's policy regarding lighter use and insisted on keeping a lighter and cigarettes on his person. On the day of the incident, the resident was taken to the smoking patio by a Certified Occupational Therapy Assistant, but no staff was present to supervise, contrary to the care plan's requirements. Interviews with staff and other residents revealed that the resident was smoking with oxygen on, which is prohibited in the smoking area. The facility's Director of Nursing confirmed that there were no interventions for oxygen use developed prior to the incident, and the resident was not educated on the risks of smoking with oxygen. The facility's policies on resident safety and smoking were not effectively followed, contributing to the accident.
Inadequate Smoking Safety Evaluations and Care Plans
Penalty
Summary
The facility failed to ensure that the Smoking and Safety (SS) Evaluation for seven residents accurately identified their ability to hold, light, and extinguish a cigarette safely. The evaluations for these residents lacked documentation regarding their smoking abilities and the type of supervision required. This oversight was confirmed during a review with the Director of Nursing (DON), who acknowledged the absence of necessary documentation in the SS evaluations. Additionally, the facility did not complete smoking care plans for ten residents. The care plans failed to address essential aspects such as cigarette and lighter storage, and the type of supervision required for smoking. The DON confirmed these omissions during a review of the residents' care plans, highlighting a lack of comprehensive documentation regarding the residents' smoking habits and safety measures. Furthermore, discrepancies were found between the SS assessments and care plans for four residents. The SS assessments indicated different levels of smoking independence and supervision needs compared to what was documented in the care plans. These inconsistencies were acknowledged by the DON, who noted that the SS assessments did not match the information in the residents' care plans. The facility's policy and procedure on smoking residents required regular assessments and individualized care plans, which were not adequately followed.
Failure to Provide Timely Care Plan Meeting
Penalty
Summary
The facility failed to provide a timely care plan meeting for a resident, which had the potential to delay or impede necessary aspects of care. The resident's family member filed a grievance after multiple attempts to schedule a care plan meeting with the physician present were unsuccessful. The facility canceled a scheduled meeting on 2/26/24 without notification and failed to have a physician present for meetings on 4/11/24 and 4/17/24, leading to their cancellation. The Director of Nursing acknowledged the miscommunication and the frustration it caused the complainant. The facility's policy requires care plan meetings to be conducted within a week or at least within 14 days of a request, but this was not adhered to in this case. The Administrator was unaware of the initial scheduled meeting in February and stated that care plan meetings should be conducted promptly. The facility's policy emphasizes the importance of person-centered, comprehensive, and interdisciplinary care planning, but this standard was not met for the resident in question.
Failure to Complete Activity Assessments
Penalty
Summary
The facility failed to ensure that activity assessments were completed for two of three sampled residents, leading to the potential for their activity needs not being met. Resident 1 was admitted on an unspecified date, and their care plan focused on activity involvement was initiated on 1/16/23 and revised on 8/30/23. However, the most recent Activities Evaluation (AE) for Resident 1 was dated 1/30/23, and subsequent quarterly assessments were not completed as required. Similarly, Resident 3 was admitted on an unspecified date, with a care plan focused on independent activities initiated on 12/20/21 and revised on 12/21/23. The most recent AE for Resident 3 was dated 8/23/23, and subsequent quarterly assessments were also not completed as required. During an interview and record review on 3/29/24, the Activities Director confirmed that the AEs for both residents were not completed according to the facility's policy and procedure. The policy, revised on 11/1/13, mandates that activity assessments be conducted on admission, quarterly, and annually, with care plans reviewed and revised at least quarterly or more often if a change of condition occurs. The failure to adhere to this policy resulted in the potential for the activity needs of Resident 1 and Resident 3 not being met, as their activity assessments were not updated as required.
Failure to Manage Resident's Pain
Penalty
Summary
The facility failed to re-assess and manage the pain of a terminally ill resident, resulting in unmanaged moderate to severe pain. The resident, who had a history of idiopathic peripheral autonomic neuropathy, primary osteoarthritis, and a displaced fracture, reported significant pain, especially at night. Despite having physician orders for pain management, including acetaminophen and morphine sulfate, the facility did not administer these medications when the resident complained of pain levels ranging from 4/10 to 8/10 over several months. Interviews and record reviews revealed that the resident's pain was not re-assessed after initial complaints, and breakthrough pain medications were not administered as needed. The Director of Nursing and Licensed Vocational Nurse confirmed that the resident should have received additional pain relief measures, but these were not provided. The hospice nurse also indicated that the resident had been educated on using liquid morphine for breakthrough pain, but this was not documented or followed by the facility staff. The facility's policy required pain assessments and re-evaluations within one hour of administering pain medications, but this was not adhered to. The resident's care plan also emphasized the need for immediate response to pain complaints and the use of PRN medications for breakthrough pain. However, the facility staff failed to document or implement these measures, leading to the resident experiencing unmanaged pain over an extended period.
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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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