The Rehabilitation Center Of Los Angeles
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 340 South Alvarado Street, Los Angeles, California 90057
- CMS Provider Number
- 555397
- Inspections on file
- 52
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Rehabilitation Center Of Los Angeles during CMS and state inspections, most recent first.
Two residents dependent on staff for daily care, including those with chronic respiratory and neurological conditions, experienced significant delays in staff response to the call system, with one reporting waits of up to half an hour and another stating it could take a couple of hours. Staff interviews confirmed awareness of the expectation for immediate response, but cited competing demands and short staffing as contributing factors. These delays led to residents feeling neglected, anxious, and unsafe.
The facility did not maintain required competency documentation for a registry LVN and a regular CNA assigned to two residents with complex medical needs. The LVN's file lacked a full skills checklist and performance evaluation, and the CNA's file was missing a skills checklist. Leadership could not confirm completion of these requirements, and the facility's own policy mandates such documentation for all staff, including agency personnel.
A resident who was fully dependent on staff and had a nephrostomy tube experienced multiple episodes of tube dislodgement, resulting in repeated hospital transfers for invasive procedures. Care plans lacked specific interventions to prevent dislodgement, and staff interviews indicated that improper handling during care likely contributed to the incidents. Unlicensed staff did not receive targeted training on nephrostomy tube care, and the facility's policies were not effectively implemented to prevent recurrence.
Two residents with severe cognitive impairment and ventilator dependence were placed in hand mittens to prevent accidental removal of tubing, with physician orders requiring removal and assessment of skin and circulation every two hours. However, staff only documented these checks every shift and did not include details about skin condition or circulation, contrary to orders and facility policy. Interviews confirmed a lack of consistent documentation and monitoring, resulting in a deficiency related to the use of physical restraints.
Three residents did not receive care according to professional standards: two residents with diabetes received insulin injections repeatedly in the same site without rotation, contrary to physician orders and facility policy, and another resident with end-stage renal disease and hypertension did not have their significantly elevated blood pressure reassessed or reported to a physician in a timely manner. Staff interviews and record reviews confirmed these failures in medication administration and monitoring.
Nursing staff failed to rotate insulin injection sites as ordered for two residents with diabetes, resulting in repeated use of the same sites. A discrepancy was found between the inventory and accountability record for a resident's oxycodone, due to a documentation error that was not corrected. Additionally, the Cubex drug dispensing record did not match the eMAR for a resident's Norco administration, as the nurse failed to document the dose after being called away.
Kitchen staff were unable to correctly demonstrate and verbalize proper dishwashing and QUAT sanitizer testing procedures, including incorrect use of the preparation sink, failure to air dry equipment, and not following manufacturer guidelines for sanitizer concentration testing. These practices had the potential to cause cross-contamination and foodborne illness among medically compromised residents.
Staff served 4 oz portions of BBQ pork instead of the prescribed 3 oz to 83 residents on regular texture diets, as confirmed by direct observation and review of facility records. The Registered Dietitian stated that this failure to follow the menu and portion guidelines resulted in meals not meeting the intended nutritional needs.
The facility did not consistently prepare or present food in a palatable, attractive, or properly textured manner, as observed with pureed cabbage that did not hold its shape, dry pork barbecue, and overcooked vegetables. Two residents with complex medical needs reported that the food was unappetizing and poorly prepared, and staff confirmed that food quality and presentation did not meet facility guidelines.
Surveyors identified multiple deficiencies in kitchen operations, including unclean equipment and storage areas, improper cold food holding temperatures, use of damaged trays and chopping boards, incorrect dishwashing and sanitizing procedures, and failure to maintain proper refrigerator temperatures. Staff did not consistently follow facility policies or manufacturer guidelines, resulting in unsanitary conditions and increased risk of food contamination for residents.
Surveyors found that food brought in by family and visitors for residents was not consistently stored at the required temperature of 41°F or below, as shown by refrigerator logs and staff interviews. Multiple days showed temperatures above the safe limit, and staff were unclear about the correct temperature range, affecting over a hundred medically compromised residents who stored food in the refrigerator.
Two dumpsters were found overflowing, uncovered, and surrounded by spilled food and trash, with both the Dietary Supervisor and Housekeeping Supervisor confirming the unsanitary conditions and failure to follow facility policy and Food Code requirements for proper garbage disposal and storage.
Two residents with severe cognitive impairment and complex medical conditions did not have comprehensive care plans developed or implemented for critical needs, including rectal tube management, edema, and pressure ulcers. Staff interviews and record reviews confirmed the absence of these care plans, with documentation lapses attributed to issues in the electronic medical record system and care plan management processes.
A resident with hypertensive chronic kidney disease and end stage renal disease did not receive a prescribed dose of furosemide during a morning med pass because an LVN withheld the medication due to the resident's scheduled dialysis later that day. Facility staff and the DON confirmed there was no clear instruction on which medications to hold or when, leading to a significant medication error.
A deficiency occurred when an LVN repeatedly left keys on top of an unattended medication cart while administering medications to a resident in the Subacute unit. The DON confirmed that these keys provide access to both medication carts and narcotic drawers, and facility policy requires secure storage of drugs accessible only to authorized personnel. The practice of leaving keys unattended did not comply with these requirements.
A resident with dementia and high fall risk experienced multiple falls, including one resulting in a shoulder fracture, due to inadequate supervision and failure to implement a person-centered care plan. Despite being identified as high risk, the facility did not provide necessary fall prevention measures such as supervision, padded mats, or a bed alarm. Family members and staff noted the lack of effective monitoring and communication regarding fall prevention strategies.
A resident with multiple health conditions was not allowed to return to the LTC facility after hospitalization, despite available isolation beds. The facility cited the need for a single isolation room, but records showed vacant beds. The resident's family was informed that a previous complaint affected the readmission, causing emotional distress.
A resident identified as a high fall risk experienced three unwitnessed falls within a month due to the facility's failure to implement its Fall Management Program. Despite being dependent on staff for orientation and ambulation, the resident attempted to self-ambulate and turn off their bed alarm. The facility's inadequate supervision and delayed response to the resident's call light contributed to the falls, highlighting the need for more effective interventions such as assigning a sitter.
A facility failed to document background checks and license information for staff assigned to a resident with severe medical conditions, increasing the risk of abuse. Despite the resident's dependency and cognitive impairment, the required documentation for the CNA and LVN was missing, contrary to the facility's abuse prevention policy.
A facility failed to develop a comprehensive care plan for a resident prescribed vancomycin, an antibiotic with serious potential side effects. The resident, with multiple health issues and total dependence on staff, did not have a care plan to manage the medication's administration and monitor for side effects. The Director of Nursing admitted the oversight, which was contrary to the facility's policies requiring person-centered care plans.
A resident undergoing chemotherapy for diffuse large B-cell lymphoma did not receive Filgrastim as ordered due to the medication's unavailability. The facility failed to ensure an adequate supply and did not notify the resident's physician. The medication was missed on two occasions, as confirmed by the MAR and staff interviews.
A CNA failed to wear a protective gown while taking vital signs of a resident on contact isolation for ESBL, contrary to the facility's infection control policy. The resident, undergoing chemotherapy for diffuse large B-cell lymphoma, required contact precautions, including PPE use. Despite posted instructions, the CNA did not comply, risking infection spread.
A facility failed to obtain physician-signed consent forms for a resident's psychotherapeutic medications before administration. The resident, with intact cognitive skills and the capacity to make decisions, was given Benztropine Mesylate and Haloperidol without documented physician consent, violating the facility's policy and the resident's rights.
A resident with an indwelling catheter was observed without a privacy cover for the drainage bag, violating their right to privacy and dignity. Despite facility policies requiring privacy bags for catheter drainage, staff had differing opinions on its necessity. The resident had severe cognitive impairment and required assistance with daily activities.
A resident with a nephrostomy tube experienced multiple dislodgements due to the facility's failure to implement and review the care plan effectively. The resident, with a history of chronic respiratory failure and urinary issues, required several hospital transfers for tube reinsertion. Observations showed improper securing of the tube and incorrect placement of the drainage bag. Staff interviews revealed inconsistent documentation and lack of investigation into the dislodgements, despite existing care plan interventions and facility policies.
A resident with a history of pressure ulcers and severe cognitive impairment developed a mark on their abdomen due to improper placement of a nephrostomy regulator. The facility failed to follow its policy on preventing pressure injuries, which required identifying at-risk residents and implementing appropriate interventions.
A facility failed to report an injury of unknown source for a non-verbal, fully dependent resident with contracted limbs. The resident was found with extensive bruising, which worsened over time. Despite the severity and unusual location of the injury, the DON did not report the incident to the State Agency, believing it was not a case of abuse or unknown source injury.
The facility failed to implement infection control policies for four residents by not identifying and preventing the spread of scabies, not placing a resident on isolation precautions, and not assessing or notifying the resident's roommates and their physicians about potential exposure. This led to a potential risk of scabies transmission to 158 in-house residents, staff, and the community.
The facility failed to conduct proper skin assessments and notify physicians about ineffective treatments for five residents, resulting in prolonged discomfort and potential harm. One resident experienced unrelieved itching and was referred for psychiatric services due to crying episodes. The facility did not follow its policies for skin assessments and infection control, leading to ongoing rashes and lack of timely diagnosis and treatment.
Failure to Respond Timely to Resident Call System
Penalty
Summary
The facility failed to ensure that two of four sampled residents received care in accordance with professional standards by not answering the resident call system in a timely manner. One resident, who was dependent on staff for most activities of daily living due to chronic respiratory failure, mobility issues, and generalized anxiety disorder, reported that call lights sometimes went unanswered for half an hour or more, leading to feelings of unsafety, frustration, and anxiety. Direct observation confirmed a delay of seven minutes in responding to this resident's call light. Staff interviews acknowledged that call lights should be answered immediately, but the assigned CNA was unaware of the call due to assisting other residents at the time. Another resident, with diagnoses including metabolic encephalopathy, COPD, and chronic kidney disease, also required significant assistance and reported that call lights often took a couple of hours to be answered. This resident stated that staff frequently cited short staffing as the reason for delays and expressed feelings of neglect. The facility's policies require prompt response to call systems and provision of care based on comprehensive assessments, but these standards were not met, as evidenced by resident reports, staff interviews, and direct observation.
Failure to Ensure Staff Competency Documentation for Nursing and CNA Staff
Penalty
Summary
The facility failed to ensure that both a registry nurse (LVN) and a regular CNA assigned to two residents had the necessary competencies documented in their employee files. For the LVN, who was assigned to a resident with Type 2 Diabetes, chronic kidney disease, and obesity, there was no full skills checklist or performance evaluation in the employee file. The Director of Staff Development (DSD) and Director of Nursing (DON) could not confirm whether the required documentation existed or was completed, and the LVN himself was unaware of any abuse training or skills checklist being completed through the facility or the registry. The only documentation provided was a nephrostomy training checklist and a vague orientation verification, which was acknowledged by facility leadership as insufficient and not specific to the facility. For the CNA, who was assigned to a resident with hemiplegia, cerebral infarction, and urinary incontinence, the employee file also lacked a skills checklist. The DSD noted that the CNA had a history of sleeping on the job, but no documentation of competency was available in the file. The Assistant Director of Nursing (ADON) was unable to provide information on when or how often performance evaluations or skills checklists were completed, indicating a lack of oversight in ensuring staff competency. A review of the facility's policy indicated that the administrator is responsible for verifying that agency and contract staff have documentation of competencies and skills to care for the resident population. However, the facility did not have the required documentation for the LVN and CNA, resulting in a failure to ensure that staff had the appropriate competencies to care for residents as required by facility policy.
Failure to Prevent Recurrent Nephrostomy Tube Dislodgement
Penalty
Summary
The facility failed to provide necessary care and services to prevent the recurrent dislodgement of a nephrostomy tube for a resident who was completely dependent on staff for all activities of daily living. The resident, who had significant medical conditions including chronic respiratory failure, anoxic brain damage, cardiac arrest, and quadriplegia, experienced multiple episodes where the nephrostomy tube became dislodged, resulting in repeated transfers to a general acute care hospital for invasive procedures. The care plans reviewed did not include specific interventions aimed at preventing the dislodgement of the nephrostomy tube, despite the resident's high risk and history of such incidents. Staff interviews revealed that the resident was unable to move or pull out the nephrostomy tube independently, and the likely cause of dislodgement was attributed to staff actions during care activities such as turning, repositioning, and bathing. Several staff members, including CNAs, LVNs, and RNs, acknowledged witnessing the tube dislodged on multiple occasions and indicated that the tube could be easily hidden under skin folds or not properly secured during care. The facility's policy and procedure for nephrostomy care required checking the placement and integrity of the tube, but there was no evidence that unlicensed staff received competency training specific to nephrostomy tube care. Documentation and interviews indicated that the care plans were updated after each incident but continued to lack preventive interventions for tube dislodgement. The repeated failure to implement effective measures to secure the nephrostomy tube and ensure staff competency in its care led to ongoing complications for the resident, including multiple hospitalizations and exposure to further medical risks.
Failure to Document Required Monitoring and Release of Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the improper use of physical restraints, specifically hand mittens, by not documenting the required release of the mittens and monitoring for skin breakdown and impaired circulation every two hours as ordered by physicians. For one resident with severe cognitive impairment and dependence on ventilator support, physician orders and care plans specified that a hand mitten should be applied to prevent accidental removal of tubing, with removal every two hours for assessment of skin and circulation. However, documentation was only completed every shift, not every two hours, and did not include details about the resident's skin condition or circulation. Staff interviews confirmed a lack of clarity on where or how to document these assessments, and the Director of Nursing acknowledged that the documentation was insufficient and did not meet the required frequency or detail. A second resident, also with severe cognitive impairment and ventilator dependence, had similar orders for the use of a right-hand mitten with checks for skin integrity and circulation every two hours. The Medication Administration Record showed check marks indicating tasks were performed, but there was no descriptive documentation of the resident's skin condition or circulation. Staff interviews revealed that nurses were expected to document any changes in condition, but there was no routine documentation of the required assessments. Observations confirmed that the hand mitten was in use and that, while the resident's skin appeared intact at the time of surveyor review, the required documentation was not present in the records. The facility's policy on physical restraints emphasized the need for ongoing monitoring and documentation to minimize risks such as skin breakdown and impaired circulation. Despite this, both residents' records lacked the necessary documentation to demonstrate that the hand mittens were being released and that skin and circulation were being assessed at the required intervals. This failure to follow physician orders and facility policy constituted a deficiency in the care provided to these residents.
Failure to Rotate Insulin Sites and Reassess High Blood Pressure
Penalty
Summary
Facility staff failed to provide care and services in accordance with professional standards for three residents. Two residents with diabetes mellitus received insulin injections without proper rotation of injection sites, despite physician orders and facility policy requiring site rotation to prevent tissue damage. Medication Administration Records (MARs) showed repeated administration of insulin in the same arm over multiple days for both residents, and interviews with nursing staff and the Director of Nursing confirmed that injection sites were not rotated as required. Additionally, a resident with end-stage renal disease and hypertension did not receive timely reassessment or appropriate follow-up after a significantly elevated blood pressure reading. The resident's blood pressure was recorded as 194/86, but the assigned nurse did not recheck the blood pressure or notify the physician, citing workload as the reason for not following up. The resident expressed concern and requested transfer to the emergency room, and subsequent interviews with nursing leadership confirmed that the nurse did not follow established protocols for managing elevated blood pressure. Facility policies and procedures reviewed during the survey specified the need for rotating insulin injection sites and prompt response to changes in resident condition, including notification of the physician and reassessment. Staff interviews and record reviews confirmed that these protocols were not followed for the affected residents, resulting in deficiencies related to medication administration and monitoring of significant changes in condition.
Medication Administration and Documentation Deficiencies
Penalty
Summary
Nursing staff failed to rotate insulin injection sites as ordered for two residents with type 2 diabetes. For one resident, insulin was repeatedly administered in the left arm over consecutive administrations, and for another, injections were frequently given in the same abdominal quadrants, as documented in the electronic medication administration record (eMAR). The facility's infection preventionist confirmed that the records showed consecutive injections at the same sites, contrary to physician orders and facility policy requiring site rotation. A discrepancy was identified in the inventory and accountability record for a resident receiving oxycodone for pain management. During a medication count, the number of tablets present did not match the count sheet, and a review revealed a duplication error on the count sheet that was not corrected or noted by the nurse. The director of nursing acknowledged the error was due to a failure to document the correction. Additionally, the Cubex automated drug dispensing system's activity record did not match the eMAR for another resident receiving Norco for pain. The Cubex system showed a tablet was dispensed, but there was no corresponding documentation in the eMAR. The director of nursing stated that the nurse forgot to document the administration after being called away to attend to another resident. The facility's documentation policy did not specify procedures for medication administration documentation.
Failure to Ensure Dietary Staff Competency in Dishwashing and Sanitizer Testing Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were regularly trained and evaluated for competency in dishwashing procedures, as evidenced by staff being unable to correctly demonstrate and verbalize the process for checking quaternary ammonium compound (QUAT) sanitizer concentration and proper dishwashing techniques. During observation, a dietary aide washed a mixer in the three-compartment sink, followed the wash, rinse, and sanitize process, but then rinsed the mixer with water in the preparation sink, which is designated exclusively for food preparation. The dietary aide acknowledged this was a mistake, as the final step should have been air drying, not rinsing with water, to prevent chemical contamination. The dietary supervisor was unsure about the correct duration for dipping items in the sanitizer and incorrectly stated that spraying with water after sanitizing would be acceptable. Further observations revealed that both dietary aides and the dietary supervisor did not follow the manufacturer's guidelines for QUAT sanitizer concentration testing. Staff demonstrated incorrect procedures by dipping test strips for 15-20 seconds instead of the required 10 seconds and did not check the solution temperature as specified by the manufacturer. The dietary supervisor confirmed that these deviations could result in inaccurate readings and improper sanitization, potentially leading to cross-contamination. Review of facility policies, job descriptions, and competency checklists showed that while staff were deemed competent in some areas, there was no specific verification of competency for air-drying procedures or adherence to the correct sanitizer testing protocol. The report notes that these deficient practices had the potential to result in harmful bacterial growth and cross-contamination, which could lead to foodborne illness in 133 of 206 medically compromised residents who received food and ice from the kitchen. The findings were based on direct observation, staff interviews, and review of facility policies, job descriptions, and relevant food safety codes.
Failure to Follow Menu Portion Sizes for BBQ Pork
Penalty
Summary
The facility failed to follow its established menu and portion guidelines for residents on regular texture diets by serving 4 ounces of BBQ pork instead of the prescribed 3 ounces. This was identified through a review of the facility's daily spreadsheet, which specified a 3-ounce portion, and confirmed by direct observation and weighing of the portions served, which consistently exceeded the specified amount. Staff interviews revealed that the incorrect portioning occurred because a different staff member was responsible for cutting and serving the BBQ pork, and the Registered Dietitian confirmed that the menu and portion sizes were not being followed as required. Further review of the facility's standardized recipe and policies confirmed that the correct portion size should have been 3 ounces. The facility's policy mandates that menus are to be developed and prepared to meet residents' nutritional needs, including providing food in the correct amount, type, and consistency. The Registered Dietitian stated that serving incorrect protein portions could alter the nutritional content of the meals, resulting in the menu no longer meeting the intended nutritional needs of the residents.
Failure to Prepare and Present Palatable, Attractive, and Properly Textured Food
Penalty
Summary
The facility failed to prepare and serve food in a manner that conserved flavor, appearance, and appropriate texture, as evidenced by multiple observations and interviews. During lunch service, pureed cabbage did not hold its shape on the plate and appeared flat, which was confirmed by the Dietary Supervisor, who stated that pureed foods should be creamy, smooth, and able to hold their shape. The Dietary Supervisor acknowledged that the dietary staff did not achieve the required presentation, making it difficult to serve and potentially decreasing residents' appetites. Additionally, the pork barbecue served was observed to be dry, and the vegetables were overcooked and olive green in color, which affected their palatability and appearance. Two residents with significant medical histories, including end stage renal disease and type 2 diabetes mellitus, were specifically identified as being affected by these deficiencies. Both residents were on specialized diets requiring careful attention to nutritional content and food preparation. One resident reported that the vegetables served were overcooked and fell apart, while the other stated that the food did not look appetizing or taste good. Observations confirmed that the pork barbecue was dry due to being left in the oven too long, and the vegetables were not visually appealing. Review of the facility's policies and procedures indicated that food should be prepared to maintain nutritive value, appearance, and resident satisfaction, with specific guidelines for vegetable cookery and pureed foods. However, the observed practices did not align with these policies, as food was not consistently prepared or presented in a palatable or attractive manner. The failure to follow established guidelines for food preparation and presentation was directly observed and confirmed by staff interviews and resident feedback.
Widespread Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, preparation, and sanitation. Kitchen equipment and areas, including reach-in freezers and refrigerators, were found with dirt buildup, dried spills, and food debris. The Dietary Supervisor confirmed that cleaning schedules were not adequately followed, resulting in unsanitary conditions that could lead to physical contamination. Additionally, food items such as tuna salad and turkey slices were stored above the required cold holding temperature, and dented cans were found mixed with non-dented cans in the emergency food supply, contrary to facility policy and food safety standards. Further deficiencies were noted in the maintenance and use of kitchen equipment and utensils. All resident trays used for meal service were cracked and chipped, and chopping boards were observed with scratches and chips, making them difficult to clean and increasing the risk of cross-contamination. Pans were stacked wet while air drying, and staff were observed rinsing sanitized equipment with water, which negated the sanitizing process. Staff also failed to follow manufacturer guidelines for testing the concentration of the QUAT sanitizer, using incorrect timing and not checking solution temperature, which could result in improper sanitization of food contact surfaces. Refrigerator temperature logs showed that food was stored at temperatures above the recommended maximum of 41°F, with staff unaware of the correct danger zone for food safety. The facility's policies and procedures were not consistently followed, and staff demonstrated a lack of understanding of proper food safety practices during interviews. These actions and inactions led to multiple deficiencies in food safety and sanitation, as directly observed and documented by surveyors.
Improper Storage Temperatures for Resident Food from Outside Sources
Penalty
Summary
The facility failed to ensure that food brought in from outside sources for residents was stored at a safe temperature of 41 degrees Fahrenheit or below, as required by both facility policy and the 2022 Food Code. During a review of refrigerator temperature logs, it was found that the food refrigerator on Station 4 had recorded temperatures of 42 F on multiple dates throughout March. Licensed Vocational Nurses (LVNs) interviewed were not fully aware of the correct temperature range for safe food storage, with one LVN stating the acceptable range was 36 F to 46 F, which is inconsistent with facility policy and regulatory standards. The facility's policies and procedures clearly state that refrigerated food must be kept at 41 F or below, and that food brought in by family or visitors should be stored safely for no more than 48 hours. The deficiency was identified through observation, interview, and record review, revealing that 133 out of 206 medically compromised residents who store food in the resident refrigerator were potentially affected. The temperature logs and staff interviews confirmed that the refrigerator was not consistently maintained at the required temperature, and staff were not fully knowledgeable about the danger zone for foodborne bacterial growth. This lapse in maintaining proper food storage temperatures and staff awareness directly led to the deficiency cited by surveyors.
Improper Disposal and Storage of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse as required, as observed during a survey. Two out of four dumpsters were found overflowing with trash, not completely covered when not in use, and the surrounding area was littered with food spillage, used gloves, and soiled paper cups. The Dietary Supervisor acknowledged that the dumpsters needed to be completely covered to prevent rodents from accessing the trash and noted that their proximity to the kitchen posed a potential hazard. The Housekeeping Supervisor also confirmed that the trash bins were full, not closed, and the area was contaminated with food splatters and used gloves. A review of the facility's policies and procedures indicated that garbage and refuse containers should be maintained in good condition, kept covered, and the storage area should be kept sanitary to prevent pest harborage. The Food Code 2022 further requires that outside receptacles have tight-fitting lids or covers and that garbage storage areas be kept clean to minimize odors and prevent attracting pests. The observed conditions did not meet these requirements, as the dumpsters were not properly covered and the surrounding area was not kept clean.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents with complex medical needs. For one resident with anoxic brain damage, pressure ulcers, and reduced mobility, the facility did not create a care plan addressing the use and management of a rectal tube. Documentation showed that the rectal tube became dislodged, and although the medical doctor was notified and orders were given to discontinue the tube, there was no care plan in place to guide staff in monitoring or caring for the rectal tube. Interviews with the treatment nurse, MDS nurse, and DON confirmed the absence of a rectal tube care plan and acknowledged that such a plan should have been developed to ensure proper care and infection control. For another resident with anoxic brain damage, chronic kidney disease, pressure ulcers, and muscle weakness, the facility did not develop care plans for the resident's edema or pressure ulcer. The resident experienced significant weight loss attributed to fluid loss from edema and was receiving Lasix. Despite ongoing wound care and weekly assessments, staff could not locate care plans for either the edema or the pressure ulcer. The treatment nurse and MDS nurse both confirmed the lack of these care plans and stated that the absence of such plans could result in improper monitoring of the resident's conditions. The deficiency was further compounded by issues with the facility's electronic medical record system, where previous care plans were closed upon the resident's readmission, and new care plans were not properly created or updated. The MDS nurse and DON both acknowledged that the process of closing and reopening care plans led to the omission of necessary care plans for the resident's current conditions. The facility's own policy required the development of person-centered comprehensive care plans to address each resident's medical, physical, and psychosocial needs, which was not followed in these cases.
Significant Medication Error Due to Unclear Orders on Dialysis Days
Penalty
Summary
A licensed vocational nurse (LVN) failed to administer a prescribed dose of furosemide to a resident with hypertensive chronic kidney disease and end stage renal disease. During a morning medication pass, the LVN withheld the furosemide, stating it was due to the resident's scheduled dialysis appointment in the afternoon. The resident's physician's order specified furosemide 40 mg by mouth twice daily for hypertension, but there was also a separate order allowing medications to be held on dialysis days without specifying which medications or the timing relative to dialysis sessions. Interviews with staff revealed that there was no clear guidance on which medications should be held or when, particularly if dialysis was scheduled for later in the day. The Director of Nursing (DON) stated that all morning medications should be given if the resident is present in the facility unless otherwise specified, and that nurses should clarify with the physician if there is any uncertainty. The facility's policy required medications to be administered according to physician orders, but this was not followed in this instance, resulting in a significant medication error.
Unattended Medication Cart Keys Lead to Drug Storage Deficiency
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) was observed leaving keys on top of an unattended medication cart in the Subacute unit. On two separate occasions, the LVN unlocked the medication cart, placed the keys on top, and then left the cart unattended while administering medications to a resident inside a room. During one observation, a housekeeping staff member confirmed that the nurse was inside the room while the keys remained on the cart in the hallway. The LVN later acknowledged that the keys should have been kept in their pocket rather than left on the cart. The Director of Nursing (DON) confirmed that the keys used by nurses open both the medication carts and the narcotic drawers, and stated that keys should not be left on top of unattended carts. A review of the facility's policy indicated that drugs should only be accessible to designated personnel and that storage methods must prevent access by other patients. The observed practice of leaving keys unattended on the cart did not align with these requirements, resulting in a deficiency related to the secure storage of drugs and biologicals.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide a safe and accident-free environment for a resident who was assessed as a high fall risk due to impaired gait, mobility, and a diagnosis of dementia. The resident experienced multiple falls, including one that resulted in a minimally displaced acute acromion fracture. The facility did not provide adequate supervision or implement a person-centered care plan to prevent falls, as required by their Fall Management Program policy. The resident's care plan included interventions such as placing the call light within reach and encouraging the resident to use the call bell for assistance. However, the resident was too confused to be oriented to the call light and did not know how to use it. Despite being identified as a high fall risk, the facility did not have orders for supervision, padded mats, or a bed alarm prior to the falls. The resident's fall risk assessment indicated a score of 14, classifying them as high risk, yet the necessary fall prevention protocols were not initiated or documented on the care plan. Interviews with staff and family members revealed that the facility did not adequately monitor the resident or modify the care plan to prevent falls. The Director of Nursing acknowledged that the resident was found on the floor and likely broke their acromion during one of the falls. Family members expressed concerns about the facility's failure to protect the resident from falls and the lack of communication regarding fall prevention measures. The facility's policy required monitoring the effectiveness of interventions and modifying the care plan as necessary, which was not done in this case.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return to the nursing home following hospitalization, which was a violation of their policy. The resident, who had a history of chronic respiratory failure, dysphagia, generalized muscle weakness, type 2 diabetes, encephalopathy, and cerebrovascular accident with paraplegia, was transferred to a general acute care hospital (GACH) on multiple occasions. Despite being ready for discharge back to the skilled nursing facility (SNF) on several dates, the facility did not permit the resident to return, citing the unavailability of a single isolation room. The facility's census records indicated that there were vacant isolation beds available on several occasions, yet the resident was not readmitted. The Director of Admissions and other staff members stated that the resident required a single isolation room and could not be cohorted with other residents. The facility's policy stated that residents should be permitted to return to their previous room if available or to an available bed in the location they previously resided, but this was not adhered to in this case. Interviews with the facility's staff and the resident's family member revealed that the family member was informed that the resident could not return due to a previous complaint filed against the facility. This situation caused emotional distress and confusion for the resident's family member, who preferred the resident to return to the same facility. The facility's actions were inconsistent with their policy of permitting residents to return after hospitalization or therapeutic leave.
Failure to Implement Fall Management Program for High-Risk Resident
Penalty
Summary
The facility failed to implement its Fall Management Program for a resident identified as a high fall risk, resulting in three unwitnessed falls within a 30-day period. The resident, who was dependent on staff for orientation and ambulation, experienced falls on three separate occasions, each requiring a transfer to an acute general care hospital for a CT scan to rule out head injuries. The resident's medical history included hemiplegia, hemiparesis, and altered mental status, which contributed to their high fall risk. The resident's care plan, which was intended to minimize the risk of injury from falls, included interventions such as anticipating and meeting the resident's needs. However, the resident was found attempting to self-ambulate and turn off their bed alarm, indicating that the interventions were not effectively preventing falls. Interviews with staff revealed that the resident was forgetful and non-compliant, often attempting to get up unassisted despite being provided with a urinal and a bed alarm. The facility's failure to provide adequate supervision and timely response to the resident's call light contributed to the falls. On one occasion, the resident's call light went unanswered for an hour while a family member was on a FaceTime call, during which the resident attempted to go to the bathroom and fell. Staff interviews indicated that the resident might benefit from having a sitter, as all other measures had failed to prevent falls. The facility's policy on adequate supervision was not effectively implemented, leading to the repeated incidents.
Failure to Document Staff Background Checks and Licenses
Penalty
Summary
The facility failed to ensure that the assigned staff for one of the residents, who had severe medical conditions, had the necessary background checks and license information documented in their employee files. The resident, who was admitted with serious diagnoses including traumatic subdural hemorrhage, persistent vegetative state, and chronic respiratory failure, was found to have a fracture in the left humerus. Despite the resident's severe cognitive impairment and total dependency on staff for care, the facility did not have the required documentation for the certified nurse assistant and licensed vocational nurse assigned to the resident, which increased the risk of abuse. The facility's policy on abuse prevention required checking with licensing boards and registries before hiring and annually thereafter, but this was not adhered to. During interviews, both the licensed vocational nurse and certified nurse assistant assigned to the resident reported not observing any signs of bruising or pain, and the resident's family was actively involved in the resident's care. However, the lack of documented background checks and license verification for these staff members was a significant oversight, as confirmed by the facility administrator during the survey.
Failure to Develop Care Plan for Antibiotic Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was prescribed the antibiotic vancomycin to treat an infection caused by Clostridium difficile. This oversight was identified during a review of the resident's records and an interview with the Director of Nursing (DON). The resident, who had been readmitted to the facility with diagnoses including diabetes mellitus type 2, anoxic brain damage, and myoclonus, was found to have moderate cognitive impairments and was totally dependent on staff for activities of daily living. Despite these needs, the facility did not create a care plan to manage the administration of vancomycin, which is known to have serious side effects, particularly in elderly patients. The deficiency was highlighted during a review of the facility's policies and procedures, which mandate the development of person-centered comprehensive care plans that address the resident's medical, physical, mental, and psychosocial needs. The DON acknowledged that the staff did not initiate a care plan for the medication, which was necessary to ensure appropriate care and prompt reporting of any side effects to the physician. This failure had the potential to result in serious adverse effects, including skin reactions, hearing loss, and kidney dysfunction, due to the lack of a structured plan to monitor and manage the resident's condition while on vancomycin.
Failure to Administer Filgrastim as Ordered
Penalty
Summary
The facility failed to administer medication as per the physician's order for a resident diagnosed with diffuse large B-cell lymphoma, who was undergoing chemotherapy. The resident was prescribed Filgrastim, a medication to increase neutrophils and help fight infections, to be administered subcutaneously once a day for five days following chemotherapy. However, the medication was not administered on two occasions, as it was not available in the facility. The missed doses occurred on 6/22/24 and 7/11/24, as documented in the Medication Administration Record (MAR). The facility also failed to ensure an adequate supply of Filgrastim was available and did not notify the resident's primary physician or oncologist about the unavailability of the medication. Interviews with the registered nurse supervisor and the Director of Nursing confirmed that the medication was not administered due to its unavailability and that the physician should have been notified. The facility's policies and procedures indicated that medications should be reordered in advance to ensure an adequate supply, but this was not adhered to in this case.
Failure to Follow Contact Isolation Protocols
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy for a resident on contact isolation due to Extended Spectrum Beta-Lactamase (ESBL) in the urine. On a specific date, a certified nursing assistant (CNA) did not wear a protective gown while taking the vital signs of a resident who was on contact isolation. This action was contrary to the facility's policy, which required staff to wear a protective gown when entering the room of a resident on contact precautions to prevent the spread of infection. The resident in question was admitted with diagnoses including diffuse large B-cell lymphoma and muscle weakness and was undergoing chemotherapy. The resident's care plan indicated the need for contact precautions, including the use of personal protective equipment (PPE) such as gowns and gloves. Despite a sign posted outside the resident's room indicating the requirement for PPE, the CNA proceeded to take the resident's vital signs without wearing a gown and then continued to take the vital signs of the resident's roommates. The infection preventionist confirmed that the CNA should have worn a protective gown to prevent potential infection spread.
Failure to Obtain Physician-Signed Consent for Psychotherapeutic Medications
Penalty
Summary
The facility failed to ensure that a resident's psychotherapeutic medication consent forms were signed by a physician prior to administration. This deficiency involved a resident who was admitted with diagnoses including malignant neoplasm of the colon, diabetes Type II, and schizophrenia. The resident was assessed to have intact cognitive skills and the capacity to understand and make decisions. However, the informed consent forms for the medications Benztropine Mesylate and Haloperidol were verified by phone but did not include the name of the physician who obtained the consent before the medications were administered. During an interview and record review, the Director of Nursing confirmed the absence of documented evidence that the informed consents were obtained from the physician before starting the drug therapy. The facility's policy required that a licensed nurse should not administer psychotherapeutic medication until a written informed consent by the prescribed physician was documented in the resident's medical record. This oversight violated the resident's right to make an informed decision regarding the use of psychoactive medications.
Failure to Provide Privacy for Resident's Catheter
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident with an indwelling catheter by not providing a privacy cover for the catheter drainage bag. The resident, who was admitted with chronic respiratory failure, obstructive and reflux uropathy, and urine retention, had severely impaired cognitive skills and was dependent on assistance for daily activities. During an observation, the resident was seen in bed with the catheter drainage bag exposed, lacking a privacy cover. Interviews with facility staff revealed conflicting views on the necessity of a privacy bag for the resident's catheter. One licensed vocational nurse (LVN) stated that the privacy bag was unnecessary because the resident did not leave her room, while another LVN acknowledged the need for a privacy bag to maintain the resident's dignity. The facility's policies on urinary catheter care and dignity and respect, which were reviewed earlier in the year, indicated that urinary drainage bags should be placed in privacy bags to preserve resident dignity.
Failure to Implement and Review Nephrostomy Care Plan
Penalty
Summary
The facility failed to ensure the care plan for a resident with a nephrostomy tube was effectively implemented and reviewed. The resident, who had a history of chronic respiratory failure, obstructive and reflux uropathy, and urinary retention, experienced multiple incidents where the nephrostomy tube was dislodged. These incidents occurred on several occasions, requiring the resident to be transferred to a general acute hospital for reinsertion of the tube. The care plan, which was supposed to minimize the risk of complications from the nephrostomy tube, was not adequately reviewed or revised after each dislodgement. The facility did not ensure that the nephrostomy tube was properly anchored and secured to prevent it from being pulled or dislodged. Observations revealed that the tube was not securely taped, and the drainage bag was placed at the level of the resident's thigh, rather than below the bladder as required. Interviews with staff, including the Director of Nursing, indicated a lack of consistent documentation and investigation into the reasons for the frequent dislodgement of the tube. Despite the care plan's interventions, there was no evidence that the facility had taken steps to address the issue effectively. The facility's policies and procedures for developing and implementing comprehensive care plans and nephrostomy care were not followed. The care plan was supposed to be person-centered and address the resident's medical and psychosocial needs, but it failed to prevent the repeated dislodgement of the nephrostomy tube. The lack of adherence to the facility's guidelines and the absence of a thorough investigation into the causes of the dislodgement contributed to the ongoing issue, impacting the resident's care and requiring multiple hospital transfers.
Failure to Prevent Medical Device-Related Pressure Injury
Penalty
Summary
The facility failed to protect the skin of a resident from prolonged pressure caused by a medical device. Specifically, the nephrostomy regulator was improperly taped against the resident's abdomen, resulting in a mark that conformed to the shape of the device. This was observed during a dressing change by an LVN, who acknowledged that the mark could potentially lead to a pressure ulcer. The resident had a history of pressure ulcers and was at a higher risk for developing them due to immobility and incontinence. The resident, who had been admitted to the facility with chronic respiratory failure and urinary issues, was dependent on staff for daily care activities. The care plan for the resident included monitoring skin status and reporting any changes to a physician. However, the facility's failure to adhere to these interventions resulted in the development of a mark on the resident's skin. The facility's policy on preventing pressure ulcers emphasized the importance of identifying at-risk residents and implementing individualized interventions, which were not effectively executed in this case.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to implement their policy regarding the reporting of an injury of unknown source for a resident. The resident, who was non-verbal, fully dependent, and had contracted limbs, was found with extensive bruising on the left side of the trunk extending to the right side under the breast. The bruising was first noticed by a CNA and reported to the charge nurse. The next day, the bruising had worsened significantly. Despite the severity and unusual location of the injury, the Director of Nursing did not report the incident to the State Agency or any other reporting agencies, as she did not believe it was a case of abuse or an injury of unknown source. The resident had multiple diagnoses, including metabolic encephalopathy, dysphagia, and unspecified dementia, and was on anticoagulant medication, which increased the risk of bleeding. The facility's policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source, be reported immediately or within 24 hours, depending on the severity. However, this policy was not followed, resulting in a delay of an onsite inspection by the Department of Public Health to investigate the injury and ensure the resident's safety.
Failure to Implement Infection Control Policies for Scabies
Penalty
Summary
The facility's staff failed to implement infection control policies and procedures for four of five sampled residents by not identifying and preventing the spread of scabies when a resident had a skin rash. The resident was not placed on transmission-based precautions when diagnosed with scabies, and control measures to prevent the transmission of scabies among residents, staff, and visitors were not implemented. Additionally, the facility did not assess the resident's roommates for potential exposure to scabies or perform contact tracing for staff and residents to identify potential scabies exposure. A resident was admitted with multiple diagnoses, including hemiplegia, hemiparesis, aphasia, dysphagia, and anxiety. The resident developed a skin rash, which was initially treated as dermatitis and later as shingles. Despite ongoing symptoms, the resident was not properly assessed for scabies until a dermatology appointment confirmed the diagnosis. The facility failed to place the resident on isolation precautions and did not assess or notify the resident's roommates and their physicians about potential exposure. The facility's infection prevention and control program was not followed, leading to a potential risk of scabies transmission to 158 in-house residents, staff, and the community. The facility's staff did not adhere to infection control policies, resulting in an Immediate Jeopardy situation. The facility's policies and procedures for infection control, resident isolation, and reporting communicable diseases were not properly implemented, contributing to the deficiency.
Removal Plan
- The licensed nurse contacted Resident 1's physician and obtained orders for a skin scraping to identify the presence of scabies mites, the test was completed and sent the specimen to the laboratory for processing. The licensed nurses began immediate cleaning and disinfection of all multi-use resident care equipment to reduce the potential to transmit contagious skin rashes to the extent possible.
- The Clinical Consultant in serviced the DON, Infection Prevention Nurse (IPN), and the Administrator on the facility's P &P and the guidelines for Prevention and Control of Scabies in California Healthcare settings.
- The DON and IPN began in servicing licensed nurses working in the facility on the facility's P & P and the guidelines for Prevention and Control of Scabies in California Healthcare settings including weekly assessments of each residents skin, completion of change in condition assessments for all resident rashes identified, notification of the resident's physician and representative and under the direction and guidance of the physician, place the resident on contact precautions, complete a skin scraping to identify the presence of scabies mites, and proper use of PPE.
- The licensed nurse completed head to toe body assessments of Residents 3, 4, and 5 to identify the presence of a skin rash. Residents 3, 4, 5 do not have evidence of skin rash or complaints of itching.
- The DON and RN Supervisors reviewed and revised Residents 3 and 4's care plans to address the changes in condition, potential exposure to a resident with possible scabies rash and to ensure continued care and services to maintain their highest practicable outcomes.
- Physical Plant and Environmental Services Consultants in-serviced housekeeping supervisor and housekeeping staff regarding Housekeeping Disinfection Plan which includes using EPA approved disinfectant for cleaning, wearing gloves and long sleeve gown while conducting disinfection, changing gloves and long-sleeve gown between affected resident rooms, performing handwashing between rooms and tasks, changing water, mop, and rags between resident rooms or between disinfection tasks, and when possible complete cleaning and disinfection of each affected room while the resident is showering. The housekeeping staff deep cleaned Resident l, 3, 4, and 5's room. 3rd and 4th Floor were deep cleaned to reduce potential for transmission of contagious pathogens.
- The DON and the IPN completed 144 of 158 resident body assessments to identify the presence of rashes on other residents to prevent harm to affected residents. Dermatologist also completed an assessment of all 158 residents to identify residents who are likely to suffer, a serious adverse outcome because of the facility's noncompliance. 17 of 158 residents were identified with rashes by the DON and the Dermatologist. 15 of the 17 residents already have on-going treatment orders for identified skin rashes. 2 of the 17 residents are newly identified with diagnosis of unspecified dermatitis. The licensed nurses completed change in condition assessments for the 17 residents identified with skin rashes and their roommates, notified their physicians and resident representatives. Placing the 17 newly identified residents with unspecified dermatitis on isolation, performed scraping for 16 out of 17 residents and completion of Elimite treatments per physician.
- Clinical Consultant continued evaluation through interview of available staff to identify any staff with skin conditions. To reduce the potential for transmission of contagious rashes, employee interviews continue in person and via the telephone, prior to staff working with residents during their next assigned shift, to identify any staff members with skin conditions. 149 of 200 staff were interviewed and contacted. Three staff who reported itchiness and identified with rashes were offered Elimite.
- The IPN revised new employee and annual infection prevention and control training to include education of Scabies prevention in Healthcare Settings and reporting the development of new skin rashes identified to their physician, especially when known to have provided direct care with residents diagnosed with contagious skin rashes.
Failure to Provide Proper Skin Assessments and Notify Physicians
Penalty
Summary
The facility failed to provide care, treatment, and services for five residents in accordance with professional standards of practice. Specifically, the facility did not conduct proper assessments to identify the cause of generalized and severely itchy skin rashes for two residents, despite multiple treatments. Additionally, the facility did not notify a physician that the treatment ordered for the skin rashes was ineffective, as required by the residents' care plans. This resulted in one resident experiencing unrelieved itching, discomfort, and inability to sleep, and an increase in their Zoloft dosage due to crying episodes. The resident was eventually referred for psychiatric services due to intermittent crying episodes. The facility also failed to assess four other residents for generalized itchy skin rashes and did not notify a physician about these conditions. These residents had no pre-existing skin conditions upon admission or readmission to the facility. The lack of timely diagnosis and appropriate treatment placed these residents at increased risk for significant decline in their physical, mental, or psychosocial well-being. The facility's failure to implement routine skin assessments and notify physicians of ineffective treatments contributed to the residents' ongoing discomfort and potential for further complications. Observations and interviews revealed that the facility did not follow its policies and procedures for skin assessments and infection control. Staff members admitted that they did not conduct proper assessments or notify physicians in a timely manner. The facility's documentation also lacked detailed descriptions of the residents' skin conditions, and there was no evidence of follow-up actions to address the ongoing rashes. This lack of adherence to professional standards of practice and facility policies resulted in the residents' prolonged suffering and potential for further harm.
Removal Plan
- The licensed nurse contacted Resident 1's physician and obtained orders for a skin scraping to identify the presence of scabies mites, the test was completed and sent the specimen to the laboratory for processing. The licensed nurses began immediate cleaning and disinfection of all multi-use resident care equipment to reduce the potential to transmit contagious skin rashes to the extent possible.
- The Clinical Consultant inserviced the DON, Infection Prevention Nurse (IPN), and the Administrator on the facility's policy and procedures (P &P) and the guidelines for Prevention and Control of Scabies in California Healthcare settings.
- The DON and IPN began in servicing licensed nurses working in the facility on the facility's P & P and the guidelines for Prevention and Control of Scabies in California Healthcare settings including weekly assessments of each residents skin, completion of change in condition assessments for all resident rashes identified, notification of the resident's physician and representative and under the direction and guidance of the physician, place the resident on contact precautions, complete a skin scraping to identify the presence of scabies mites, and proper use of PPE.
- The licensed nurse completed head to toe body assessments of Residents 2, 3, 4, and 5 to identify the presence of a skin rash.
- The DON and Registered Nurse (RN) Supervisors reviewed and revised Residents 3 and 4's care plans to address the changes in condition, potential exposure to a resident with possible scabies rash and to ensure continued care and services to maintain their highest practicable outcomes.
- Physical Plant and Environmental Services Consultants in-serviced housekeeping supervisor and housekeeping staff regarding Housekeeping Disinfection Plan which includes using EPA approved disinfectant for cleaning, wearing gloves and long sleeve gown while conducting disinfection, changing gloves and long-sleeve gown between affected resident rooms, performing handwashing between rooms and tasks, changing water, mop, and rags between resident rooms or between disinfection tasks, and when possible complete cleaning and disinfection of each affected room while the resident is showering. The housekeeping staff deep cleaned Resident l, 2, 3, 4, and 5's room. The 3rd and 4th Floor were deep cleaned to reduce potential for transmission of contagious pathogens.
- The DON and the IPN completed resident body assessments to identify the presence of rashes on other residents to prevent harm to affected residents. Dermatologist also completed an assessment of all residents to identify residents who are likely to suffer, a serious adverse outcome because of the facility's noncompliance. The Don and the dermatologist, identified residents were identified with rashes. Residents already had on-going treatment orders for identified skin rashes. Residents are newly identified with diagnosis of unspecified dermatitis. The licensed nurses completed change in condition assessments for the residents identified with skin rashes and the roommates for the residents. The residents' physicians and resident representatives were notified. Residents that were newly identified with unspecified dermatitis, were placed on isolation. Skin scraping was performed on residents and Elimite treatments per physician were completed.
- Clinical Consultant continued evaluation through interview of available staff to identify any staff with skin conditions. To reduce the potential for transmission of contagious rashes, employee interviews were continued in person and via the telephone, prior to staff working with residents during their next assigned shift, to identify any staff members with skin conditions. Staff were contacted and interviewed. Staff who reported itchiness and identified with rashes were offered Elimite.
- The IPN revised new employee and annual infection prevention and control training to include education of Scabies prevention in Healthcare Settings and reporting the development of new skin rashes identified to their physician, especially when known to have provided direct care with residents diagnosed with contagious skin rashes.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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