The Springs Healthcare Center At The Carlotta
Inspection history, citations, penalties and survey trends for this long-term care facility in Palm Desert, California.
- Location
- 41505 Carlotta Drive, Palm Desert, California 92211
- CMS Provider Number
- 555226
- Inspections on file
- 26
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Springs Healthcare Center At The Carlotta during CMS and state inspections, most recent first.
Surveyors found that, during a period of active COVID-19 cases, staff were required by facility policy to wear N95 respirators and to use the exact make and model established during annual fit testing. An RN and the IP confirmed that N95 use was mandatory and that three specific N95 models were in use. Observation and record review showed that a CNA and an LVN were each wearing a solid white circular N95, while their fit test records specified different models (a 3M duckbill N95 for the CNA and a Medline striped N95 for the LVN). The IP confirmed these mismatches and stated that wearing a respirator different from the fit-tested model does not protect staff from infectious disease and creates a risk of transmission, contrary to the facility’s written fit testing and COVID-19 PPE policies.
A resident with a change in mental status had a STAT urinalysis and urine culture ordered to rule out infection, but the specimen was not picked up by the lab within the required 4-6 hour window. The nurse did not document contacting the lab to expedite the STAT order, and the Director of Nursing confirmed the facility's policy was not followed.
Surveyors found that large plastic pans were stacked while still wet and four containers of low fat cottage cheese were stored past their use-by dates in the kitchen. The Dietary Manager, Registered Dietician, and kitchen Chef confirmed these practices did not follow facility policy or professional standards, potentially affecting all residents receiving food from the kitchen.
Surveyors found that a recycle bin lid was left open, a dumpster was overflowing with trash preventing the lid from closing, and debris including wood pallets was scattered on the ground. Both the DM and MD acknowledged that trash should be inside closed dumpsters and the area kept clean, in accordance with facility policy.
Staff failed to follow infection control protocols for several residents on Enhanced Barrier Precautions, including not wearing required PPE such as gowns and gloves during high-contact care activities, not performing hand hygiene, and not disinfecting shared medical equipment between uses. These lapses occurred despite clear facility policies and posted instructions, and involved residents with Foley catheters and complex medical histories.
Two residents were administered psychotropic medications without documented evidence that non-pharmacological interventions were attempted or evaluated prior to starting these drugs, and there was no monitoring of such interventions during ongoing medication use. Additionally, a prescriber failed to document the rationale for extending a PRN psychotropic medication order beyond 14 days, contrary to facility policy. These deficiencies were confirmed through record review and interviews with the DON.
A resident recovering from hip replacement surgery was given an enteric coated aspirin tablet instead of the prescribed chewable aspirin by an LVN. The error was confirmed by both the LVN and the DON, who acknowledged that the facility's medication administration policy, which requires verification of orders and triple-checking medications, was not followed.
Surveyors found expired vancomycin in the medication refrigerator, expired lutein in the house supply cabinet, and expired glucose gel in a medication cart. Staff, including the DON and LVNs, confirmed that these medications should have been removed and disposed of per facility policy, but they remained accessible in various storage areas.
A resident with diabetes and hypertension had two critically high blood sugar readings, both above 400 mg/dL, which were recorded and treated with insulin by two LVNs. However, neither nurse notified the physician as required by the physician's order and facility protocol. The DON confirmed that such notifications were expected for out-of-range blood sugar results.
Two residents in a facility experienced progression of pressure injuries due to inadequate care. One resident's coccyx redness worsened into a Stage 3 pressure injury due to lack of treatment and weekly assessments. Another resident's Stage 2 injuries on the coccyx and buttocks were not consistently assessed, delaying treatment. Facility policies for wound care and assessments were not followed, leading to these deficiencies.
Two residents admitted with diarrhea due to hospital-administered laxatives and stool softeners did not have care plans developed to address their condition. Interviews with an LVN and the DON confirmed that care plans should be updated with any change in resident status, but this was not done. The facility's policy requires comprehensive care plans with measurable objectives, which were not provided in these cases.
A facility failed to implement proper infection control practices for a resident on C-diff isolation precautions. The room lacked necessary signage, and staff used hand sanitizer instead of washing with soap and water, contrary to facility policy. Interviews with staff revealed a lack of adherence to infection control protocols, as confirmed by the infection prevention nurse.
The facility failed to develop and implement care plans for two residents, one with a pacemaker and another with multiple bruises and skin tears. Essential pacemaker information was not documented for one resident, and a person-centered care plan was not created for another resident with skin conditions, despite documented incidents. The DON confirmed these oversights, which were against the facility's policies.
A resident with a history of stroke and cognitive impairment pulled out their indwelling urinary catheter, but the facility failed to update the care plan with new goals and interventions. The Director of Nursing acknowledged the oversight, which did not comply with the facility's policy requiring care plans to be revised as new information about the resident's condition becomes available.
A facility failed to document and assess a resident's shoulder wound following a fall, leading to a delay in treatment. Despite orders for daily dressing changes, the wound was not properly documented until much later, contrary to the facility's policy.
The facility failed to ensure proper storage and disposal of medications and biologicals when an expired COVID-19 test was found in a medication cart. An LVN acknowledged the test should have been discarded, and the DON confirmed the test was expired despite an extended expiration date by the manufacturer.
The facility failed to ensure the cook followed the directions for preparing a pureed egg salad diet, potentially compromising the nutritional status of a resident. The cook admitted to not following the recipe, and the Registered Dietician confirmed the error.
Improper N95 Respirator Use Contrary to Fit Test Results During COVID-19 Outbreak
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of N95 respirators by staff during a period when the facility had active COVID-19 cases. A sign at the entrance indicated there were current COVID-19 cases and requested visitors to wear masks. The RN stated that, due to positive COVID-19 cases in the facility, staff were required to wear N95 masks throughout their shifts and that staff were fit tested to ensure they wore the correct N95 model to decrease the spread of COVID-19. The Infection Preventionist (IP) confirmed there were eight COVID-19 positive residents in the facility and that staff were required to wear N95 masks while in the building. During observations and interviews, surveyors found that two staff members were not wearing the N95 respirator models for which they had been fit tested. A CNA was observed wearing a solid white circular N95 mask and stated she had been fit tested approximately six months earlier and was wearing the mask she believed was indicated. However, review of her Respirator Fit Test Record dated March 26, 2025, showed she was fit tested for a 3M N95 (white duckbill-shaped mask), not the solid white circular model she was wearing. Similarly, an LVN was observed wearing a solid white circular N95 mask and reported she had been fit tested about one month earlier and was wearing the mask she believed was indicated. Her Respirator Fit Test Record dated November 24, 2025, showed she was fit tested for a Medline N95 (green and white striped mask), not the solid white circular model. The IP verified these discrepancies and stated that wearing the wrong N95 mask does not protect staff from infectious disease and that they then pose a risk of spreading infectious disease to others. Facility policies on fit testing and COVID-19 PPE requirements specified that employees must be fit tested using the same size, make, model, and style of respirator they will wear and that staff are required to wear N95 respirators and be fit tested annually.
Delayed STAT Urine Specimen Pickup and Lack of Documentation
Penalty
Summary
The facility failed to ensure that a STAT urinalysis (UA) and urine culture and sensitivity (C&S) specimen for one resident was picked up by the laboratory within the required 4-6 hour timeframe. The resident, who was cognitively intact and admitted with osteomyelitis, experienced a change in condition characterized by confusion and hallucinations. The physician ordered a STAT UA with C&S to rule out a urinary tract infection. Documentation showed that the urine sample was collected in the evening, but the laboratory did not pick up the specimen until the following morning, well beyond the facility's policy timeframe for STAT orders. Interviews with the Director of Nursing (DON) and the nurse involved confirmed that the facility's policy requires immediate notification to the lab for STAT orders and documentation of this communication. The DON verified that there was no documentation indicating the lab was called to expedite the STAT order, and the nurse could not recall if she had contacted the lab before her shift ended. The facility's policy, which was reviewed, clearly states that STAT orders must be called in to the laboratory immediately and prioritized for completion within 4-6 hours, which did not occur in this instance.
Improper Food Storage and Sanitation in Kitchen
Penalty
Summary
Surveyors observed that multiple large plastic pans were stacked while still wet in the kitchen storage rack. The Dietary Manager, Registered Dietician, and kitchen Chef all confirmed that these pans should have been air dried before storage, in accordance with facility policy and professional standards. The failure to properly air dry and store these items was directly observed during the inspection. Additionally, four containers of low fat cottage cheese, each weighing five pounds, were found stored in the refrigerator past their use-by dates. The Dietary Manager and kitchen Chef both acknowledged that expired food items should have been discarded, as per facility policy. These deficiencies were identified during an inspection and had the potential to affect all 40 residents who received food from the kitchen.
Improper Disposal of Garbage and Refuse
Penalty
Summary
During an inspection of the facility's outside garbage storage area, surveyors observed that one of two blue recycle bins had its lid open, and one of four black dumpster containers was overflowing with bags of trash, preventing the lid from closing. Additionally, multiple pieces of debris and trash, including wood pallets, were found scattered on the ground around the dumpsters. The Dietary Manager confirmed that trash bags should always be inside the dumpsters with lids closed and that the area should be kept free of debris. The Maintenance Director also stated that dumpster lids should remain closed, garbage bags should be inside the dumpsters, and the ground should be clean. A review of the facility's policies indicated that dumpsters are to be kept closed and free of surrounding litter, and the area must be free of debris with lids closed.
Failure to Implement Infection Control Practices for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for several residents on Enhanced Barrier Precautions (EBP). For one resident with a Foley catheter and a history of Parkinson's disease and cystostomy, a physical therapist assisted with transferring and repositioning without donning the required gown, only using gloves, and did not perform hand hygiene before leaving the room or entering another resident's room. The therapist stated he was aware of the EBP requirement but did not see the disposable gown, which was later found in the resident's closet. The facility's policy required both gown and gloves for high-contact care activities and hand hygiene before leaving the room. Another resident with a Foley catheter due to cancer and a recent history of sepsis and cholecystitis was also on EBP. A CNA provided direct care, including changing bed linens and assisting with hygiene, while only wearing gloves and not the required gown. The CNA acknowledged awareness of the EBP status but stated she only used the gown when emptying the catheter. The disposable gowns were available in the resident's closet, and both the Infection Preventionist and DON confirmed that proper PPE should have been used for all high-contact care activities as per facility policy. Additionally, a LVN failed to disinfect a shared blood pressure cuff after use with a resident, placing it back on the medication cart and then into a drawer without cleaning. The LVN admitted to not cleaning the equipment and acknowledged that shared equipment should be disinfected after each use. The facility's policy required reusable items to be cleaned and disinfected between residents. Another incident involved a LVN entering a resident's room, who was on EBP for a Foley catheter, and handling the catheter tubing without performing hand hygiene or donning gown and gloves, contrary to posted instructions and facility policy.
Failure to Document Non-Pharmacological Interventions and Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications by not documenting the use or evaluation of non-pharmacological interventions (NPI) prior to initiating these medications. For both residents, there was no evidence in the medical records that behavioral, environmental, or person-centered approaches were attempted or monitored before and during the administration of psychotropic drugs, including duloxetine, amitriptyline, citalopram, and temazepam. The care plans referenced the need for non-drug interventions, but there was no documentation that these were implemented or evaluated in practice. For one resident with major depressive disorder, orders for duloxetine and amitriptyline were initiated without any documented trial or assessment of NPI, and the care plan did not address non-pharmacological strategies for the ongoing use of these medications. Similarly, another resident with insomnia and depression was started on citalopram and temazepam without documentation of attempted or evaluated NPI, despite the care plan instructing staff to assess and modify environmental or behavioral factors before starting hypnotic therapy. In both cases, the Director of Nursing confirmed the absence of documentation regarding the implementation and monitoring of NPI alongside the continued use of psychotropic medications. Additionally, for the resident receiving temazepam as a PRN medication, there was no documented rationale from the prescriber for extending the PRN order beyond 14 days, as required by facility policy. The facility's own policy mandates that psychotropic medications should not be used without first attempting non-drug interventions and that PRN orders for such medications must be justified and time-limited unless a rationale is documented. These documentation failures were confirmed during interviews and record reviews with facility leadership.
Incorrect Form of Aspirin Administered Due to Failure to Follow Physician's Order
Penalty
Summary
A licensed vocational nurse (LVN) administered an enteric coated (EC) aspirin 81 mg tablet to a resident instead of the prescribed chewable aspirin 81 mg tablet. The physician's order and the Medication Administration Record (MAR) specified that the resident, who was recovering from a hip replacement, was to receive a chewable aspirin 81 mg tablet by mouth twice daily. During a medication pass observation, the LVN was seen preparing and administering the EC aspirin tablet, which was not in accordance with the physician's order. Upon review, both the LVN and the Director of Nursing (DON) confirmed that the wrong form of aspirin was given, acknowledging the difference between EC and chewable aspirin in terms of absorption and onset of action. The facility's policy required verification of medication orders and comparison with the MAR and medication label prior to administration, as well as triple-checking the medication before giving it to the resident. These procedures were not followed, resulting in the administration of the incorrect medication form.
Expired Medications Not Removed from Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and timely disposal of expired medications in accordance with its own policies and procedures. During inspections, two bags of expired vancomycin were found in the medication refrigerator, with pharmacy labels indicating a use-by date that had already passed. The Director of Nursing confirmed that the medication order had been discontinued prior to the expiration date and that the expired medications should have been removed and placed in the pharmaceutical bin for disposal. Additionally, two unopened bottles of expired lutein were found in the house supply medication cabinet, and a tube of expired Microdot Glucose Gel was identified in a medication cart. In each instance, staff acknowledged that expired medications should have been removed and disposed of according to facility policy, but this had not occurred. Record reviews and staff interviews confirmed that the facility's policies require discontinued and expired medications to be immediately removed from stock and disposed of in a secure manner. Despite these policies, expired medications remained accessible in multiple storage locations, including the medication refrigerator, medication room, and medication cart. The failure to remove and dispose of these medications as required was verified by both nursing staff and the Director of Nursing during the survey.
Failure to Notify Physician of Critically High Blood Sugar Readings
Penalty
Summary
The facility failed to ensure that high blood sugar readings above 401 mg/dL were reported to the physician in a timely manner as ordered for one resident with diabetes and hypertension. According to the physician's order, insulin was to be administered based on a sliding scale, and the physician was to be notified if blood sugar levels reached 401 mg/dL or higher. On two occasions, a resident's blood sugar levels were recorded at 447 mg/dL and 442 mg/dL, and 12 units of insulin were administered each time by two different LVNs. However, there was no documented evidence that the physician was notified of these elevated readings as required by the physician's order. Interviews with the LVNs involved revealed that both nurses acknowledged they failed to contact the physician after recording the high blood sugar levels, citing reasons such as forgetting or being busy. The Director of Nursing confirmed that the expectation was for licensed nurses to follow physician orders regarding diabetic management and to treat out-of-range blood sugar checks as a change of condition requiring physician notification. Review of the facility's diabetes clinical protocol further supported the requirement for staff to report issues affecting diabetes management according to physician-ordered parameters.
Inadequate Pressure Ulcer Care Leads to Injury Progression
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to the progression of pressure injuries. For Resident 2, the facility did not conduct consistent weekly skin assessments to monitor changes in the resident's coccyx redness identified upon admission. Additionally, the facility did not initiate treatment for the redness, which subsequently worsened into a Stage 3 pressure injury. The Director of Nursing (DON) and Treatment Nurse 2 acknowledged that the necessary treatment orders were not transcribed into the resident's medical record, delaying the provision of care. Resident 1 also experienced inadequate care, as the facility did not perform consistent weekly skin assessments to evaluate the changes in the resident's Stage 2 pressure injuries on the coccyx and left buttocks, as well as the reddened sacrum identified upon admission. This lack of assessment potentially allowed the pressure injuries to progress without staff knowledge, delaying treatment. The DON confirmed that weekly skin assessments were not completed for Resident 1, and the resident was not evaluated by a Wound Care Specialist during their stay. The facility's policies and procedures for wound care and comprehensive assessments were not followed, as evidenced by the lack of documentation and communication regarding the residents' skin conditions. The failure to adhere to these protocols resulted in the progression of pressure injuries for both residents, highlighting deficiencies in the facility's care delivery process.
Failure to Develop Care Plans for Diarrhea Episodes
Penalty
Summary
The facility failed to develop a care plan to address episodes of diarrhea for two residents, which was identified during an unannounced visit. Resident 1 was admitted with a history of displaced intertrochanteric fracture, fracture of the right radius, hypertension, and Type 2 diabetes. Upon admission, Resident 1 experienced diarrhea due to laxatives and stool softeners administered at the hospital, but no care plan was documented to address this condition. Similarly, Resident 2, who was admitted with a fracture of the right tibia, hypertension, and hyperlipidemia, also experienced diarrhea upon arrival at the facility due to similar medications given at the hospital. However, there was no documented care plan for Resident 2's diarrhea either. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that care plans should be updated when there is a change in resident status. Both staff members acknowledged that a care plan should have been in place for residents experiencing diarrhea. The facility's policy on comprehensive person-centered care plans, revised in December 2016, mandates that care plans include measurable objectives, time frames, and describe the services furnished to maintain the resident's highest practicable wellbeing. The absence of care plans for the residents' diarrhea episodes indicates a failure to adhere to this policy.
Inadequate Infection Control Practices for C-diff Precautions
Penalty
Summary
The facility failed to implement appropriate infection control practices for a resident in a room on isolation precautions for Clostridium difficile (C-diff). During an unannounced visit, it was observed that the room did not have the necessary isolation signage, although a PPE cart was present outside. A Licensed Vocational Nurse (LVN) was seen exiting the room after doffing PPE and using hand sanitizer, which is not appropriate for C-diff precautions as hand washing with soap and water is required to prevent cross-contamination. Interviews with staff, including another LVN, a housekeeper, an activities assistant, and the infection prevention (IP) nurse, revealed a lack of adherence to proper infection control protocols. The IP nurse confirmed the importance of placing appropriate signage and using soap and water for hand hygiene in C-diff cases. The facility's policies, revised in October 2018, emphasize the need for transmission-based precautions and vigilant hand hygiene to prevent the spread of C-diff, highlighting the deficiency in the facility's infection control practices.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a care plan for two residents, leading to potential risks for both. For Resident 142, who was admitted with a pacemaker, the facility did not document essential pacemaker information such as the manufacturer, type, model, serial number, and the date of implantation. This omission was noted despite the resident's history of COPD, CHF, and the presence of a cardiac pacemaker. The lack of a care plan was confirmed through multiple observations and interviews with the resident, LVN, and DON, who acknowledged the oversight and the absence of a care plan for the pacemaker. For Resident 143, who was admitted with multiple bruises, skin tears, and a history of stroke, the facility did not develop a person-centered care plan to address these issues. The resident, who was on blood thinners and had a cognitive impairment, sustained additional skin tears and bruises after admission. Despite these incidents being documented in the nurse's notes, there was no evidence of a care plan being developed to manage the resident's skin conditions. The DON confirmed that a care plan should have been initiated but was not. The facility's policies on care planning and managing residents with pacemakers were not followed, leading to these deficiencies. The policies required comprehensive, person-centered care plans to be developed within seven days of admission, including specific details for residents with pacemakers. The failure to adhere to these policies resulted in the lack of appropriate care plans for both residents, potentially compromising their care and safety.
Failure to Update Care Plan After Resident Pulled Out Catheter
Penalty
Summary
The facility failed to ensure the care plan for a resident with an indwelling urinary catheter was updated and revised after the resident pulled out the catheter. The resident, who had a history of stroke, left-sided weakness, PTSD, and falls, was admitted with a Foley catheter. Despite an incident where the resident pulled out the catheter with the balloon inflated and was sent to the emergency room for evaluation, the care plan was not revised to include new goals and interventions to prevent further incidents. During an interview and record review, the Director of Nursing acknowledged that the care plan should have been revised following the change in the resident's condition. The facility's policy requires that care plans be comprehensive, person-centered, and revised as new information about the resident's condition becomes available. However, this policy was not followed, potentially placing the resident at risk for further trauma.
Failure to Document and Assess Resident's Shoulder Wound
Penalty
Summary
The facility failed to ensure a skin assessment was completed and documented for Resident 11, who had a foam dressing on her left shoulder due to a deep cut sustained from a fall. Despite the resident's fall and subsequent injury, there was no documented evidence of a skin assessment or identification of the wound until much later. The resident's Minimum Data Set (MDS) indicated no skin problems on admission, and a Change in Condition (CIC) report from April 7, 2024, also indicated no observable injury. However, the resident was later seen by a wound specialist for a boil on her left shoulder, which was not documented until April 25, 2024. Interviews with the Treatment Nurse (TN) and the Director of Nursing (DON) revealed that the TN had observed a scratch on the resident's shoulder two weeks prior but did not document it. The DON confirmed that there was an order for daily foam dressing changes, which should have included an assessment and documentation of the wound. The Registered Nurse (RN) also failed to document the redness observed on the resident's shoulder and did not record the request for a wound care specialist evaluation. The facility's policy and procedure for resident examination and assessment were not followed, leading to a delay in the identification and treatment of the resident's wound.
Expired COVID-19 Test Found in Medication Cart
Penalty
Summary
The facility failed to ensure medications and biologicals were properly stored and disposed of when an expired COVID-19 test was found inside a medication cart, readily available for use. During a medication cart inspection with an LVN, a box containing a COVID-19 test with an expiration date was observed. The LVN acknowledged that the expired test should not have been stored in the medication cart and should have been discarded. Further interviews with the DON and the Infection Preventionist confirmed that the test's expiration date had been extended by the manufacturer. However, the DON still considered the test expired. A review of the FDA website verified that the test's expiration date had indeed been extended. The facility's policy on medication labeling and storage indicated that outdated or deteriorated medications or biologicals should be returned or destroyed, which was not followed in this instance.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to ensure the cook followed the directions for preparing a pureed egg salad diet for lunch on April 30, 2024. During an observation, the cook prepared a new serving of pureed egg salad by blending two hard-boiled eggs, mayonnaise, and a mixture of liquid chicken broth made from hot water and powdered chicken bouillon. This method did not follow the recipe directions, which required using portions from a regular prepared recipe and adding broth slowly until achieving a smooth consistency. The cook admitted to not following the procedure as indicated in the recipe for a pureed diet. The Registered Dietician (RD) confirmed that the cook did not follow the correct procedure for preparing the pureed diet. The facility document titled 'Diet Type Report' indicated that Resident 20 was on a regular diet with a pureed texture. This failure had the potential to compromise the nutritional status of Resident 20, who was reviewed for a pureed diet. The RD emphasized that the cook should have adhered to the recipe directions to ensure the proper consistency and nutritional value of the pureed egg salad.
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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