Trabuco Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Forest, California.
- Location
- 25652 Old Trabuco Road, Lake Forest, California 92630
- CMS Provider Number
- 555308
- Inspections on file
- 41
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Trabuco Hills Post Acute during CMS and state inspections, most recent first.
Surveyors found that two residents received PRN medications, including an antianxiety drug, an antidepressant, and a narcotic pain medication, without adherence to facility policies requiring non-pharmacological interventions and informed consent. For one resident, Ativan was given for anxiety while behavior monitoring flowsheets showed non-pharmacological interventions and outcomes as "NA," and Cymbalta was started for pain without any documented informed consent from the resident or representative. For another resident lacking decision-making capacity, Tramadol was administered for moderate pain without any physician order for non-pharmacological measures and without documentation that such interventions were attempted before giving the PRN dose. An RN confirmed that non-pharmacological interventions should have been used and documented for these PRN medications.
A resident who lacked capacity to make medical decisions had a care log binder containing their name, room number, and care notes left on a hallway railing near the main entrance. Over an extended period, multiple CNAs and visitors walked past the unsecured binder without addressing it. An LVN acknowledged the binder and reported that the family liked it kept in the hallway, and the DON later confirmed the binder should have been kept in the resident’s room and not in a public area, resulting in a failure to protect confidential health information.
A resident was admitted with matted hair over the occipital area, and nursing documentation noted that the scalp could not be visualized. Although facility policy required a licensed nursing assessment on admission, staff did not reassess the obscured area for an extended period, deferring to a family member who wished to work through the matted hair. The occipital scalp was not reassessed until the family member was able to detangle the hair and then observed dry blood, confirming that the area had not been timely or thoroughly assessed as required.
A resident with multiple pressure ulcers, including unstageable elbow ulcers and a stage 4 mid-lower back ulcer, had a physician’s order for a low air loss mattress with placement and settings to be checked every shift. Facility policy required evidence-based pressure injury prevention interventions and appropriate support surfaces, and the mattress manufacturer’s instructions specified that pressure settings be adjusted according to the resident’s weight and height. During observation, the resident’s low air loss mattress was found set at 450 psi despite the resident weighing 162 pounds, and an LVN confirmed the setting was incorrect and had been that way for some time. The Administrator and DON were informed and acknowledged that the mattress setting did not comply with the ordered and policy-based pressure injury prevention measures.
A resident had a PRN order for Dulcolax suppository to be given only if MOM was ineffective for constipation. Review of the MAR and staff interview showed that an RN administered Dulcolax without first giving MOM or obtaining an alternative one-time order, contrary to the physician’s instructions and the facility’s medication administration policy.
A resident with a recent fall, poor balance, and care plan interventions for neuro-checks had missing entries on the neurological flowsheet, and physician-ordered daily treatment for an eyebrow laceration and monitoring of a deep purplish discoloration were not documented on the TAR for a specific day. During interviews and concurrent record reviews, the DON confirmed the neuro assessments should have been completed, and an LVN acknowledged the absence of TAR entries and uncertainty about her presence that day, while facility leadership later acknowledged these documentation gaps.
A resident who exhibited aggressive behavior and required IM Ativan was not monitored every shift for 72 hours following the incident, as required by facility policy. Additionally, the resident's care plan was not updated to include interventions or monitoring related to the recent behavioral episode, despite documentation of the change in condition and staff acknowledgment of the oversight.
A resident with anxiety did not receive their prescribed clonazepam for several days due to the medication being unavailable, and there was no documentation that the physician, pharmacy, or responsible party were notified. Additionally, required narcotic count sheets for the medication were missing from the medical record, and the DON was unaware of the issue.
A resident with orders for stat CBC, BMP, and urinalysis had abnormal lab results, including elevated WBC and BUN, as well as abnormal urinalysis findings. These results were not promptly reported to the physician, and there was no documentation of notification, despite facility policy requiring timely communication of out-of-range lab values. Nursing staff and the DON confirmed the lack of prompt notification and documentation.
A resident experienced poor PO intake, increased weakness, sleepiness, and confusion, but the facility did not notify the resident's representative of these significant changes in condition as required by policy. Staff interviews and record review confirmed the lack of notification.
A resident's stat orders for CBC, BMP, and urinalysis with C&S were not completed promptly as required, with delays in sample collection and no documentation that the lab was contacted immediately. Nursing staff confirmed the lack of timely action and follow-up, and the DON acknowledged the deficiency.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions. Review of records showed incomplete documentation and planning, with missing interventions and unclear goals for the resident's care.
Two residents were found self-administering medicated products, including a zinc oxide cream and menthol cough drops, without required physician orders, IDT assessments, or care plans in place. Staff confirmed that these items should not have been accessible without proper documentation and assessment for safe self-administration.
A resident with spinal stenosis and neurogenic claudication did not receive the prescribed frequency and duration of PT and OT services as ordered and documented in the care plan. Facility records and interviews confirmed that multiple therapy sessions were missed, and the DOR acknowledged the failure to ensure therapy was provided according to the individualized plan.
A resident with dysphagia did not receive the ordered speech therapy (ST) services four times a week, as required by the physician. The resident, who was developmentally delayed, was admitted for rehabilitative services after aspirating. Despite an initial evaluation, the resident did not receive further ST treatment, and the diet was downgraded by nursing staff without notifying the physician. The DOR and DON confirmed the oversight.
A resident's cell phone was lost due to the facility's failure to adhere to its policy on safeguarding personal belongings. The cell phone was listed in the initial inventory upon admission but was missing after the resident was transferred to a hospital. Interviews with staff confirmed the oversight, and the DON acknowledged the findings.
The facility failed to follow food safety and sanitation guidelines, leading to potential foodborne illness risks for residents. Observations included dirty pan lids, improperly stored wet blenders and meal trays, a non-cleanable cutting board, unlabeled desserts, inadequate hair restraints by dietary staff, and unsanitary condiment storage. These issues were verified by the DSS and LVN, and acknowledged by the RD.
The facility failed to implement its infection control surveillance program, resulting in discrepancies in infection documentation and non-compliance with basic infection control practices. Nursing staff did not perform hand hygiene or sanitize equipment properly, and a resident's urinal was improperly placed, posing infection risks. These actions demonstrate a lack of adherence to infection prevention measures.
The facility failed to document Zone 1 entrapment measurements for 18 residents using side rails, posing a risk of entrapment. Despite care plans requiring monthly measurements, the Maintenance Director admitted these were not performed, believing measurements would not change. Residents with cognitive impairments and physical limitations relied on side rails for mobility, but necessary safety checks were not documented. The DON acknowledged these deficiencies.
The facility failed to ensure proper use and safety of bed rails for 19 residents, with issues including incomplete assessments, lack of alternatives, and missing informed consent. Residents were observed with side rails that did not match physician orders or consent documentation, posing potential risks for entrapment and injury. Staff confirmed these discrepancies, highlighting systemic issues in bed rail management.
The facility failed to provide necessary care for two residents, leading to deficiencies in treatment and communication. One resident experienced an assisted fall and received inconsistent treatment orders, while another had a delayed urine sample collection and late urinalysis result reporting. Staff interviews confirmed documentation and communication discrepancies.
Two residents were found self-administering medications without documented assessments by the facility. One resident with moderate cognitive impairment had been taking supplements without a physician's order, while another cognitively intact resident was using eye drops. The RN confirmed the lack of assessments, and the DON acknowledged the issue.
The facility failed to accommodate resident needs by not providing an extension cord for a resident's phone and placing call lights out of reach for several residents, including those with cognitive impairments and physical limitations. These deficiencies were observed and verified by staff, indicating a lack of responsiveness to resident requests.
A facility failed to obtain a copy of a resident's advance directive, as required by its policy. Although the resident's POLST indicated the presence of an advance directive, it was not found in the medical record. Interviews with the SSD and MRD confirmed the oversight, and the DON acknowledged the deficiency.
Two residents refused laboratory tests, and the facility failed to notify their physicians, potentially impacting their treatment. One resident, on potassium chloride for hypokalemia, refused a potassium level test, and another resident with moderate cognitive impairment refused multiple tests. The Director of Nursing confirmed the lack of physician notification.
The facility failed to maintain privacy for three residents during GT medication administration, as LVNs did not fully close privacy curtains, exposing residents' abdomens. Additionally, a resident's confidential health information was left visible on an unattended computer monitor at a nursing station. These incidents were confirmed through staff interviews and violated the facility's policies on resident dignity and information safeguarding.
The facility failed to notify the State LTC Ombudsman of a resident's transfer to a hospital and did not provide another resident with a written transfer notice. The absence of documentation for these notifications was confirmed through interviews with the SSD, DON, and an RN.
A resident with severe cognitive impairment and a risk for social isolation did not receive an individualized activity program as outlined in their care plan. Observations showed the resident without sensory stimulation, and staff interviews revealed a lack of participation in activities unless requested by family. The Activity Director confirmed missing documentation for activities, acknowledging the deficiency.
The facility failed to maintain safety in the laundry area and did not implement fall prevention measures for a resident. The laundry closet was found dirty with lint and improperly stored linens, posing a fire hazard. Additionally, a resident at risk of falls had only one floor mat in place, contrary to the physician's order for bilateral mats. Staff confirmed these deficiencies during interviews.
Two residents in the facility experienced deficiencies in gastrostomy tube (GT) care during medication administration. One resident's LVN failed to check the residual volume before administering medication, while another LVN did not confirm GT placement by injecting air and listening with a stethoscope. Both LVNs acknowledged their omissions, and the DON verified these findings.
A resident was observed receiving oxygen at 2 liters per minute, contrary to the physician's order of 3 liters per minute as needed to maintain an oxygen saturation level of 92% or higher. The facility's policy requires oxygen to be administered under a physician's order, except in emergencies. However, there was no documented evidence that the resident's oxygen saturation level was below 92%, necessitating oxygen administration. Both RN 4 and the DON confirmed the lack of documentation justifying the oxygen administration.
A facility failed to provide appropriate dialysis care for a resident by not ensuring medications were administered or rescheduled on dialysis days, and by not monitoring the resident's fluid restriction. Insulin lispro and midodrine were not given on multiple occasions without notifying the physician, and there was no documentation of the total daily fluid intake from nursing and dietary departments, posing a risk of medical complications.
The facility failed to ensure proper documentation and accountability for controlled medications, with missing signatures and incorrect counts on shift logs. Additionally, emergency kit procedures were not followed, as logs were improperly stored and not updated. These deficiencies were confirmed by staff and the DON.
A facility failed to follow a Pharmacy Consultant's recommendation for a resident receiving potassium chloride for hypokalemia. The consultant advised follow-up lab tests to monitor potassium levels, but these were not conducted. The resident refused the lab tests, and the physician was not notified of this refusal, posing a risk of unnecessary medication use.
A resident was prescribed bupropion, escitalopram, and trazodone for depression, but the facility failed to monitor side effects specific to each medication. The MAR showed inconsistent monitoring and confusing chart codes, which the DON confirmed. This lack of specific monitoring could impact the resident's well-being.
A facility's medication error rate was found to be 13.79%, exceeding the acceptable limit of 5%. An LVN failed to prepare and administer UTI-STAT and polyethylene glycol 3350 powder for a resident, did not assess for loose stools before giving Colace, and administered hydrocodone-acetaminophen late. These actions were contrary to physician orders and facility policies.
The facility failed to ensure proper storage, labeling, and disposal of medications, leading to several deficiencies. Medications were left unattended, improperly stored, and not disposed of correctly, with unauthorized access possible. Additionally, temperature logs were inaccurately recorded, and expired items were found in medication carts. These issues were verified by staff, indicating non-compliance with facility policies.
The facility failed to follow menu and recipe guidelines, impacting residents' nutritional needs. A staff member did not measure ingredients for pureed meals, and a resident received an inadequate fruit plate. The Dietary Services Supervisor confirmed the recipes were not followed, despite the availability of required ingredients.
The facility failed to implement its antibiotic stewardship program, as two residents were prescribed antibiotics without proper documentation or confirmation of infection. One resident was given levofloxacin for pneumonia without a chest x-ray result, and another was on dual antibiotics for suspected C. difficile without lab confirmation or physician notification. The Infection Preventionist and Administrator confirmed these deficiencies.
The facility failed to maintain glucometers in safe operating condition, with mismatched serial numbers and test strip lot numbers in Medication Carts A and C. Additionally, ice buildup was observed in the residents' refrigerators in Stations A, B, and C, requiring defrosting. These issues were verified by staff and acknowledged by the DON.
A resident at risk for falls did not have a comprehensive care plan addressing this risk, as required by facility policy. Despite a fall risk score indicating the need for such a plan, it was not developed until after the resident experienced a fall, resulting in injuries. Interviews with RNs confirmed the absence of a preemptive care plan.
The facility failed to treat two residents with dignity and respect by using the term 'feeders' to describe those needing assistance with eating. A staff member referred to a resident with severe cognitive and psychiatric impairments as a 'feeder,' and a CNA used the term for another resident with cognitive impairment and quadriplegia. This terminology was learned in CNA school.
A resident with impaired vision due to glaucoma was found without necessary assistive devices, such as eyeglasses, in a facility. Despite policies requiring such devices based on assessments and care plans, the resident was unable to read or see clearly, and staff confirmed the absence of these devices. The deficiency was acknowledged by the facility's staff, including the DON.
A resident's privacy was compromised due to the absence of ceiling-suspended privacy curtains in their room, allowing visibility from the hallway during a medication administration. Despite facility policy requiring staff to maintain resident privacy, an LVN acknowledged the issue but did not report it to maintenance. The DON confirmed these findings.
A facility failed to monitor a resident for side effects of Bactrim, prescribed for a UTI, despite having a policy for systematic medication management. The resident's medical records lacked documentation of side effect monitoring, which was confirmed by an RN who stated monitoring occurred only if adverse effects were observed. The DON acknowledged these findings.
The facility failed to maintain complete and accurate medical records for two residents. A resident's POLST form was incomplete, missing crucial information in Section D, as confirmed by staff. Another resident's medical record lacked a signed AMA form, despite documentation indicating it was signed. These deficiencies could impact the residents' care.
A resident on blood thinners developed bruising on her arms and legs, which was reported by a family member to facility staff. However, the facility failed to notify the resident's physician and responsible party, as required by their policy. Interviews revealed that a CNA did not report the bruising, assuming nurses were aware, and an LVN did not complete a change in condition report. The resident, lacking capacity for medical decisions, was observed with purple discoloration, with no prior history of bruising documented.
A resident with moderate cognitive impairment and upper extremity impairment did not receive recommended built-up utensils for self-feeding, despite OT recommendations. The facility's failure to provide these utensils, as required by their P&P, was acknowledged by the DON and DSD. Interviews revealed that the OT did not notify the physician or request orders for the utensils, and the RD was unaware of the recommendations.
A resident with high blood pressure was not correctly administered her medication as per the prescribed orders. Despite instructions to hold the medication if SBP was less than 130 mmHg, the resident received Hyzaar and later losartan on multiple occasions when her SBP was below this threshold. The DON confirmed these findings.
A facility failed to ensure a resident was invited to care plan conferences, despite the resident's requests and the facility's policy. The resident, who was alert and oriented, wanted to discuss her lab results, therapy frequency, and medication dosages but was not scheduled for any care plan meetings. Medical records and staff interviews confirmed the oversight.
Failure to Use Non-Pharmacological Interventions and Obtain Informed Consent Before PRN Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary drugs by not implementing or documenting required non-pharmacological interventions and not obtaining informed consent prior to administering certain medications. Facility policies on psychotropic medication use required that non-pharmacological interventions be attempted unless clinically contraindicated and that residents or their representatives be informed in advance of risks, benefits, and alternatives, with documentation of this informed consent. The facility’s pain management policy similarly required development, implementation, monitoring, and revision of interventions to manage pain, including a range of non-pharmacological measures. For one resident, the physician ordered Ativan 0.5 mg by mouth every six hours as needed for anxiety manifested by inability to relax, along with behavior monitoring that specified non-pharmacological interventions such as relaxation, adjusting room temperature/lighting, repositioning, toileting, music/television, and snacks, with outcomes to be documented every shift. The MAR for March showed Ativan was administered on multiple occasions, but the behavior monitoring documentation for the relevant dates and shifts listed the non-pharmacological interventions and outcomes as "NA," indicating they were not documented as attempted. The same resident had an order for Cymbalta 40 mg at bedtime for pain management, which was administered on two occasions in March. Review of the medical record showed no documented evidence that informed consent for Cymbalta was obtained prior to its administration, either via a written consent form or a narrative note. For another resident, the H&P documented that the resident had no capacity to make medical decisions. A physician’s order directed Tramadol 50 mg by mouth every six hours as needed for moderate pain. The orders did not include any directive for non-pharmacological interventions to be attempted prior to administering Tramadol. The MAR showed Tramadol was administered twice, and there was no documentation that non-pharmacological interventions were performed before giving the medication. During interviews, an RN confirmed that non-pharmacological interventions should be used for as-needed medications and acknowledged that there were no such interventions documented for this resident, and also verified the lack of behavior monitoring interventions for the first resident. The Administrator and DON were informed of and acknowledged these findings.
Failure to Safeguard Confidential Resident Care Log in Public Hallway
Penalty
Summary
The deficiency involves the facility’s failure to safeguard a resident’s confidential medical information in accordance with its policy on confidentiality of personal and medical records. The facility’s policy dated 12/2022 defined keeping information confidential as safeguarding written and other stored information from unauthorized disclosure without the consent of the individual or representative. Resident 4, who had been admitted on an unspecified date and whose H&P dated 7/19/25 documented no capacity to make medical decisions, had a Resident Care Log binder containing personal health information. On 1/9/26 at 1538, this binder was observed tucked on the railings outside the resident’s room in a hallway leading to the facility’s main entrance, rather than being secured. From 1538 to 1557 on the same day, multiple staff and visitors were observed repeatedly walking past the binder without acknowledging or securing it, including CNAs and groups of visitors exiting near the front entrance. During an interview and concurrent observation at 1609, an LVN acknowledged the binder in the hallway and stated the resident’s family liked to have it there. When the binder was opened, it contained the resident’s name, room number, and care notes. The LVN acknowledged that people walked up and down the hallway near the front exit. In a subsequent interview at 1634, the DON verified that the Resident Care Log binder was not supposed to be in the hallway, stated it should be in the resident’s room, and acknowledged that the binder contained the resident’s name, confirming that the medical record was not properly safeguarded from unauthorized access.
Failure to Timely Reassess Resident’s Occipital Area Obscured by Matted Hair
Penalty
Summary
The facility failed to complete a timely and thorough assessment of a newly admitted resident’s occipital (back of head) area when it was initially unable to be visualized due to matted hair. Facility policy titled “admission of a Resident” required a licensed nursing assessment and development of a plan of care upon admission. The resident was admitted and a nurse’s progress note, entered late and dated 3/12/24, documented that the resident’s hair was matted to the occipital area and the scalp could not be visualized. Despite this, there was no documented reassessment of the occipital area until 3/27/24, 16 days later, when a family member worked through the matted hair and observed dry blood on the scalp. In an interview, an LVN stated that at admission staff could only see the matted hair, that the family member wanted to work through the matted hair, and that the scalp was only seen once the hair was worked through, confirming the delay in reassessment and complete assessment of the resident’s occipital area. The Administrator and DON were later informed of and acknowledged these findings, and the surveyor concluded that the failure to reassess the occipital area in a timely manner had the potential to negatively impact the resident.
Improper Low Air Loss Mattress Setting for Resident With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services to prevent the development or worsening of pressure injuries for one resident with existing pressure ulcers. Facility policy on Pressure Injury Prevention and Management, revised 9/2023, required evidence-based interventions for residents at risk or with pressure injuries, including use of appropriate pressure-redistributing devices and support surfaces. The Apex Domus 4 low air loss mattress manual specified that mattress pressure settings should be adjusted according to the resident’s weight and height to avoid bottoming out. The resident’s medical record showed orders for a low air loss mattress for wound management with placement and settings to be checked every shift, as well as detailed wound care orders for unstageable pressure ulcers on both elbows and a stage 4 pressure ulcer on the mid lower back. During an observation and concurrent record review, the resident was found on a low air loss mattress set at 450 psi, while the resident’s current weight was documented as 162 pounds. The LVN present confirmed that the mattress setting was incorrect for the resident’s weight and stated that the setting had been at that level “for a while.” The facility’s Administrator and DON were later informed of and acknowledged these findings. The failure to ensure the low air loss mattress was properly set in accordance with the resident’s weight constituted noncompliance with the facility’s own pressure injury prevention policy and the physician’s order to check mattress placement and settings every shift.
Failure to Follow PRN Laxative Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders and its own medication administration policy for one resident. The facility’s policy dated 12/2022 required that medications be administered by licensed nurses or other legally authorized staff as ordered by the physician and in accordance with professional standards of practice. For this resident, the physician’s order dated 3/11/24 specified that Dulcolax 10 mg rectal suppository was to be administered every 24 hours as needed for constipation only if Milk of Magnesia (MOM) was ineffective. Review of the resident’s March 2024 MAR showed that Dulcolax was administered on 3/16/24, but there was no documentation that MOM had been given prior to the suppository as required by the order. In an interview, RN 1 confirmed that Dulcolax was administered on that date and that MOM had not been administered beforehand, acknowledging that the resident should have received MOM first or that a one-time order for Dulcolax should have been obtained. The Administrator and DON were later informed of and acknowledged these findings.
Incomplete Neurological and Wound Care Documentation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident in accordance with its documentation policy. The facility’s policy titled “Documentation in Medical Record” (revised 12/2022) required licensed staff and interdisciplinary team members to document all assessments, observations, and services provided, ensuring documentation was accurate, relevant, and complete. For one resident who had an actual fall with no injury and poor balance, the care plan dated 3/20/24 included an intervention to complete neuro-checks. Review of this resident’s Neurological Flowsheet showed missing entries under the every-eight-hours section for items numbered 17 and 18. During an interview and concurrent closed medical record review with the DON and ADON, the DON verified that the neurological assessments should have been completed and documented. Further review of the same resident’s Order Summary Report showed physician orders dated 3/12/24 for treatment of a right above-eyebrow laceration with betadine daily for 21 days, and for daily monitoring of a deep purplish discoloration on the left side of the body for 30 days. Examination of the Treatment Administration Record (TAR) for 3/24/24 revealed no entries documenting the eyebrow laceration treatment or the monitoring of the purplish discoloration on that date. In a subsequent interview and concurrent record review with an LVN, the LVN acknowledged the lack of entries on the TAR for that day and stated she would need to investigate further, as she was unsure if she had been out of the facility that day. The Administrator and DON were later informed of and acknowledged these findings.
Failure to Monitor and Update Care Plan After Resident's Change in Condition
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain the highest practicable well-being for one resident who experienced a change in condition characterized by aggressive behavior. The resident, who had the capacity to make medical decisions, was observed barricading himself in his room, yelling, and posing a danger to himself and others. The licensed nurse administered IM Ativan as ordered and indicated that the resident would be monitored closely for safety. However, there was no documented evidence that the resident's change in condition was monitored every shift for 72 hours as required by facility policy. Progress notes and the eINTERACT Change of Condition Report confirmed the aggressive episode, but subsequent monitoring was not documented in the medical record. Additionally, the resident's care plan, which previously addressed a mood problem, was not revised to include new interventions or monitoring related to the recent episode of physical aggression. Review of the care plan and interviews with nursing staff confirmed that the care plan was not updated to reflect the resident's change in condition. The facility's policy required care plan revisions upon a status change, but this was not followed in this instance. The Administrator and DON acknowledged these findings during the survey.
Failure to Provide and Document Pharmaceutical Services for Antianxiety Medication
Penalty
Summary
The facility failed to provide pharmaceutical services as required for one resident with a history of generalized anxiety disorder. Specifically, the resident had a physician's order for clonazepam, an antianxiety medication, to be administered at bedtime. Review of the medication administration record (MAR) showed that the medication was not available and not administered from 6/22 to 6/28, with the MAR marked as absent or left blank for those dates. There was no documented evidence that the physician, pharmacy, or the resident's responsible party were notified about the unavailability of the medication, despite a nurse stating that such notifications were made but not documented in the medical record. Additionally, the facility failed to maintain required narcotic count sheets for the resident's clonazepam for May and June, as these records were missing from the medical record. Interviews with staff revealed that a new supply of the medication was not reordered as needed, and the DON confirmed the absence of the narcotic count sheets and was unaware of the medication's unavailability. These failures were identified through observation, interviews, and review of facility policies and records.
Failure to Promptly Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to provide timely notification of abnormal laboratory results to a resident's physician, as required by facility policy. Specifically, a resident was admitted with the capacity to make medical decisions and had physician orders for stat CBC, BMP, and urinalysis with culture and sensitivity, as well as IV hydration. The laboratory results for these tests, including a significantly elevated WBC, abnormal urinalysis findings, and a high BUN, were received and reported by the laboratory, but there was no documented evidence that these abnormal results were promptly communicated to the resident's physician. Interviews with nursing staff, including an LVN and an RN, confirmed that the abnormal laboratory results were not promptly reported to the physician and that there was no documentation of such notification in the resident's medical record. The facility's policies required prompt notification of out-of-range laboratory results to the ordering provider, but this was not followed in the case of this resident. The DON acknowledged these findings during the investigation.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition, as required by facility policy. Specifically, the resident experienced poor oral intake, refused meals and fluids, exhibited increased weakness, was sleepy, and showed increased confusion on 8/3/25. Despite these changes, there was no documented evidence in the closed medical record that the resident's family member or representative was informed of these developments. The facility's policy mandates prompt notification of the resident, physician, and representative in such situations, especially when the resident may not be able to communicate these changes personally. Interviews with facility staff, including an LVN and the DON, confirmed that the resident's representative was not notified following the change in condition. The LVN acknowledged that both the physician and family member should have been informed after the change was identified. The deficiency was identified through interviews, closed medical record review, and review of the facility's policies and procedures.
Failure to Timely Complete Stat Laboratory Orders
Penalty
Summary
The facility failed to ensure that stat laboratory tests ordered for one resident were performed in a timely manner as required by physician orders and facility policy. Specifically, a stat order for CBC, BMP, and urinalysis with culture and sensitivity was placed by the physician, but documentation showed delays in the collection of these samples. The CBC and BMP were collected the following day at 1145 hours, and the urinalysis was collected at 0500 hours, rather than immediately as required for stat orders. There was no evidence in the medical record that the laboratory was contacted promptly to perform the stat tests. Interviews with nursing staff confirmed that the licensed nurse did not collect the urine sample or contact the laboratory right away, and there was no documentation of follow-up or shift-to-shift endorsement regarding the stat laboratory orders. The Director of Nursing acknowledged these findings. The resident involved had the capacity to make medical decisions and was admitted and discharged within the review period. Facility policies required timely provision of laboratory services and proper urine sample collection, but these were not followed in this instance.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not include all necessary interventions or clearly defined goals and timelines for meeting the resident's needs.
Failure to Assess and Document Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents were properly assessed for safe self-administration of medications, as required by facility policy. One resident, who was cognitively intact and able to ambulate independently, was observed with an uncovered tub of zinc oxide cream in his restroom, which he reported applying himself to prevent skin irritation. There was no documentation in the medical record of a physician's order, an interdisciplinary team (IDT) assessment, or a care plan addressing self-administration of this medicated cream. Staff confirmed that medicated creams should not be left unattended and verified the absence of required documentation for self-administration. Another resident, also cognitively intact, was found with Halls cough drops containing menthol on her bedside table, which she reported taking independently without informing staff. Staff initially considered the cough drops as candy, but upon review of the packaging, acknowledged they were medicated and should have required a physician's order, assessment, and care plan for self-administration. The medical record for this resident also lacked evidence of a physician's order, self-administration assessment, IDT notes, or a care plan related to self-administration of medication.
Failure to Provide Prescribed PT and OT Services as Ordered
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for a resident diagnosed with spinal stenosis and neurogenic claudication. According to the physician's orders and the initial physical therapy (PT) and occupational therapy (OT) evaluations, the resident was to receive PT and OT services five times a week for two weeks. However, medical record reviews and service logs revealed that the resident did not receive the prescribed frequency and duration of PT and OT sessions. Specifically, there were multiple dates within the planned treatment period where the resident did not receive either PT or OT services as scheduled. The facility's policies required therapists to develop and follow individualized plans of care, including specified treatment frequencies and durations. Despite these requirements, the Director of Rehabilitation (DOR) confirmed that the resident's therapy sessions were not provided as planned, due to an incorrect assumption about the scheduling of services. The interim Administrator and Director of Nursing (DON) acknowledged these findings during interviews, confirming that the resident did not receive the rehabilitative services as ordered and documented in the care plan.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered by the physician for one of the sampled residents. Resident 7, who was developmentally delayed and diagnosed with dysphagia, was admitted to the facility for rehabilitative services after experiencing aspiration and difficulty breathing. A physician's order dated 12/18/24 required Resident 7 to be evaluated and treated by a speech therapist (ST) four times a week to assess and determine the least restrictive diet to minimize aspiration risks. However, the resident did not receive the prescribed ST treatment since the initial evaluation on 12/21/24. The Director of Rehabilitation (DOR) confirmed that Resident 7 had not received the required ST treatment and that the resident's diet was downgraded to moderately thick liquids by the nursing staff after the resident coughed during eating. The physician was not notified of the failure to provide the ordered ST services. The Director of Nursing (DON) acknowledged that the physician should have been informed if an order was not followed, confirming the findings of the deficiency.
Loss of Resident's Personal Belongings
Penalty
Summary
The facility failed to ensure the safe keeping of personal belongings for a resident, resulting in the loss of the resident's cell phone. The facility's policy, revised in December 2022, mandates the protection of residents' personal belongings and their rightful return upon discharge or death. However, this policy was not adhered to in the case of a resident who was transferred to an acute care hospital, leaving their belongings at the facility. The resident's family member filed a complaint when the cell phone, which was included in the initial inventory list upon admission, was reported missing. Interviews conducted with facility staff revealed that the resident's belongings were supposed to be placed in a bag, labeled, and brought to social services for safekeeping upon discharge. However, the cell phone was not found in the bag, and it was documented as missing. The Director of Nursing acknowledged these findings, confirming the failure to protect the resident's personal belongings as per the facility's policy.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as observed during a survey. Multiple deficiencies were noted, including the storage of pan lids with food crumbs and dirt, and the improper storage of wet blenders and meal trays, which were not air-dried before being stacked. Additionally, a cutting board with a blue handle was found to have a surface that was not cleanable due to heavy marring and discoloration. A cart containing desserts in small bowls was found unlabeled in the walk-in refrigerator, contrary to the facility's policy on date marking for food safety. Further observations revealed that a dietary staff member did not wear appropriate hair restraints, with half of their scalp uncovered. In the main dining room, a drawer containing condiments was found to have spilled sugar and black pepper, resulting in an unsanitary condition. These failures were verified by the Dietary Services Supervisor (DSS) and Licensed Vocational Nurse (LVN) 7, respectively, and acknowledged by the Registered Dietitian (RD). These deficiencies had the potential to result in foodborne illnesses for the majority of the residents receiving kitchen services.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control surveillance program in accordance with its policies and procedures, leading to several deficiencies in infection prevention and control practices. The facility did not maintain an accurate infection surveillance program for several months, as evidenced by discrepancies in the documentation of healthcare-acquired infections (HAI) and community-acquired infections (CAI). The Infection Prevention and Control Surveillance Log lacked evidence of whether residents' infections were classified as HAI or CAI, and there was no documentation to confirm if the infections met the McGeer's Criteria. Additionally, the total number of infections recorded did not match the monthly reports, indicating a lack of proper data collection and analysis. Specific instances of non-compliance were observed among the nursing staff. For example, a Licensed Vocational Nurse (LVN) failed to perform hand hygiene after removing gloves during medication administration for multiple residents. Another LVN did not sanitize medical equipment, such as a stethoscope and blood pressure machine, after use, which could contribute to the spread of infections. These actions demonstrate a failure to adhere to basic infection control practices, posing a risk of transmitting communicable diseases within the facility. Furthermore, the facility did not adequately address infection control risks in residents' personal care. A resident's urinal was found hanging by a trash bin, which was acknowledged as a potential infection control risk by the nursing staff. Despite the resident's preference, there was no evidence of prior education on the risks and benefits of this practice. These findings highlight the facility's failure to maintain effective infection prevention and control measures, as required by their policies and procedures.
Failure to Document Zone 1 Entrapment Measurements
Penalty
Summary
The facility failed to document Zone 1 entrapment measurements for 18 out of 20 residents who were reviewed for side rail use. Zone 1 is identified as the open space within the perimeter of a bed rail, and its measurement is crucial to prevent resident entrapment. The absence of documented evidence for Zone 1 measurements was observed across multiple residents, including those with cognitive impairments and physical disabilities, who relied on side rails for mobility and positioning. This oversight was confirmed through interviews with the Maintenance Director and staff, who acknowledged that the Zone 1 measurements were not documented on the Bed System Measurement Device Test Results Worksheets. The facility also failed to conduct monthly entrapment measurements as outlined in the residents' care plans. Despite the care plans specifying the need for monthly measurements to ensure safety, the Maintenance Director admitted that these measurements were not performed, as they believed the measurements would not change. This lack of adherence to the care plans posed a risk of not identifying potential entrapment areas, which could lead to serious harm for the residents. Observations and interviews revealed that residents with severe cognitive impairments and physical limitations were using side rails for assistance with bed mobility and positioning. However, the facility's documentation did not reflect the necessary safety checks for these enablers. The Maintenance Director and staff were responsible for the bed inspections, which included visual checks but not the required entrapment measurements. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiencies in the facility's processes.
Deficiencies in Bed Rail Use and Safety
Penalty
Summary
The facility failed to ensure the safety and proper use of bed rails for 19 out of 20 residents reviewed. The deficiencies included incomplete assessments and evaluations for side rail use, lack of attempts to use alternatives before installing bed rails, and failure to obtain informed consent from residents or their representatives. These failures were observed across multiple residents, including those with severe cognitive impairments and those dependent on staff for mobility and activities of daily living (ADLs). Specific instances included residents being observed with side rails that did not match the physician's orders or the informed consent documentation. For example, one resident had bilateral side rails up despite the order and consent being for one-fourth side rails. Another resident's informed consent was for grab bars, but the facility installed side rails without documented evidence of alternatives being attempted. These discrepancies were verified through interviews with facility staff, including licensed vocational nurses (LVNs) and registered nurses (RNs), who confirmed the lack of proper documentation and adherence to policies. The facility's policies required that alternatives to bed rails be attempted and documented before installation, and that informed consent be obtained and specific to the device ordered by the physician. However, the facility failed to adhere to these policies, resulting in potential risks for entrapment and serious injuries to the residents. The Director of Nursing (DON) acknowledged these findings, indicating a systemic issue in the facility's management of bed rail use and resident safety.
Deficiencies in Resident Care and Communication
Penalty
Summary
The facility failed to provide necessary care and services for two discharged residents, leading to deficiencies in their treatment and care. For Resident 828, the facility did not document a follow-up call to the physician after the resident felt light-headed, had an assisted fall, and sustained a skin tear on the right lower leg. The treatment order obtained from the physician was inconsistent with the resident's injury, as it was for the left lower leg instead of the right. The medical record lacked documentation of the exact time of the fall, and there was no follow-up notification to the physician regarding the fall and injuries until much later. For Resident 731, the facility failed to collect a urine sample in a timely manner and did not promptly report the urinalysis result to the resident's physician. The urine sample was ordered on October 1st but was not collected until October 5th. The urinalysis result was reported on October 5th, but the physician was not notified until October 7th, after the resident's family member inquired about the results. The delay in collecting the urine sample and reporting the results was acknowledged by the staff, who stated that the sample should have been collected within 24 hours and the physician notified immediately upon receiving the results. Interviews with the facility's staff, including the RN and DON, confirmed the discrepancies in documentation and communication regarding the residents' care. The staff acknowledged the inconsistencies in the treatment orders and the lack of timely follow-up with the physician. The DON verified that the facility's policies were not followed, leading to the deficiencies in care for both residents.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess two nonsampled residents for their ability to self-administer medications, as required by their policy and procedure. Resident 113 was observed with bottles of D-mannose and herbal supplements at her bedside, which she had been self-administering since her admission. Despite her moderate cognitive impairment, there was no documented evidence in her medical records that an assessment for self-administration had been conducted. Additionally, there was no physician order for the supplements she was taking. Similarly, Resident 980 was found with carboxymethylcellulose eye drops at her bedside, which she had been self-administering. Although Resident 980 was cognitively intact and had the capacity to make medical decisions, her medical records also lacked documentation of an assessment for self-administration. The RN on duty confirmed the presence of medications at the bedside for both residents and was unable to find any completed assessments for their self-administration of medications. The Director of Nursing acknowledged these findings.
Failure to Provide Reasonable Accommodations for Resident Needs
Penalty
Summary
The facility failed to provide reasonable accommodations for several residents, impacting their ability to access necessary items and services. Resident 16, who had a moderate cognitive impairment and physical limitations, requested an extension cord for his landline phone, which was not provided by the facility staff despite being logged in the maintenance request system. The resident's friend eventually provided the extension cord, highlighting a lapse in the facility's response to resident needs. Additionally, the facility did not ensure that call lights were within reach for multiple residents, which could delay their ability to request assistance. Resident 128, who was in a wheelchair, could not reach the call light, which was positioned on the opposite side of the bed. Similarly, Resident 97, who had severe cognitive impairment and required substantial assistance, had both the call light and bed remote control on the floor, out of reach. This was acknowledged by the staff during an observation. Furthermore, Residents 1 and 22 also had their call lights placed out of reach. Resident 1, who had left-side paralysis and was wheelchair-bound, and Resident 22, who had cognitive impairment and quadriplegia, were unable to access their call lights due to their placement on nightstands. These deficiencies in accommodating resident needs were observed and verified by facility staff, indicating a systemic issue in ensuring accessibility and responsiveness to resident requests.
Failure to Obtain Advance Directive for Resident
Penalty
Summary
The facility failed to ensure a copy of the advance directive was obtained for a resident reviewed for advance directives. According to the facility's policy and procedure, upon admission, the facility is required to determine if a resident has an advance directive and, if so, make copies to be placed on the chart and communicated to the staff. However, for the resident in question, although the POLST indicated that an advance directive was available and reviewed, there was no copy of the advance directive in the resident's medical record. Interviews and medical record reviews with the Social Services Director (SSD) and the Medical Records Director (MRD) confirmed the absence of the advance directive in the resident's file. The SSD acknowledged documenting that the resident had a Power of Attorney for healthcare authority but failed to document any follow-up to obtain the advance directive. The Director of Nursing (DON) was informed and acknowledged the findings, confirming the deficiency in the facility's adherence to its policy regarding advance directives.
Failure to Notify Physicians of Residents' Laboratory Test Refusals
Penalty
Summary
The facility failed to notify the residents' physicians when two residents refused laboratory tests, which could have impacted their treatment and well-being. Resident 95, who was on potassium chloride for hypokalemia, had a physician's order for a potassium level test on 9/17/24. However, the resident refused the blood collection on 9/17 and 9/18/24, and there was no documented evidence that the physician was informed of this refusal. The Director of Nursing (DON) confirmed these findings during an interview and medical record review. Similarly, Resident 16, who had moderate cognitive impairment, had a physician's order for several laboratory tests, including CBC with differential, CMP, magnesium, and procalcitonin, on 9/17/24. The medical record did not show the results of these tests, and the DON indicated that the resident likely refused the laboratory draw. The laboratory request form confirmed the refusal, but there was no documentation that the physician was notified of the refusal. The DON verified these findings during the review.
Privacy and Confidentiality Breaches in Resident Care
Penalty
Summary
The facility failed to maintain personal privacy for three residents during medication administration and did not protect confidential health information for one resident. LVN 4 and LVN 3 did not fully close the privacy curtains while administering GT medications to Residents 26 and 72, respectively, resulting in their abdomens being exposed. Additionally, Resident 931's room lacked a privacy curtain, and the door was left open during medication administration, allowing visibility from the hallway. Furthermore, the facility did not safeguard confidential health information for Resident 6. A computer monitor at Nursing Station C was left unattended, displaying Resident 6's progress notes. The DSD/IP confirmed that the monitor was left on and unattended, and the username on the screen was identified as LVN 6. LVN 6 acknowledged the oversight and admitted that she should have logged off to prevent unauthorized access to the resident's health information. These incidents were verified through interviews with the involved LVNs and the DON, who acknowledged the findings. The facility's policies on promoting resident dignity and safeguarding identifiable information were not adhered to, leading to potential privacy violations for the residents involved.
Failure to Notify Ombudsman and Provide Written Transfer Notice
Penalty
Summary
The facility failed to notify the representative of the Office of the State Long-Term Care Ombudsman regarding the transfer of a resident to an acute care hospital. This deficiency was identified during a closed medical record review for a resident who was transferred to the hospital. The facility's policy and procedure for non-emergency transfers or discharges require that the Ombudsman be notified, but there was no documentation of such notification in the resident's medical record. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed the absence of the required notification. Additionally, the facility did not provide a written notice of transfer or discharge to another resident or their representative. The medical record review revealed that the resident was transferred to an acute care hospital for further evaluation due to low oxygen saturation, high blood pressure, and heart rate. However, there was no documentation indicating that the resident or their representative received a written notice of the transfer, as required by the facility's policy. Interviews with a registered nurse (RN) and the DON verified the lack of documentation for the written notification.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of a resident, identified as Resident 83, who was at risk for social isolation. The resident's medical records indicated severe cognitive impairment and a care plan that included interventions to prevent social isolation, such as regular 1:1 room visits, encouragement to participate in group activities, and opportunities for social contact. Despite these documented interventions, observations over several days showed the resident lying in bed without sensory stimulation, and interviews with staff revealed that the resident did not attend activities unless requested by family. Further investigation with the Activity Director confirmed a lack of documentation for activities provided to the resident, particularly noting the absence of activity notes for specific dates. The Activity Director acknowledged that there were no records of room visits or activities for the resident during the week of 9/22-9/28/24 and on 10/8 and 10/9/24. The Director of Nursing was informed of these findings and acknowledged the deficiency in providing the necessary activities to meet the resident's preferences and needs.
Failure to Maintain Safety in Laundry Area and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to maintain a safe environment in the laundry area and for a resident at risk of falls. During an inspection of the laundry department, it was observed that the heating furnace inside the laundry closet was not properly cleaned or maintained. The floor was dirty with lint on the vent tubes, a stack of linens was improperly stored inside a clear plastic bag, and there was black discoloration on the insulator foam on top of the furnace. The Laundry Supervisor confirmed these findings and acknowledged the need to notify the Maintenance Supervisor. The Maintenance Director later verified the condition of the closet and took steps to address the issue. Additionally, the facility did not implement the physician's order and care plan for a resident at risk of falls. The resident was observed in bed with a floor mat only on the left side, despite a physician's order and care plan indicating the need for bilateral floor mats. The resident's medical records showed a history of fall risk and behaviors of sitting or crawling on the floor. RN 2 confirmed the absence of the floor mat on the right side and suggested it might have been removed during cleaning. The DON acknowledged the requirement for a mat on the right side of the bed.
Deficiencies in GT Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for two residents, leading to deficiencies in medication administration procedures. For Resident 26, the licensed vocational nurse (LVN) did not assess the residual volume from the GT before administering medication, despite physician orders requiring this check. The LVN injected air into the GT and listened with a stethoscope to verify placement but neglected to aspirate and assess the residual volume, which is crucial for ensuring safe medication administration. Similarly, for Resident 72, the LVN assessed the residual volume by aspirating a small amount from the GT but failed to confirm the tube's placement by injecting air and listening with a stethoscope. This step is essential to ensure the GT is correctly positioned before medication administration. Both LVNs acknowledged their omissions during interviews, and the Director of Nursing (DON) verified these findings, indicating a lapse in adherence to the facility's policies and procedures for GT care.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to the physician's order for oxygen therapy for a resident, identified as Resident 95, who was reviewed for oxygen administration. The facility's policy and procedure for oxygen administration, revised in May 2024, mandates that oxygen is administered under a physician's order, except in emergencies. However, during observations on multiple occasions in October 2024, Resident 95 was found receiving oxygen at 2 liters per minute via nasal cannula, contrary to the physician's order of 3 liters per minute as needed to maintain an oxygen saturation level of 92% or higher due to a diagnosis of acute respiratory failure. The medical record review for Resident 95 revealed no documented evidence indicating that the resident's oxygen saturation level was below 92%, which would necessitate the administration of oxygen. During an interview and concurrent medical record review, RN 4 confirmed the findings and acknowledged the absence of documentation justifying the administration of oxygen to Resident 95. The Director of Nursing (DON) was also unable to provide documented reasons for the oxygen administration, highlighting a lapse in following the physician's order and maintaining proper documentation.
Failure to Provide Appropriate Dialysis Care and Fluid Monitoring
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, identified as Resident 931, by not ensuring that medications scheduled for administration on dialysis days had a physician's order to be held or rescheduled. Specifically, the medications insulin lispro and midodrine were held and not administered on multiple occasions when the resident was at the dialysis center. There was no documented evidence that the physician was notified about the non-administration of these medications, which were ordered to be given at specific times. This lack of communication and documentation posed a risk of medical complications for the resident. Additionally, the facility did not adequately monitor Resident 931's fluid restriction, as there was no documentation of the total daily fluid intake from both the nursing and dietary departments. The charge nurses and CNAs documented fluid intake separately, but there was no evidence that the total daily intake was being monitored or that the registered dietitian was involved in this process. This oversight in monitoring fluid intake could lead to potential health issues for the resident, who was on a strict fluid restriction due to their medical condition.
Deficiencies in Controlled Medication Documentation and Emergency Kit Procedures
Penalty
Summary
The facility failed to provide necessary pharmaceutical services by not ensuring all controlled medications were accounted for and documented. During an inspection of Medication Cart A, it was found that the Controlled Substances Shift Count Log had unreadable headings, and there were missing signatures and documentation for the total number of cards/count sheets on multiple dates. LVN 2 confirmed these findings and explained the importance of signatures for the endorsement of keys and ensuring correct medication counts. Similarly, Medication Cart C also had missing signatures and documentation, and a discrepancy was found in the count of Morphine Sul ER tablets for a resident, which was not documented correctly. Additionally, the facility did not follow proper procedures for the emergency kit. An inspection of Medication Room A revealed that the emergency kit was opened, and the Emergency Kit Pharmacy Log was not placed on the clipboard as required. Instead, it was found inside the emergency kit, and the most recent entry was not documented correctly. RN 2 acknowledged these findings and confirmed that the instructions for using the emergency kit were not followed. The Director of Nursing (DON) verified all the findings, including the incorrect placement of the Emergency Kit Pharmacy Log and the failure to follow the facility's procedures for documenting the removal of medications from the emergency kit. These deficiencies indicate a lack of adherence to the facility's policies and procedures for handling controlled substances and emergency medications, potentially leading to drug diversion.
Failure to Follow Pharmacy Consultant's Recommendations for Lab Tests
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations from the drug regimen review were followed for a resident reviewed for unnecessary medications. The Pharmacy Consultant had recommended follow-up laboratory tests to recheck the potassium level for the resident, who was receiving potassium chloride for hypokalemia. However, this recommendation was not acted upon, as the necessary lab tests were not conducted. The resident had been receiving potassium therapy since July, but no follow-up lab was done to monitor the potassium levels, which is a requirement under CMS regulation (F757) to ensure that each resident's drug regimen is free from unnecessary drugs. The medical record review revealed that an order for a potassium level test was placed but was discontinued the following day after the resident refused to have the lab collected. The facility's Director of Nursing (DON) confirmed that the physician was not notified of the resident's refusal to undergo the potassium level test. This oversight posed a risk of the resident not receiving the necessary care and services or receiving unnecessary medications, as the facility did not follow through with the Pharmacy Consultant's recommendations and failed to notify the physician of the resident's refusal.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 72, was free from unnecessary psychotropic medications. The resident was prescribed bupropion, escitalopram, and trazodone for depression, but the facility did not adequately monitor for side effects associated with these medications. The facility's policy required monitoring and documentation of the resident's response to psychotropic medications, but this was not done specifically for each medication, which could lead to an inability to identify which medication caused any side effects. The medical record review revealed that Resident 72 was administered these medications over a period of time, but the monitoring for side effects was inconsistent. There were gaps in the monitoring records, and the Medication Administration Record (MAR) contained chart codes with two different meanings, leading to potential confusion. The Director of Nursing (DON) confirmed that the monitoring was not specific to each antidepressant medication, as the facility's standard practice was to monitor side effects for all psychotropic medications collectively, except for antipsychotic medications. The lack of specific monitoring for each psychotropic medication and the inconsistent documentation in the MAR could negatively impact the resident's well-being by failing to identify adverse effects. The DON acknowledged these deficiencies during an interview, verifying the findings and the issues with the MAR chart codes.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 13.79%. This deficiency was identified during a medication administration observation involving one licensed nurse (LVN 1) and a nonsampled resident (Resident 829). LVN 1 did not prepare and administer UTI-STAT oral liquid and polyethylene glycol 3350 powder as ordered by the physician. Additionally, LVN 1 failed to assess Resident 829 for loose stools or review her medical record before administering Colace 100 mg, which was ordered to be held in the presence of loose stools. Furthermore, LVN 1 administered hydrocodone-acetaminophen 10-325 mg outside the prescribed time frame, administering it at 0949 hours instead of the scheduled 0800 hours. Resident 829 had several physician orders, including medications for neuropathic pain, urinary prophylaxis, hypertension, bowel management, and pain management. The orders specified administration times and conditions under which certain medications should be held. LVN 1 acknowledged not preparing the UTI-STAT and polyethylene glycol 3350 powder, citing the resident's usual refusal, but admitted that the medications should have been prepared regardless. LVN 1 also confirmed the late administration of hydrocodone-acetaminophen and the failure to assess for loose stools before administering Colace, as per the physician's instructions.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage, labeling, and disposal of medications and treatment supplies, leading to several deficiencies. Medications were left unattended on top of a medication cart and a resident's bedside table during administration, which was verified by LVN 5. This oversight could potentially allow unauthorized access to medications. Additionally, medications were not stored according to professional principles, with oral medications mixed with transdermal and ophthalmic medications, and subcutaneous injections stored with ophthalmic medications in Medication Cart A. A nasal solution bottle was improperly labeled, and an opened insulin pen lacked a proper label. The facility also failed to monitor and record the room temperature for Medication Storage Room A accurately. RN 4 admitted to signing the temperature log incorrectly, which could lead to improper storage conditions for medications. Furthermore, the facility did not properly dispose of medications, as evidenced by accessible medications in the incineration containers in Medication Rooms A and C. The DON confirmed that medications should be destroyed and not accessible, but the process was not followed. Additional issues included an expired silicone suction tubing connector found in Medication Cart D and a tube of Anasept cream left at a resident's bedside without a physician's order. LVN 8 and the DON verified these findings, indicating a lack of adherence to the facility's policies and procedures for medication storage and disposal. These deficiencies highlight the potential for unsafe medication administration and unauthorized access to medications.
Failure to Follow Menu and Recipe Guidelines
Penalty
Summary
The facility failed to adhere to its menu and recipe guidelines when preparing meals for residents, specifically those on a pureed diet. During an observation, a staff member was seen preparing pureed roast beef and potatoes without measuring ingredients or following the recipe. The staff member added unmeasured water to the roast beef, which was against the facility's policy, and did not measure the butter, milk, or dry potato mix for the potatoes. The Dietary Services Supervisor (DSS) confirmed that the recipes were not followed, and the Registered Dietitian (RD) acknowledged the findings. Additionally, a resident expressed dissatisfaction with a fruit plate ordered from the alternative menu. The resident received a plate with only cantaloupe slices and grapes, contrary to the expected variety of fruits and cottage cheese. The DSS confirmed that the recipe for the fruit plate was not followed, despite the availability of the required fruits. The DSS later revealed that the chef's choice recipe allowed for some discretion in fruit selection, but the serving did not meet the expected variety or portion size. These deficiencies indicate a failure to meet the nutritional needs of residents, as the facility did not follow established recipes and menu guidelines. The lack of adherence to recipes and portion sizes could potentially lead to nutritional-related health complications for residents, as noted in the report.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by the inappropriate and untimely review of antibiotic use for two nonsampled residents. Resident 73 was prescribed levofloxacin for pneumonia, but there was no documented evidence of a chest x-ray result in the medical records to confirm the diagnosis. Additionally, the Infection Screening Evaluation did not indicate whether the resident's infection met the criteria for a true infection. This lack of documentation and verification of the necessity for antibiotics suggests a failure in the facility's process for ensuring appropriate antibiotic use. Similarly, Resident 110 was prescribed Fidaxomicin and Vancomycin for a suspected C. difficile infection. However, the medical records lacked laboratory results to confirm the diagnosis, and there was no evidence that the physician was informed about the dual antibiotic therapy. The Infection Preventionist and the Administrator both verified these findings, acknowledging the absence of documentation to support the use of antibiotics for these residents. This oversight in documentation and communication with the physician highlights a significant gap in the facility's antibiotic stewardship efforts.
Deficiencies in Glucometer Maintenance and Refrigerator Conditions
Penalty
Summary
The facility failed to maintain two glucometers in safe operating condition, as observed during an inspection of Medication Carts A and C. In Medication Cart A, the serial number of the glucometer used for daily quality control testing did not match the serial number of the glucometer stored in the cart. Additionally, there was a discrepancy in the open date of the test strips used. In Medication Cart C, the daily quality control log lacked the serial number of the glucometer, and the lot numbers of the test strips did not match those recorded in the log. These inconsistencies were verified by the respective LVNs during the inspection. Furthermore, the facility failed to ensure that the residents' refrigerators in Stations A, B, and C were free of ice buildup in the frozen storage area. This was confirmed during an observation and interview with an RN, who acknowledged the need for defrosting the refrigerators. The DON was informed of these findings and acknowledged the issues identified during the survey.
Failure to Develop Fall Risk Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 828, who was at risk for falls. The facility's policy mandates the creation of such care plans, which should include measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. Despite this policy, the care plan for Resident 828 did not address the resident's fall risk, which was identified through a fall risk assessment conducted on 8/31/24, showing a fall risk score of 11. This oversight was discovered during a closed medical record review initiated on 10/8/24. The deficiency was further highlighted when Resident 828 experienced an actual fall on 9/4/24, resulting in skin tears to the right lower leg and left hand. The incident occurred when a CNA was assisting the resident to the bathroom, and the resident felt light-headed and stated her legs were giving out. The CNA was unable to support the resident's full weight, leading to the fall. Interviews with RN 1 and RN 2 confirmed that a care plan for the actual fall was developed only after the incident, and no prior care plan was in place to address the resident's fall risk, despite the facility's expectations for such interventions.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect, as observed by surveyors. On October 8, 2024, staff were overheard in the hallway outside residents' rooms using the term 'feeders' to describe residents who required assistance with eating. Specifically, a staff member referred to Resident 111 as a 'feeder' at the door entry of their room. Resident 111, who was admitted with severe cognitive and psychiatric impairments, required extensive assistance for eating and had episodes of refusing to eat. Additionally, on October 9, 2024, during an interview, CNA 13 referred to Resident 22 as a 'feeder' when discussing the resident's inability to fully feed themselves. CNA 13 mentioned learning this term in CNA school. Resident 22, admitted with cognitive impairment, malnutrition, quadriplegia, and aspiration precautions, was also affected by this undignified terminology.
Failure to Provide Vision Assistive Devices
Penalty
Summary
The facility failed to provide necessary assistive devices for a resident with impaired vision, identified as Resident 47. The facility's policy on the use of assistive devices, revised in December 2022, mandates that such devices should be provided based on a comprehensive assessment and the resident's care plan. Despite this, Resident 47, who has impaired vision due to glaucoma and requires glasses, was found without his eyeglasses or any other visual assistive devices during an observation on October 9, 2024. The resident was unable to read printouts on his bulletin board, see the time on the wall clock, or watch television clearly, indicating a lack of adherence to the care plan interventions that included ensuring the resident wears clean and undamaged glasses. Interviews with facility staff, including a CNA and an RN, confirmed the absence of the resident's eyeglasses and any visual assistive devices in his room. The staff acknowledged the deficiency and suggested potential solutions such as providing magnifying glasses and arranging an optometrist appointment. The Director of Nursing verified these findings, highlighting a lapse in the facility's responsibility to maintain the resident's ability to see and perform daily activities as per the established policies and care plan.
Failure to Provide Privacy Curtains for Resident
Penalty
Summary
The facility failed to ensure privacy for one of the residents, identified as Resident 931, by not providing ceiling-suspended privacy curtains in the resident's room. This deficiency was observed during a medication administration observation, where the resident was visible from the hallway due to the absence of a privacy curtain and the room door being left open. The facility's policy on promoting and maintaining resident dignity, revised in December 2022, mandates that all staff members are responsible for ensuring resident privacy. However, during an interview, LVN 3 confirmed the absence of the privacy curtain and admitted to not informing the maintenance staff to rectify the situation. The Director of Nursing (DON) also verified and acknowledged these findings.
Failure to Monitor Bactrim Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for the side effects of Bactrim, a medication used to treat infections. The facility's policy and procedure for medication monitoring, revised in December 2022, outlines a collaborative and systematic approach to medication management, including monitoring for efficacy and adverse consequences. However, a review of the medical records for a resident, who was being treated for a urinary tract infection with Bactrim, revealed no documentation of monitoring for side effects. During an interview, a registered nurse confirmed that the resident was not monitored for side effects and stated that monitoring was only conducted if an adverse effect was observed, which would then be documented in the progress notes. The Director of Nursing was informed and acknowledged these findings.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for two residents, leading to potential gaps in their care. For Resident 69, the POLST form, which is crucial for documenting medical orders for life-sustaining treatment, was incomplete. Specifically, Section D of the POLST form was left blank, and this was confirmed by multiple staff members, including an LVN, an RN, and the Director of Nursing (DON). This lack of documentation could result in the resident's care needs not being fully understood or met. In the case of Resident 731, the facility did not maintain a signed Against Medical Advice (AMA) form in the resident's medical records, despite a progress note indicating that the family had signed it. This discrepancy was verified by an LVN and the Medical Records Director, who both confirmed the absence of the signed form in the medical records. The DON was also informed and acknowledged the missing documentation. These documentation failures highlight the facility's inability to maintain complete and accurate medical records, which are essential for ensuring appropriate care for residents.
Failure to Notify Physician and Responsible Party of Resident's Skin Changes
Penalty
Summary
The facility failed to notify the physician and responsible party (RP) of skin changes in a resident, which posed a risk of delayed care. The facility's policy and procedure (P&P) required prompt consultation with the resident's physician and notification of the RP when there is a change in the resident's physical status that requires treatment alteration. However, this protocol was not followed for a resident who was on blood thinner medication and exhibited new bruising on her arms and legs. The family member reported the bruising to the facility staff, but there was no documented evidence that the physician and RP were notified of the skin discoloration. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition. A Certified Nursing Assistant (CNA) was aware of the bruising but did not report it, assuming the nurses were already informed. A Licensed Vocational Nurse (LVN) acknowledged that the family member reported the change in the resident's condition but failed to complete a change in condition report. The resident, who lacked the capacity to make medical decisions, was observed with generalized purple discoloration on her extremities, and the medical records did not indicate any prior history of bruising.
Failure to Provide Adaptive Equipment for Self-Feeding
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident who had occupational therapy (OT) recommendations for built-up utensils from January 2024 through April 2024. Despite these recommendations, the resident did not receive the built-up utensils during therapy sessions, which could have negatively impacted their health condition and well-being. The facility's policy and procedure (P&P) on Notification of Changes required informing the resident, consulting with the physician, and notifying the family or legal representative when there is a change requiring such notification, including the need to alter treatment. However, there was no documentation showing that the resident was provided or trialed with the built-up utensils, and no physician's order was found for these utensils. The resident, who had moderate cognitive impairment and impairment on one side of the upper extremity, required assistance with eating. The OT's evaluation and plan of treatment included goals for the resident to perform self-feeding tasks with built-up utensils, but these goals were not addressed. Interviews with the OT and the registered dietitian (RD) revealed that the OT was responsible for notifying the physician and requesting orders for the built-up utensils, but this was not done. The RD was unaware of the OT recommendations, and the Director of Nursing (DON) and Director of Staff Development (DSD) acknowledged the findings.
Improper Administration of Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that a resident was correctly administered her blood pressure medication according to the prescribed orders. The resident, who had the capacity to make decisions and was diagnosed with high blood pressure, was prescribed Hyzaar to be held if systolic blood pressure (SBP) was less than 130 mmHg. However, in January 2024, the resident was administered Hyzaar on multiple occasions despite having SBP readings below 130 mmHg, specifically on 1/1/24, 1/4/24, 1/22/24, 1/23/24, and 1/24/24. In February 2024, the resident's medication was changed to losartan, with the same instruction to hold for SBP less than 130 mmHg. Despite this, the resident was administered losartan on 2/8/24, 2/9/24, 2/10/24, 2/11/24, 2/12/24, and 2/13/24, even when the SBP was below 130 mmHg on several occasions. The Director of Nursing (DON) verified these findings during an interview.
Failure to Include Resident in Care Plan Conferences
Penalty
Summary
The facility failed to ensure that a resident was provided the opportunity to participate in care plan conferences. Despite the facility's policy stating that residents should be informed of their rights regarding care planning and implementation, and that requests for care plan meetings should be honored, the resident reported not being invited to any care plan meetings. The resident had requested care plan meetings twice but was not scheduled for any. The resident expressed concerns about her laboratory results, therapy frequency, and medication dosages, which she wanted to discuss in a care plan meeting to better work towards her goals. Medical record reviews confirmed that there was no documented evidence that the resident was offered to participate in a care plan conference. The resident was alert, oriented, and had an intact cognitive response, as indicated by her BIMS score. Interviews with the Social Services Assistant (SSA) and the Director of Nursing (DON) verified that no care plan meeting was scheduled for the resident before the SSA set up an appointment after the resident's interview with the health facilities evaluator nurse. The SSA acknowledged that care plan meetings should be completed within two weeks of admission, but this was not done for the resident in question.
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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