University Park Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 230 E Adams Blvd, Los Angeles, California 90011
- CMS Provider Number
- 056206
- Inspections on file
- 69
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at University Park Healthcare Center during CMS and state inspections, most recent first.
A resident with paranoid schizophrenia and psychosis had a physician order and care plan for Depakote 125 mg BID to manage delusions. Over an extended period, the resident repeatedly refused Depakote at scheduled doses, including multiple consecutive refusals documented on the MAR. Staff reported that medication should be offered twice and the physician notified when refusals occurred, and the facility’s change-in-condition policy required physician notification after two or more consecutive refusals. However, there was no documentation that the physician or psychiatrist was notified of these refusals until a change-of-condition note was entered and the primary physician was contacted much later, despite the DON and RN supervisor acknowledging the importance of the medication for controlling the resident’s delusions.
Physician-ordered daily wound care and monitoring were not provided to five residents with complex medical needs on two occasions. The absence of the treatment nurse, lack of reassignment by the RN Supervisor, and incomplete coverage by the DON led to missed treatments, with no documentation of completion, refusal, or holding of care, contrary to facility policy.
Multiple residents with complex medical needs and high risk for pressure injuries did not receive physician-ordered daily wound care on two occasions due to staff absences and lack of reassignment, with no documentation or communication regarding the missed treatments.
A resident who was cognitively intact but fully dependent on staff for care lent $3,000 to a CNA's friend, with only a small portion repaid. The CNA did not report this financial transaction, despite facility policies requiring staff to report suspected exploitation or misappropriation of resident property. Other CNAs and the social service designee confirmed that soliciting money from a resident is inappropriate and constitutes financial abuse.
A resident with end stage renal disease and depression experienced discomfort due to a room temperature of 84°F, which was above the facility's policy range. The resident reported feeling hot and uncomfortable, and the use of an electric fan provided only minimal relief. Multiple rooms were found to be above the recommended temperature range during the survey.
A facility failed to protect residents from physical abuse by another resident with schizoaffective disorder. The aggressive resident was not provided with a specific care plan, leading to incidents where he hit two different roommates, causing harm and distress. The facility did not implement its Abuse Prevention Program policy, resulting in inadequate management of the resident's behavior.
A resident with pneumonia and COPD did not receive necessary care and services according to professional standards. The facility failed to implement a comprehensive care plan for oxygen use and did not conduct routine resident checks. Vital signs were inaccurately documented, and the resident was found unresponsive and later pronounced dead. Interviews revealed discrepancies in care plan implementation and documentation practices.
The facility failed to provide necessary therapy services for two residents with limited ROM, leading to significant health issues. One resident experienced a decline in ROM in the left upper extremity, resulting in a contracture and a Stage IV pressure injury due to inconsistent RNA treatments and unreported refusals. Another resident faced a delay in RNA services for PROM and AFO application, posing potential injury risks. The facility's deficiencies in therapy services contributed to adverse outcomes and potential risks.
The facility failed to provide necessary respiratory care for two residents, as one resident's oxygen tubing was found on the floor and undated, while another resident's tubing was not changed weekly as required. Staff confirmed these practices posed infection control issues, and the facility's policies for oxygen administration and infection prevention were not followed.
The facility failed to timely initiate the process for appointing resident representatives for two residents unable to make medical decisions. One resident had severe cognitive impairments and physical disabilities, while another had multiple diagnoses affecting decision-making capacity. The Bioethics Committee initially managed care, but applications for conservators were delayed, with no specific guidance or timeline followed.
A resident, who was cognitively intact and capable of decision-making, was not included in care plan meetings at the facility, despite expressing concerns about premature discharge. The Social Services Director confirmed the lack of documentation of the resident's participation, contrary to the facility's policy encouraging resident involvement.
A resident with multiple health conditions, including blindness and hemiplegia, had their call light placed out of reach, contrary to their care plan and facility policy. This oversight was confirmed by the Infection Preventionist and acknowledged by the DON, highlighting a failure to ensure the resident could call for assistance when needed.
A resident with multiple health conditions was not provided with his preferred daily shave, as outlined in his care plan. Despite being able to communicate his needs, the facility only provided shaves twice a week on shower days. Staff interviews confirmed the oversight, acknowledging the resident's right to request a daily shave and the facility's failure to adhere to its policies on accommodating resident preferences.
A resident with severe cognitive impairments and hemiplegia repeatedly refused RNA treatments, which were not reported to the physician as required by facility policy. The resident's care plan included PROM exercises and a hand splint to prevent contractures, but refusals were not documented or communicated, leading to a Stage 4 pressure injury on the resident's hand.
A resident with multiple health conditions reported verbal harassment by the DON, but the facility failed to develop a care plan addressing the alleged abuse. Despite the resident's cognitive intactness and potential emotional distress, no care plan was initiated, contrary to facility policy requiring comprehensive, person-centered care plans.
A resident with multiple health issues was inaccurately assessed as low risk for falls due to errors in the fall risk assessment, which did not account for their medication use and medical history. This misclassification could have led to insufficient preventive measures, despite the care plan identifying the resident as high risk for falls.
A facility failed to provide and document necessary colostomy care for a resident, leading to potential complications. The resident, with a history of quadriplegia and diabetes, was readmitted without appropriate colostomy care orders. Observations showed the colostomy bag lacked date and time markings, and there was no documentation in the EHR. Staff were unaware of the facility's policy on documenting colostomy care, which could lead to infection control issues.
A resident with significant weight loss did not receive prescribed Magic Cup supplements twice daily with meals, and weekly weights were not documented as required. The resident, with a history of schizoaffective disorder and anemia, experienced severe weight loss. Staff confirmed the absence of the supplement on meal trays and missing weight records, indicating a lapse in care.
The facility failed to provide a Restorative Nursing Assistant (RNA) certificate for a sampled RNA, leading to an inability to verify the RNA's competency. The Director of Staff Development, who was new to the position, was unable to locate the certificate in the facility's files. Interviews with the Registered Nurse Consultant, Director of Nursing, and Administrator confirmed the lack of certification, which was necessary to demonstrate the RNA's ability to perform restorative care, as required by the facility's policy.
A LTC facility experienced a medication error rate of 22.22%, affecting three residents. Errors included omitted or late administration of vitamin D and artificial tears, and an attempt to administer a mixture of crushed medications without verifying compatibility. The errors were identified during a survey, highlighting lapses in medication administration protocols.
The facility failed to remove discontinued divalproex tablets from a medication cart, leading to potential overmedication of a resident. Additionally, dronabinol capsules were improperly stored at room temperature instead of being refrigerated, as required. These deficiencies in medication management could lead to adverse effects and reduced efficacy of treatments.
The facility failed to follow fortified diet guidelines during lunch preparation, affecting seven residents who required increased caloric intake. Dietary Aide (DA1) did not communicate fortified diet orders, leading Cook1 to omit necessary additions to meals. Interviews confirmed the oversight, and the Registered Dietitian emphasized the importance of fortified diets for residents experiencing weight loss.
The facility failed to provide the correct food texture for residents on modified diets, with 15 residents receiving improperly pureed corn salad and others receiving flaked fish instead of finely chopped or ground textures. This oversight could pose risks for residents with chewing and swallowing difficulties.
The facility failed to maintain safe food storage practices, with several items in the kitchen found without proper labeling or dating. Observations revealed undated sandwiches and salads in the refrigerator, and a bag of deli meat in the freezer without a label or date. Interviews with staff indicated a lack of adherence to facility policies on food labeling and storage, posing potential risks to residents.
The facility lacked a policy for its Bioethics Committee, affecting 13 residents who could not make medical decisions. The committee, including the Medical Director and Administrator, acted as responsible parties without formal guidance. Resident 19, with multiple diagnoses, was represented by the committee without documentation of a conservator application. Staff interviews confirmed the absence of specific guidance, leading to a deficiency in care.
The facility failed to ensure accurate documentation of medical records for seven residents, with identical vital signs recorded by the same LVN across multiple shifts. This issue was identified for residents with various medical conditions, including metabolic encephalopathy and schizophrenia. The DON acknowledged the identical records but did not classify them as falsification, despite the lack of variation in the documented vital signs. The facility's policy on routine resident checks contradicted the DON's statement, requiring documentation for each shift.
A resident with a history of aggression due to schizophrenia and mood disorder became physically aggressive towards another resident, resulting in a skin tear. The aggressive behavior was known to staff, who reported previous incidents. The facility's policy on abuse was not effectively implemented to prevent this incident.
A resident with severe cognitive impairments was moved to a different room without notifying their representative, violating facility policy. The social service assistant attempted to contact the representative but failed to document the attempt, leading to a lack of communication about the room change.
A cognitively impaired resident was left unattended and exposed in a hallway for nearly an hour, despite being within eyesight of multiple staff members. The resident, diagnosed with dementia, was observed crawling and lying on the floor without receiving assistance or comfort. The facility's staff failed to implement the resident's care plan, which required constant supervision, leading to a deficiency in care.
Two residents with severe cognitive impairments and physical limitations experienced unwitnessed falls, but the facility failed to conduct required PT evaluations to assess and address potential safety issues. Despite the facility's policy, no PT evaluations were performed, as confirmed by the DOR and DON.
A resident with schizophrenia and a history of wandering was not adequately monitored or provided with effective care plan interventions, leading to an incident where the resident entered another resident's room and caused physical harm. The facility's failure to implement individualized care plans and accurately document the resident's condition contributed to the deficiency.
A resident admitted with anxiety disorder and schizophrenia did not have a complete baseline care plan within 48 hours, as required by the facility's policy. The DON acknowledged that only the dietary section was completed, and the MDS Coordinator confirmed the plan was not finished, potentially affecting the resident's immediate care needs.
The facility failed to implement the care plan for a resident with burns and a skin graft, neglecting required skin assessments every shift and upon readmission. Interviews with staff confirmed the lack of documentation and adherence to facility policies.
The facility failed to protect a resident from physical abuse when a resident with moderate cognitive impairment hit another resident on the head with a sign in the smoking patio. The incident could have been prevented with better supervision, as indicated by staff interviews. The facility's abuse prevention policy was not effectively implemented, leading to this deficiency.
Failure to Timely Notify Physician of Ongoing Psychotropic Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to timely notify a resident’s physician of ongoing refusals of a prescribed psychotropic medication, Depakote, ordered for paranoid schizophrenia. The resident was admitted with diagnoses including paranoid schizophrenia, psychosis, and muscle weakness, and had a physician’s order for Depakote 125 mg twice daily for schizophrenia. The resident’s care plan, initiated and later revised, documented use of Depakote for paranoid schizophrenia, with interventions to assess daily for behaviors, notify the physician if the medication could be reduced, and monitor and report behaviors monthly to the physician/psychiatrist. The MDS indicated the resident was cognitively intact and required set-up assistance with ADLs. Review of the MAR for January showed the resident repeatedly refused Depakote at scheduled 9 a.m. and 5 p.m. doses on numerous days throughout the month, including multiple consecutive refusals. Facility staff, including an LVN, stated that when the resident refused medications, they would offer them twice and that the physician should be notified when refusals occurred. The RN supervisor acknowledged the resident had been refusing Depakote and that the medication was for control of delusions. The DON stated that refusal of Depakote would exacerbate the resident’s condition and confirmed there was no documentation that the primary physician or psychiatrist had been notified of the refusals prior to a change-of-condition note created on January 30, when the physician was finally notified. The facility’s policy on change in condition required physician notification when a resident refused treatment or medications two or more consecutive times, which was not followed in this case.
Failure to Provide Physician-Ordered Wound Care and Treatment
Penalty
Summary
The facility failed to implement physician-ordered daily wound treatments for five residents on two separate days. These residents had significant medical needs, including quadriplegia, colostomy status, open wounds, dementia, contractures, hemiplegia, hemiparesis, and severe cognitive impairment. Physician orders for wound care, skin management, and monitoring of specialized equipment such as low air loss mattresses and casts were not carried out as scheduled. Documentation confirmed that the required treatments were not provided, and there was no record of treatments being completed, refused, or held. Interviews with facility staff revealed that the treatment nurse, who was responsible for administering these treatments, was absent on one of the days and did not report missed treatments on another. The Registered Nurse Supervisor, who was aware of the absence of a treatment nurse, did not reassign the responsibility to another licensed nurse or ensure that the treatments were completed. The Director of Nursing acknowledged that she attempted to provide treatments herself but was unable to complete all required treatments for residents with extensive or complex wound care needs. Facility policy required that medications and treatments be administered only upon written physician orders and that licensed nurses demonstrate competency in providing care as identified in resident assessments and care plans. The failure to follow these orders and policies resulted in residents not receiving necessary wound care and monitoring as prescribed by their physicians.
Failure to Provide Physician-Ordered Wound Care for Multiple Residents
Penalty
Summary
The facility failed to implement physician-ordered daily wound care treatments for five residents who were at risk for or had existing wounds and pressure injuries. On two specific dates, the Treatment Administration Record (TAR) showed that required wound care was not provided as scheduled for these residents. The affected individuals had complex medical histories, including quadriplegia, colostomy, contractures, dementia, and existing pressure injuries, and were dependent on staff for most activities of daily living. Physician orders included specific wound care regimens such as cleansing with normal saline, application of Santyl collagenase ointment, use of barrier creams, and monitoring of low air loss mattresses, all of which were not carried out on the identified dates. Interviews with facility staff revealed that the treatment nurse, who was responsible for administering these treatments, was absent on one of the days and did not complete or document the required care on another. The Registered Nurse Supervisor, who was present during one of the shifts, acknowledged that no alternative licensed nurse was assigned to complete the treatments, nor was there any communication regarding the missed care. The Director of Nursing confirmed that despite being aware of the staffing gap, she was unable to ensure all necessary treatments were provided, resulting in multiple residents missing their prescribed wound care. Facility policy required that medications and treatments be administered only upon written physician orders, and that wound treatments be managed according to clinical protocols. The failure to follow these orders and protocols led to a lack of daily wound care for residents with significant risk factors for skin breakdown and delayed healing. There was no documentation of treatments being completed, refused, or held, and no evidence that missed treatments were reported to the physician or other responsible parties.
Failure to Prevent and Report Financial Exploitation of a Resident by Staff
Penalty
Summary
The facility failed to ensure that services provided to a resident met professional standards of practice when a certified nursing assistant (CNA) and the CNA's friend solicited and received money from a resident. The resident, who was cognitively intact but totally dependent on staff for most activities of daily living due to quadriplegia, diabetes mellitus, and anemia, lent $3,000 to the CNA's friend, of which only $200 was repaid. The incident was not reported by the CNA, despite facility policies requiring staff to report suspected exploitation, theft, or misappropriation of resident property. Interviews with other CNAs and the social service designee confirmed that asking for money from a resident is considered inappropriate and constitutes financial abuse. The facility became aware of the situation when the resident's next of kin reported the financial transaction. The facility's policies and procedures, reviewed prior to the incident, clearly outlined expectations for staff to report such incidents and to uphold ethical standards in their interactions with residents.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable room temperature for one of four sampled residents, resulting in a room temperature of 84°F, which exceeded the facility's policy range of 71°F to 81°F. This was confirmed through observation, interview, and record review. The resident, who was cognitively intact and required moderate assistance with activities of daily living, reported feeling hot and uncomfortable in his room. He used an electric fan, but stated it only helped a little to cool down the room. On the day of the survey, the maintenance supervisor measured the temperatures in several rooms, all of which were found to be 84°F. The facility's policy and procedures, reviewed earlier in the year, specified that residents should be provided with a comfortable and safe temperature within the stated range. The resident's medical history included end stage renal disease and depression, and he had been admitted and re-admitted to the facility prior to the incident.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, specifically involving two residents who were subjected to physical aggression by a third resident diagnosed with schizoaffective disorder bipolar type. The facility did not implement its Abuse Prevention Program policy to protect residents from abuse by others, including fellow residents. This resulted in incidents where the aggressive resident hit two different roommates on separate occasions, causing physical harm and psychological distress. The aggressive resident, who had a history of combative and agitated behavior, was not provided with a specific care plan addressing his schizoaffective disorder. Despite having a physician's order for antipsychotic medication and a need for behavior monitoring, the facility did not develop a care plan with interventions to manage the resident's behavior. This lack of a tailored care plan contributed to the resident's aggressive actions, as there were no specific strategies in place to monitor and mitigate his behavior effectively. The incidents occurred when the aggressive resident was moved to different rooms after altercations with roommates. The facility's failure to verify the resident's diagnosis and create an appropriate care plan led to inadequate management of his behavior, resulting in physical confrontations with his roommates. The facility's inaction in developing a comprehensive care plan and implementing its abuse prevention policy increased the risk of harm to other residents.
Failure to Implement Care Plans and Accurate Documentation Leads to Resident's Death
Penalty
Summary
The facility failed to provide necessary care and services to Resident 77, who had diagnoses of pneumonia and chronic obstructive pulmonary disease (COPD), in accordance with professional standards of practice. The facility did not implement the Speech Therapy at Risk for Aspiration care plan interventions, which included oral pharyngeal stimulation and exercises. Additionally, the facility did not develop a comprehensive, person-centered care plan that included the physician's order for Resident 77 to receive oxygen at two liters per minute via nasal cannula as needed for shortness of breath related to COPD. Furthermore, the facility did not ensure that Resident 77's vital signs documented by the Licensed Vocational Nurse (LVN 4) were accurate on multiple dates. The facility also failed to implement its policy and procedure titled Routine Resident Checks, as there was no routine resident check at least once per each 8-hour shift for Resident 77. The last skilled nursing assessment was documented at 1:45 PM, and Resident 77 was found unresponsive in his room the following morning at 7:32 AM. Cardiopulmonary Resuscitation (CPR) was initiated, and Emergency Medical Services (EMS) were called, but Resident 77 was pronounced dead by the paramedics at 8:08 AM. The facility's documentation practices were called into question, as vital signs for Resident 77 and five additional residents were documented as exactly the same across different shifts, raising concerns about the accuracy and reliability of the records. Interviews with facility staff revealed discrepancies in the implementation of care plans and documentation practices. The Director of Nursing (DON) acknowledged the issues with vital sign documentation but did not consider it falsification of records. The Minimum Data Set Nurse (MDSN) confirmed that a care plan for oxygen use should have been initiated for Resident 77. The facility's policies and procedures for routine resident checks and documentation were not followed, contributing to the lack of timely assessments and accurate records for Resident 77. These deficiencies in care and documentation ultimately led to the resident being found unresponsive and subsequently pronounced dead.
Failure to Provide Therapy Services Leads to Severe Contracture and Pressure Injury
Penalty
Summary
The facility failed to provide necessary therapy services for two residents with limited range of motion (ROM), leading to significant health issues. Resident 48, who had a history of hemiplegia and hemiparesis following a cerebral infarction, experienced a decline in ROM in the left upper extremity. Despite a physician's order for Restorative Nursing Aide (RNA) services to perform passive range of motion (PROM) exercises and apply a left resting hand splint, these treatments were inconsistently provided or refused by the resident. The facility did not report these refusals or missed treatments to the charge nurse or therapy staff, nor did they conduct a nursing assessment following the refusals, as required by facility policy. Resident 48's condition worsened over several months, resulting in a contracture of the left hand into a fisted position. This contracture led to the development of a Stage IV pressure injury on the left middle finger, which was identified in January 2025. The facility's failure to provide consistent RNA treatments and to address the resident's refusals contributed to this severe outcome. Additionally, the facility did not conduct an Occupational Therapy (OT) evaluation after identifying the decline in ROM, which could have provided alternative interventions to prevent the contracture and subsequent pressure injury. Resident 6 also experienced a delay in the start of RNA services for PROM and the application of left ankle foot orthotics (AFO), as ordered by physical therapy. This delay had the potential to cause injury due to the improper application of the AFO. The facility's lack of timely and appropriate therapy services for both residents highlights significant deficiencies in their care, leading to adverse health outcomes for Resident 48 and potential risks for Resident 6.
Failure to Provide Safe Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents, Resident 55 and Resident 291, as observed during a survey. Resident 55, who was admitted with chronic obstructive pulmonary disease (COPD) and anemia, had a physician's order for oxygen therapy via nasal cannula as needed. During an observation, Resident 55's oxygen cannula tubing was found on the floor, undated, and dirty, which was confirmed by a Certified Nursing Assistant (CNA) and other staff members. The facility's staff acknowledged that using tubing from the floor posed an infection control issue and could lead to respiratory infections. Resident 291, admitted with acute respiratory failure and hypoxia, was observed using oxygen therapy continuously. The oxygen tubing for Resident 291 was dated 1/29/2025, indicating it had not been changed weekly as required by the facility's policy. The Infection Preventionist (IP) confirmed that the tubing should have been changed on 2/5/2025, and the Director of Nursing (DON) acknowledged the potential for infection control issues if the tubing was not changed weekly. The facility's policies and procedures for oxygen administration and infection prevention were reviewed, indicating that oxygen cannula and tubing should be changed every seven days or as needed, and that oxygen humidifiers should be dated and changed after 24 hours. The failure to adhere to these policies resulted in deficiencies in providing safe and appropriate respiratory care for the residents, potentially exposing them to complications associated with oxygen therapy.
Delayed Appointment of Resident Representatives
Penalty
Summary
The facility failed to timely initiate the process for appointing a resident representative for two residents who were unable to make medical decisions. Resident 48 was admitted with severe cognitive impairments and physical disabilities, including hemiplegia and hemiparesis following a cerebral infarction. Despite these conditions, the facility did not start the process for appointing a conservator until two months after the resident's admission. The Social Services Director acknowledged that the process should have begun earlier when it was clear that Resident 48 could not make decisions and had no known family. Similarly, Resident 19 was admitted with multiple diagnoses, including metabolic encephalopathy, schizophrenia, dementia, and bipolar disorder, which impaired the resident's decision-making capacity. The Bioethics Committee initially acted as the responsible party for Resident 19, but the application for a conservator was not submitted until four months after admission. The facility's Medical Director and Social Services Director confirmed that the Bioethics Committee was responsible for managing care until a conservator was appointed, but there was no specific timeline for this process. The facility's policy titled 'Resident Representative' did not provide guidance on the role of the Bioethics Committee or the process for appointing a conservator. Interviews with facility staff revealed that there was no specific guidance or timeline followed by the Bioethics Committee, leading to delays in appointing a responsible party for residents unable to make decisions. This deficiency highlights the facility's failure to ensure timely initiation of the process for appointing a resident representative, potentially leaving residents without a responsible party to assist in making medical decisions.
Resident Excluded from Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 62, participated in care plan meetings, which are essential for discussing care and discharge goals. Resident 62, who was cognitively intact and capable of making decisions, expressed concerns about being discharged prematurely and not being involved in the care planning process. Despite being aware of the meetings, Resident 62 was not included in them, as confirmed by the Social Services Director (SSD) during a review of the resident's records. The SSD acknowledged the absence of documentation indicating Resident 62's participation in the care plan meetings, despite the facility's policy encouraging resident involvement. The facility's policy, last revised in January 2025, emphasizes the importance of resident participation in care planning to address concerns and set goals. The lack of involvement of Resident 62 in these meetings represents a failure to uphold the resident's right to be an active participant in their care, as outlined in the facility's procedures.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the residents, identified as Resident 51. This resident was readmitted to the facility with multiple diagnoses, including HIV, epilepsy, blindness, and hemiplegia, and required substantial assistance for daily activities. The resident's care plan specifically indicated the need for the call light to be within reach to prevent injury and ensure prompt assistance. However, during an observation, the call light was found on the bedside dresser, out of the resident's reach. The Infection Preventionist confirmed the call light was not accessible to the resident and moved it to the bed. The Director of Nursing acknowledged that call lights should be within reach to allow residents to call for help, and failure to do so could delay care. The facility's policy on answering call lights emphasized the importance of having the call light within easy reach of residents, especially those confined to bed or a chair.
Failure to Honor Resident's Preference for Daily Shave
Penalty
Summary
The facility failed to respect a resident's right to self-determination and choice by not providing a daily shave as preferred by the resident. The resident, who was admitted with multiple diagnoses including seizures, COPD, muscle weakness, bipolar disorder, anxiety, neuropathy, exposure to war, abnormal posture, and a history of traumatic brain injury, expressed his preference for a daily shave. Despite having the capacity to understand his medical condition and rights, and being assessed as able to make himself understood, the facility only provided shaves twice a week on shower days, contrary to the resident's care plan which specified a daily shave. Interviews with facility staff, including a CNA, LVN, RN, and the DON, confirmed that the resident's preference for a daily shave was not being met. The CNA stated that shaves were only given on shower days and would only provide additional shaves if time permitted. The LVN and RN acknowledged the resident's right to request a daily shave and recognized that the facility was not adhering to the care plan. The DON also confirmed the oversight and noted that the facility was not following the resident's rights as outlined in their policies and procedures, which emphasize accommodating individual needs and preferences.
Failure to Notify Physician of Resident's Refusal of RNA Program
Penalty
Summary
The facility failed to notify the resident's physician for a change in condition for a resident who repeatedly refused participation in the Restorative Nursing Aide (RNA) program. The resident, who had severe cognitive impairments and was dependent on staff for various activities of daily living, was at risk for contracture development due to hemiplegia and hemiparesis following a cerebral infarction. Despite the resident's refusals to participate in RNA treatments, which were documented on multiple occasions, the facility did not assess, address, or report these refusals to the physician as required by their policy. The resident's care plan included interventions to prevent further contractures, such as performing passive range of motion (PROM) exercises and applying a left resting hand splint. However, the resident frequently refused these treatments, and there was no documentation of a change in condition assessment or notification to the physician. Observations revealed that the resident's left hand was in a fisted position, and a contracture-related pressure injury developed on the left middle finger, which was assessed as a Stage 4 wound. Interviews with facility staff, including the Wound Treatment Nurse, Occupational Therapist, and Registered Nurse Supervisor, confirmed that the refusals were not communicated to the physician or adequately documented. The facility's policy required notification of the physician after two consecutive refusals of treatment, but this was not followed. The lack of communication and documentation led to a delay in assessment and intervention, contributing to the resident's worsening condition.
Failure to Develop Care Plan for Alleged Abuse
Penalty
Summary
The facility failed to develop an individualized person-centered care plan for a resident, identified as Resident 60, following an allegation of verbal harassment by the Director of Nursing (DON). Resident 60, who was readmitted to the facility with multiple diagnoses including end-stage renal disease, hypertension, hemiplegia, and hemiparesis, reported feeling verbally harassed by the DON during an interaction on February 3, 2025. Despite the resident's cognitive intactness and the potential for emotional distress, no care plan was initiated to address the alleged abuse. The incident was first brought to the attention of the facility's Administrator on February 10, 2025, during an interview with the resident. The resident described the DON as aggressive and intimidating, which made him upset. Although the facility conducted an investigation and reported the incident to the surveyor, they were unable to substantiate the allegation of abuse. However, the lack of a care plan for the alleged abuse was confirmed during a review of the resident's care plans with the MDS Nurse. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, including measurable objectives and timetables to meet their physical, psychosocial, and functional needs. The MDS Nurse and the DON both acknowledged that a care plan should have been initiated for the alleged abuse to ensure the resident's needs were met and to monitor for any emotional symptoms. The absence of such a care plan indicated a failure to adhere to the facility's policy and potentially delayed the delivery of appropriate care for Resident 60.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to accurately assess a resident's fall risk, which led to a deficiency in providing necessary care and services to prevent accidents and falls. The resident, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, and a history of stroke, was initially assessed as low risk for falls. However, this assessment was incorrect as it did not account for the resident's use of antihypertensive and narcotic medications, nor the presence of a cerebrovascular accident diagnosis, which should have classified the resident as moderate risk for falls. The resident's care plan, revised shortly after admission, correctly identified the resident as high risk for falls due to factors such as confusion, deconditioning, and balance problems. Despite this, the initial fall risk assessment failed to reflect these risks accurately. Observations confirmed that the resident was provided with interventions such as a low bed and floor mats, but the inaccurate assessment could have led to inadequate preventive measures being implemented. Interviews with facility staff, including an LVN and the MDS Nurse, revealed acknowledgment of the incorrect fall risk assessment. The MDS Nurse confirmed that the assessment did not accurately reflect the resident's medication use and medical history, which would have increased the fall risk score. The Director of Nursing also recognized the importance of accurate fall risk assessments in developing effective care plans and preventing falls, highlighting the potential for falls if assessments are not conducted correctly.
Failure to Provide and Document Colostomy Care
Penalty
Summary
The facility failed to provide necessary colostomy care for a resident, identified as Resident 4, who was readmitted with a colostomy but did not have appropriate orders for colostomy care until several months later. The resident's medical history included quadriplegia, an ulcer, obesity, type 2 diabetes, and a colostomy. Upon review, it was found that there were no documented orders for cleaning, applying skin prep, and changing the colostomy bag until the survey began. This lack of documentation and orders could lead to potential complications such as infection, skin irritation, and obstruction. Observations and interviews revealed that the colostomy bag was not dated or timed, and there was no documentation of colostomy care in the resident's electronic health record. The Infection Preventionist and a Licensed Vocational Nurse confirmed the absence of documentation and were unaware of the facility's policy regarding colostomy care documentation. The Director of Nursing acknowledged that without documentation, it could not be confirmed that the care was provided, which could lead to infection control issues. The facility's policy required documentation of colostomy care, including the date, time, and any signs of infection or skin issues.
Failure to Provide Nutritional Supplements and Monitor Weight
Penalty
Summary
The facility failed to perform weekly weights and provide a Magic Cup supplement twice a day with meals for a resident who had a history of significant weight loss. The resident was admitted with multiple diagnoses, including schizoaffective disorder, major depressive disorder, and anemia, and was identified as having a nutritional risk due to these conditions. The resident experienced a weight loss of 10.2 lbs. or 8.9% in one month and 13.2 lbs. or 11.3% in three months, indicating severe weight loss. The physician orders for the resident included receiving a Magic Cup supplement twice a day with meals and weekly weights for four weeks. However, the resident's meal tray did not include the Magic Cup supplement, and the dietary supervisor confirmed that the meal tray card did not indicate the need for the supplement. Additionally, the resident's weight was not documented weekly as required, with missing records for January 2025. The lack of documentation and failure to provide the supplement were confirmed by various staff members, including the Licensed Vocational Nurse, Registered Dietitian, and Director of Nursing. The facility's policy on weight assessment and intervention emphasized the importance of monitoring resident weights for undesirable weight loss and implementing interventions based on various factors. Despite this policy, the resident did not receive the necessary care to address her weight loss, as evidenced by the failure to perform weekly weights and provide the prescribed Magic Cup supplement. This deficiency had the potential to result in further weight loss for the resident.
Lack of Restorative Nursing Assistant Certification
Penalty
Summary
The facility failed to provide a Restorative Nursing Assistant (RNA) certificate for one of the two sampled Restorative Nursing Assistants, identified as RNA 1. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), who had been on the job for only seven days and was in the process of organizing the facility's files. RNA 1's employee record did not contain a copy of the RNA certificate, and the DSD stated that RNA 1 was attempting to locate his certificate since the facility did not have it on file. Further interviews with the Registered Nurse Consultant 2 (RNC 2), the Director of Nursing (DON), and the facility Administrator (ADM) confirmed that without the RNA certificate, the facility could not verify RNA 1's competency to perform restorative nursing aid care. The facility's policy and procedure on the competency of nursing staff required that nursing staff meet specific competency requirements for their respective licenses and certifications. The absence of RNA 1's certificate meant the facility could not demonstrate that RNA 1 had the necessary education or skills to provide restorative care, potentially placing residents at risk.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 22.22% due to six medication errors out of 27 opportunities. These errors affected three residents during medication administration. The errors included the omitted or late administration of vitamin D to one resident and artificial tears to another. Additionally, there were attempts to administer a mixture of crushed medications without proper verification of their compatibility, which could have led to adverse effects. One resident, diagnosed with dementia and schizoaffective disorder, did not receive their prescribed vitamin D supplement during the 9:00 AM medication pass. The Licensed Vocational Nurse (LVN) responsible for the administration failed to remove discontinued medications from the cart, leading to confusion and the omission of the vitamin D. Another resident, with a history of hypertension and dry eye syndrome, did not receive their prescribed artificial tears, as the LVN did not include them in the medication pass. A third resident, who lacked the capacity to make decisions, was nearly administered a mixture of crushed medications, including escitalopram, hydrochlorothiazide, losartan, and aspirin, without verifying their compatibility. The LVN involved did not consult with other staff or reference materials to ensure the safety of the medication combination. This oversight was identified and halted by a surveyor before administration, preventing potential medical complications.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly manage medications in two inspected medication carts, leading to potential risks for residents. In one instance, 36 doses of discontinued divalproex 125 mg tablets were not removed from Medication Cart 2, which resulted in a Licensed Vocational Nurse (LVN 1) administering both the discontinued tablets and the sprinkle capsules of divalproex to Resident 191. This oversight occurred despite the order for the tablets being discontinued the previous day. LVN 1 acknowledged the risk of administering discontinued medications, which could lead to adverse effects such as drowsiness or dizziness for the resident. Additionally, Medication Cart 1 contained dronabinol 10 mg capsules stored at room temperature instead of the required refrigeration, as per the manufacturer's instructions. LVN 3 was unaware of the storage requirements, which could affect the medication's efficacy in stimulating appetite. The facility's policy on medication storage, which mandates the removal of discontinued drugs and proper storage conditions, was not adhered to, increasing the risk of negative health outcomes for residents.
Failure to Follow Fortified Diet Guidelines
Penalty
Summary
The facility failed to ensure that fortified diet guidelines were followed during lunch preparation and tray line observation. On the specified date, Dietary Aide (DA1) did not communicate the fortified diet orders written on the meal tickets during the lunch service. As a result, Cook1, who was responsible for serving the food, did not add the necessary additional food items per the fortified menu. This oversight affected seven residents who required a fortified diet to increase their caloric intake. During interviews, Cook1 and DA1 acknowledged the failure to follow the fortified diet protocol. Cook1 explained that melted margarine should have been added to the meals of residents on fortified diets, but this was not done because DA1 did not announce the fortified diet orders. The Registered Dietitian confirmed that fortified diets are essential for residents experiencing weight loss, as they provide additional calories and protein. The dietary supervisor emphasized the importance of following the menu, and a review of the facility's policy highlighted the procedure for fortifying food to meet residents' nutritional needs.
Failure to Provide Correct Food Texture for Residents on Modified Diets
Penalty
Summary
The facility failed to provide food in the correct texture for residents on modified diets, leading to potential risks for those with chewing and swallowing difficulties. During a lunch service observation, it was noted that 15 residents on a pureed diet received corn salad that was thin and soupy instead of having a smooth, pudding-like consistency. The dietary aide, instructed by a cook, blended the corn salad with water, resulting in a liquid mixture with pulp, contrary to the facility's policy for pureed diets. The Registered Dietitian confirmed the inappropriate texture, which could pose a problem for residents requiring pureed diets and thickened liquids. Additionally, two residents on a finely chopped diet and three residents on a ground meat diet received flaked fish instead of the required textures. The cook admitted to only preparing regular and flaked fish, without chopping or grinding it as per the residents' diet orders. The Registered Dietitian acknowledged the absence of guidance for these diet textures in the facility's menu and serving guide, indicating a need for reevaluation and clarification of diet orders. This oversight could lead to issues with chewing or swallowing for residents on these modified diets.
Deficient Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices in the kitchen, as observed during a survey. Several food items, including turkey and cheese sandwiches and a plate of salad with chopped ham, were found in the reach-in refrigerator without any dates. Additionally, a tuna salad sandwich and another turkey and cheese sandwich were stored with dates exceeding the recommended storage periods. A bag of deli meat in the reach-in freezer was also found without a label or date, and ice crystals were observed on the meat, indicating improper storage. Interviews with the cook and dietary supervisor revealed a lack of knowledge about when the sandwiches and salads were prepared, as they were not dated. The dietary supervisor confirmed that all prepared salads and sandwiches should be dated on the day they are made and discarded if not used within the same or next day. The registered dietitian stated that tuna salad should be kept for about three days per storage guidelines, but was unaware of when the tuna salad for the sandwich was prepared. The facility's policies on labeling, dating, and storing food were not followed, leading to potential harmful bacteria growth and decreased food quality for 83 out of 84 residents.
Lack of Policy for Bioethics Committee in LTC Facility
Penalty
Summary
The facility failed to establish a policy and procedure for their Bioethics Committee, which is responsible for making medical decisions for residents who lack the capacity to do so themselves. This deficiency affected 13 residents, including Resident 19, who were represented by the Bioethics Committee. The absence of a formal policy placed these residents at risk for ineffective care and unmet needs. Resident 19 was admitted with multiple diagnoses, including metabolic encephalopathy, schizophrenia, dementia, bipolar disorder, and hemiplegia. The Bioethics Committee, consisting of the Medical Director, Administrator, Director of Nursing, and Social Worker, assumed the role of Resident 19's responsible party due to the resident's inability to make informed decisions and lack of family support. However, there was no documentation regarding the application for a state-appointed conservator or guardian for Resident 19. Interviews with facility staff revealed that the Bioethics Committee operated without specific guidance or a formal policy. The Administrator provided a policy titled 'Resident Representative,' which did not address the Bioethics Committee's role. The Social Services Director confirmed that 13 residents were under the committee's representation, and the process for applying for conservatorship lacked a specific timeline. The facility's failure to have a structured policy for the Bioethics Committee led to a deficiency in providing effective and efficient care for residents unable to make their own medical decisions.
Inaccurate Documentation of Vital Signs Across Shifts
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for seven residents, as evidenced by identical vital signs recorded by the same LVN across multiple shifts. This issue was identified for Residents 77, 53, 341, 32, 62, 21, and 19, with the same vital signs documented on consecutive days for both the 3:00 PM - 11:30 PM and 11:00 PM - 7:30 AM shifts. The Director of Nursing (DON) acknowledged the identical records but did not classify them as falsification, despite the lack of variation in the documented vital signs. Resident 19, for example, was admitted with multiple diagnoses, including metabolic encephalopathy, schizophrenia, dementia, bipolar disorder, and hemiplegia. The review of the Medication Administration Record (MAR) for Resident 53 showed consistent vital signs across shifts and days, which were identical to those recorded for other residents. This pattern was repeated for Residents 341 and 32, as well as for Residents 62, 21, and 19, indicating a systemic issue with the documentation process. During interviews, the DON stated that daily documentation by the LVN was required but not necessarily for each shift, and no specific policy was provided to support this claim. The facility's policy on routine resident checks contradicted the DON's statement, requiring documentation for each shift. LVN 4, who worked the night shift during the period in question, claimed the documented vital signs were accurate but could not explain the identical records across shifts. This discrepancy highlights a failure in maintaining accurate and reliable medical records, which is crucial for ensuring adequate resident care.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, resulting in an incident where one resident, diagnosed with schizophrenia and mood disorder, became physically aggressive towards another resident. The aggressive resident, who had a history of ineffective coping skills and poor impulse control, approached the second resident while they were resting in bed, leading to a physical altercation. This resulted in the second resident sustaining a skin tear on the left ear. The aggressive resident had been admitted with diagnoses including anxiety and depressive episodes, and was noted to have no cognitive impairments according to their Minimum Data Set (MDS). Despite this, the resident had a known history of aggression, particularly when things were not done according to their preferences, such as volume control on TVs and adherence to bathing schedules. Staff interviews revealed that the resident's aggressive behavior was a known issue, with several instances of aggression reported to the charge nurse prior to the incident. The second resident, who also had a diagnosis of schizophrenia and mood disorders, was noted to have no cognitive impairments or history of aggressive behavior. The facility's staff, including the Director of Nursing, were aware of the aggressive resident's triggers and acknowledged that the facility might not be equipped to meet the resident's needs. The facility's policy on abuse and neglect defines abuse as the willful infliction of injury or intimidation, which was not adequately prevented in this case.
Failure to Notify Resident's Representative of Room Change
Penalty
Summary
The facility failed to notify a resident's representative before moving the resident from one room to another, which is a violation of the resident's rights. The resident, who had severe cognitive impairments and required substantial assistance with daily activities, was moved from Room A to Room B without prior notification to their responsible party (RP). The facility's policy requires that residents and their families be informed of room changes, but this was not adhered to in this case. The social service assistant attempted to contact the RP but was unable to leave a message and did not document the attempt in the progress notes. The facility's policies on room transfers and changes in a resident's condition or status clearly state that the resident's representative should be notified, but this procedure was not followed. This oversight resulted in the resident and their RP not being informed of the room change or the reasons behind it.
Neglect of Cognitively Impaired Resident in Hallway
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the resident being left unattended and exposed in a hallway for approximately 59 minutes. The resident, who was cognitively impaired and diagnosed with dementia, was observed crawling and lying on the floor with his body partially uncovered. Despite being within eyesight of multiple staff members, including CNAs and LVNs, the resident did not receive assistance, comfort, or safety measures during this time. The resident's care plan, initiated on the same day, highlighted the need for constant supervision due to the resident's behavior of crawling out of bed. However, the staff failed to implement these interventions, as evidenced by surveillance footage showing the resident's prolonged exposure and lack of assistance. Interviews with staff members revealed that they were aware of the resident's behavior but did not take appropriate action to address it, citing reasons such as being assigned to other residents or not being directly responsible for the resident. The facility's policy and procedure on abuse and neglect emphasized the importance of addressing residents' needs to prevent neglect. However, the staff's inaction and failure to preserve the resident's dignity were acknowledged by the facility's administrator and DON. The surveillance footage, which was later deleted, captured multiple instances where staff members ignored the resident's plight, further highlighting the deficiency in care provided to the resident.
Failure to Conduct PT Evaluations After Resident Falls
Penalty
Summary
The facility failed to ensure that residents who experienced falls were assessed by a physical therapist (PT) to identify causative factors and implement safety interventions. Resident 1, admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, had an unwitnessed fall on 8/12/24, resulting in a bump on the forehead. Despite the fall, no PT evaluation was conducted to assess the resident's physical function and safety awareness. Similarly, Resident 2, who had diagnoses including right hip osteoarthritis and lack of coordination, experienced an unwitnessed fall on 8/14/24, resulting in a laceration on the cheek and a partially detached thumbnail. The facility did not perform a PT evaluation following this incident. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed the absence of PT evaluations for both residents after their falls, contrary to the facility's policy requiring post-fall evaluations to enhance safety awareness and prevent further incidents.
Failure to Monitor and Manage Resident's Schizophrenia and Wandering
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizophrenia and a history of wandering. The resident was not monitored for schizophrenic behavior each shift as per the physician's order, and the care plan interventions were not evaluated for effectiveness or updated based on the resident's behavior and needs. Additionally, the facility did not develop an appropriate care plan for the resident's wandering behavior, nor did they provide adequate supervision or anticipate the resident's needs to prevent agitation. As a result of these deficiencies, the resident wandered the facility and entered another resident's room, leading to a physical altercation where the resident struck the other resident in the face, causing a bleeding lip. The incident highlighted the lack of effective interventions and monitoring for the resident's wandering and aggressive behaviors, which were not addressed in the care plan. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed that the care plans lacked individualized, person-centered interventions and that staff documentation inaccurately reflected the resident's condition. The facility's policies on wandering, elopement, and abuse prevention were not effectively implemented, contributing to the incident and the potential for harm to other residents.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with diagnoses of anxiety disorder and schizophrenia, did not have a complete baseline care plan within the specified timeframe. The Director of Nursing (DON) acknowledged that only the dietary section of the baseline care plan was completed, and the rest was not finished. The DON was unaware of the specific timeframe required for completing the baseline care plan. The Minimum Data Set (MDS) for the resident indicated moderately impaired cognitive skills and a need for partial/moderate assistance with daily activities such as toileting hygiene, dressing, bathing, and walking. The MDS Coordinator confirmed that the baseline care plan was not completed upon admission, which could lead to an inability to meet the resident's immediate care needs. The facility's policy, revised in December 2016, mandates that a baseline care plan be developed within 48 hours of admission to address the resident's immediate needs, including initial goals based on admission orders and other relevant services.
Failure to Implement Care Plan for Resident with Altered Skin Integrity
Penalty
Summary
The facility failed to implement the care plan for a resident with altered skin integrity in the right antecubital space and bilateral inner thigh. The care plan required skin assessments every shift, but these assessments were not conducted. Additionally, upon the resident's readmission, a skin assessment was not completed, which was a requirement according to the facility's policy. The resident had suffered burns from a coffee spill, and a skin graft was performed on the right antecubital space. Despite these conditions, the necessary skin assessments were not documented or performed as required by the care plan and facility policies. Interviews with the licensed vocational nurse (LVN) and the Director of Nursing (DON) confirmed that the skin assessments were not completed. The LVN stated that other LVNs were responsible for applying Neosporin to the burn sites, but there was no documentation of the required skin assessments. The DON acknowledged the absence of a skin assessment upon the resident's readmission and the lack of documentation for the burn sites and skin graft. The facility's policies clearly indicated the need for comprehensive, person-centered care plans and skin assessments upon admission and readmission, which were not followed in this case.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse. Resident 1, who had intact cognition and required partial assistance with daily activities, was involved in a physical altercation with Resident 2 in the facility's smoking patio. Resident 2, who had moderate cognitive impairment and a history of alcohol dependence, hit Resident 1 on the head with a sign after Resident 1 refused to give a cigarette. This incident resulted in a small abrasion on Resident 1's head, and although the physician ordered Resident 1 to be sent to the hospital, Resident 1 refused the transfer. Interviews with staff revealed that the altercation could have been prevented with better supervision. The Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RNS) both indicated that the incident was considered abuse and could have been avoided if more staff were monitoring the smoking area. The Director of Nursing (DON) also confirmed that the altercation was considered abuse and stated that it could have been prevented if staff had noticed the residents going to the smoking patio and supervised them. The facility's policy on abuse prevention indicated that residents have the right to be free from abuse and that the administration is responsible for protecting residents from abuse by anyone, including other residents. Despite this policy, the lack of supervision in the smoking patio led to the physical altercation between Resident 1 and Resident 2, resulting in a deficiency in protecting residents from abuse.
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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