Valley View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Delano, California.
- Location
- 729 Browning Road, Delano, California 93215
- CMS Provider Number
- 555053
- Inspections on file
- 44
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Valley View Care Center during CMS and state inspections, most recent first.
Surveyors identified that an annual performance evaluation was not completed for one of five sampled CNAs, contrary to facility policy requiring at least yearly reviews of each employee’s job performance. Review of the CNA’s personnel file with the DSD showed the last evaluation was documented more than a year prior, and the DSD acknowledged that no subsequent evaluation had been done. The facility’s policy also required that completed evaluations be forwarded to HR for inclusion in the personnel record, but no current evaluation was present, creating the potential for the CNA to provide care that may not meet residents’ needs.
The facility failed to follow its Drug Diversion policy to ensure secure storage, accurate documentation, and accountability of hydrocodone for three residents. An LVN discovered that a hydrocodone bubble-pack and its inventory sheet were missing for a resident, prompting a broader review that revealed additional missing hydrocodone bubble-packs and inventory sheets for two other residents, as well as multiple additional missing packs for the first resident. Because the inventory sheets were missing and no copies were kept when narcotics were delivered, narcotic counts appeared correct and the losses went undetected, resulting in the diversion of a total of 164 hydrocodone tablets.
A resident with major depressive disorder and other medical conditions was started on Depakote 250 mg twice daily for mixed mania and bipolar with aggressive behaviors, but the facility did not conduct an IDT review prior to initiating the psychotropic medication. The MARs showed the resident received Depakote consistently while behavior monitoring specific to the medication was not initiated until several days after treatment began. The Social Services Director confirmed that required behavioral monitoring and IDT involvement, as outlined in the facility’s psychotropic medication and Psychotropic Drug Committee policies, were not implemented when the medication was started.
The facility did not follow its Background Investigations policy when an LVN was hired and allowed to work without a completed reference check in the employee file. During review, the Administrator confirmed that the reference check should have been completed before the LVN began working, as the policy requires job reference checks, drug screenings, licensure verifications, and criminal conviction record checks for all applicants. This lapse was identified as having the potential to expose residents to abuse, neglect, and mistreatment.
A CNA was observed mimicking and laughing at a resident with severe cognitive impairment who was calling out for help in Spanish. The CNA's actions, witnessed by staff and confirmed in facility records, were deemed unprofessional and failed to uphold the facility's policy on resident dignity and respect.
A resident's care plan was found to be incomplete, missing measurable timetables and specific actions to address all identified needs. Review of records and observations confirmed that the care plan did not fully document or plan for the resident's care requirements.
A resident with a history of physical aggression and multiple psychiatric diagnoses was not properly monitored or separated from others in the dining area as required by their care plan. This lapse allowed the resident to physically touch another resident on the jaw with a closed fist. Staff interviews confirmed knowledge of the care plan but acknowledged it was not followed at the time of the incident.
A resident with epilepsy and capsular glaucoma reported increased sunlight in her room due to a new untinted sliding glass door. Despite voicing her complaint to the maintenance worker, no action was taken, and the facility failed to document or address the grievance as per their policy.
A resident with a history of falls and mobility issues fell and injured their foot when two CNAs failed to use a Hoyer lift as required by the care plan. Instead, they attempted to transfer the resident using a bath towel, resulting in a fall and a possible fracture. The CNAs were aware of the care plan but did not follow it, leading to the incident.
The facility failed to educate staff on Legionnaires' Disease, lacked proper infection control surveillance, and did not adhere to CDC guidelines. Observations showed improper storage and cleaning of equipment, and inconsistent hand hygiene practices by staff, potentially leading to the transmission of infectious diseases.
The facility did not follow its policy on Resident Rights for three residents who were unaware of how to contact the Ombudsman. During interviews, the residents stated they did not know the Ombudsman contact information or where related posters were located. The Activities Director confirmed that this information was not provided during group meetings, contrary to the facility's policy.
The facility failed to document Advance Directives (AD) for 12 residents, including new admissions, as required by their policy. During interviews and record reviews, it was confirmed that these residents did not have AD acknowledgments in their medical records, which could lead to their healthcare wishes not being honored in emergencies.
The facility failed to provide the Binding Arbitration Agreement in a language and form that residents and their representatives could understand. The agreements were only available in English, despite some residents speaking other languages. The Business Office Manager did not ensure full understanding of the agreement's terms, and some residents signed without comprehension. The facility's policy required explanations in a language understood by the resident or representative, which was not followed.
The facility failed to ensure proper informed consent for antipsychotic medications for three residents. Physician statements of risks, benefits, and alternatives were missing from the PMEC forms, and physician signatures were absent. Verbal consent was obtained via telephone but was not validated by two licensed personnel as required. This deficiency was identified during interviews and record reviews, highlighting a breach in the facility's informed consent policy.
A facility failed to ensure a resident was trained in self-administration of suction, potentially risking respiratory complications. The resident, who was alert and able to communicate, had a suction machine with a container of tan frothy liquid at his bedside. An LVN was seen replacing the container, but no documentation of training or assessment for the resident's ability to use the machine was found. The resident reported using the machine up to five times daily, and a policy for its use was not provided.
A facility failed to notify the OSLTCO about a resident's transfer to an acute care facility, as required by regulations. The resident, who was hospitalized multiple times due to low hemoglobin and high potassium levels, did not have their transfers reported to the Ombudsman. The facility's policy mandates timely notification to the resident, their representative, and the Ombudsman, but this was not adhered to for transfers in October and November.
A facility failed to complete a baseline care plan (BCP) for a resident with COPD, Diabetes Mellitus, and Congestive Heart Failure within 48 hours of admission. The MDS Coordinator confirmed that the BCP was not documented, and the resident did not receive a summary, contrary to the facility's policy requiring a BCP and summary within 48 hours.
The facility failed to update comprehensive care plans for three residents, leading to potential unmet care needs. A resident with foot issues had no care plan for foot care, another had eating difficulties without a documented plan, and a third with diabetes lacked a care plan for diabetes management. Observations and interviews confirmed these deficiencies.
A facility failed to notify the attending physician of a psychiatrist's recommendation to increase Trazodone for a resident with depression. The resident was observed in poor hygiene and expressed feelings of depression, impacting his daily activities. The facility's policy requires notifying the physician of significant changes, but this was not done, as confirmed by the MDS Coordinator.
The facility failed to provide adequate foot care and documentation for two residents. One resident had significant foot issues, including foot drop and discolored, swollen toes, without proper assessment or physician notification. A podiatry recommendation for a vascular surgeon referral was also ignored. Another resident had edematous feet and long toenails, with a doctor's recommendation for a podiatry referral not documented or acted upon. The facility did not adhere to its policies on documentation and podiatry services.
A resident with neuromuscular dysfunction of the bladder had an indwelling urinary catheter without a physician's order for catheter care, leading to frequent urinary tract infections. The DON could not provide documentation for catheter care orders, and the last catheter replacement was months ago, contrary to the facility's policy requiring detailed physician's orders.
A resident was observed with a nasal cannula attached to an empty oxygen tank while sitting in her wheelchair on the facility's patio. She was pursed lip breathing, indicating potential respiratory distress. An LVN confirmed the tank was empty and admitted to not checking it before taking the resident outside. The resident had a physician's order for continuous oxygen at 2 to 4 L/Min for shortness of breath, and the facility's policy requires oxygen to be administered under a physician's order.
The facility failed to provide required annual training on recognizing and reporting elder and dependent adult abuse, neglect, and exploitation to a significant number of CNAs, LVNs, and RNs. This deficiency was identified during a review of training records, which showed no documented training for many staff members, as confirmed by the DSD. The facility's policy requires annual education, but the lack of compliance could lead to unreported abuse incidents.
The facility failed to provide necessary follow-up for medically-related social services for two residents, resulting in delays in dental and vision care. One resident required dentures and vision follow-up, but there was no documentation of referrals or follow-up. Another resident had dental x-rays taken, but no subsequent follow-up was documented. The facility did not adhere to its policy for providing and documenting these services.
A facility failed to follow its medication storage policy when a medication cup containing Bio-freeze gel was left unattended at a resident's bedside. LVN 6 identified the substance and was unaware of how long it had been there. The facility's policy requires medications to be stored in locked compartments and under direct observation during medication passes.
A resident did not receive the prescribed meal items necessary for their nutritional needs, as indicated on their meal ticket. The meal tray was missing several items, including ice cream and fortified soup, which were confirmed by the LVN and CDM. Additionally, the resident struggled to cut meat into bite-sized pieces, and there was no documentation or notification to the physician regarding this issue, contrary to the facility's policy.
A facility failed to provide a necessary assistive feeding device for a resident, as observed during a meal service. The resident was served on a regular ceramic plate instead of the required divided plate, as indicated on their Meal Ticket. The Certified Dietary Manager confirmed the oversight, which was contrary to the facility's policy on providing adaptive equipment for meal consumption.
The facility failed to maintain an effective antibiotic stewardship program. A resident was treated with Fluconazole without proper evaluation or follow-up by the IP, who lacked documentation of diagnostic tests and did not consult the physician. Additionally, the facility did not conduct required Antibiotic Stewardship Meetings, and the IP failed to provide necessary education to the nursing staff, as outlined in the facility's policy.
The facility failed to obtain informed consent for flu vaccines for three residents and did not provide risk and benefit explanations for two residents who refused the vaccine. Additionally, documentation for a resident's vaccine administration was incomplete, lacking essential details such as lot number and site of injection.
The facility failed to obtain COVID-19 vaccination consent for two residents and did not inform two others of the risks and benefits of vaccine refusal. The Infection Preventionist acknowledged the absence of consent forms and lack of documentation, while the Nurse Consultant confirmed the absence of a policy on vaccination consents.
A resident's oxygen tank was found unsecured in their room, posing a potential health hazard. An LVN observed the tank standing without proper support, contrary to the facility's policy requiring oxygen cylinders to be secured in racks. A Respiratory Therapist confirmed the incident was unacceptable and dangerous, highlighting a lapse in adherence to safety protocols.
A resident's personal funds, initially totaling $2,600, were not properly accounted for while stored in a nurse's medication cart, resulting in only $50 remaining without documentation of withdrawals. The facility's policies on fund management and abuse prevention were not followed, leading to potential emotional distress for the resident.
The facility failed to administer physician-ordered treatments for several residents, including medicated ointments and wound dressings, as confirmed by the DON. The staff did not document these treatments, suggesting they were not performed, which is against the facility's wound treatment management policy.
A resident recovering from surgery was subjected to undignified treatment by a CNA, who made an inappropriate comment about starving children and failed to deliver the resident's breakfast tray on time. The resident, who was cognitively intact, felt demeaned and confused by these actions, which violated the facility's policy on maintaining resident dignity.
A resident with anxiety disorder and paraplegia reported that staff placed a towel in her rectal area, causing her to scream. An LVN responded by closing the resident's door during these episodes, without attempting appropriate interventions or informing the DON. The facility's policy on resident dignity was not upheld, as the situation was not investigated or care planned.
A resident with anxiety disorder and paraplegia made multiple allegations of staff inserting chili and towels into her rectum, but staff failed to report these incidents as required by facility policy. Despite the resident's intact cognition and need for maximum assistance, staff, including CNAs and LVNs, did not follow procedures for reporting abuse. The facility's Administrator was aware of the allegations but did not report them due to the resident's history of false claims, leading to a deficiency.
A resident with Parkinson's disease, convulsions, and schizophrenia experienced ten falls due to inaccurate fall risk assessments by nursing staff. The DON acknowledged that the assessments were not conducted correctly, leading to inappropriate interventions. The facility's policy required accurate assessments to ensure safety, but this was not achieved, resulting in a deficiency.
Failure to Complete Required Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure an annual performance evaluation was up to date for one of five sampled CNAs, as required by facility policy. During an interview and concurrent record review with the Director of Staff Development (DSD), the CNA’s personnel file, initiated on 8/10/20, showed that the last documented annual performance review was completed on 12/28/24, and the DSD confirmed that no annual performance evaluation had been conducted for 2025. Review of the facility’s undated Performance Evaluations policy indicated that each employee’s job performance shall be reviewed and evaluated at least annually, and that completed evaluations are to be sent by the director or supervisor to the HR Director for placement in the employee’s personnel record. The surveyor determined that this lapse had the potential to result in the CNA providing care that does not meet residents’ needs. No additional resident-specific clinical information or medical history was provided in the report related to this deficiency.
Failure to Prevent and Detect Diversion of Hydrocodone for Multiple Residents
Penalty
Summary
The facility failed to implement its Drug Diversion policy and procedure to ensure secure storage, accurate documentation, proper administration, monitoring, and accountability of narcotic controlled substances for three residents. During an interview and record review with the Administrator, it was determined that one nurse discovered a missing hydrocodone 10/325 mg bubble-pack containing 28 pills for one resident, along with the corresponding inventory sheet, when starting an evening shift. The Administrator stated that the nurse knew this hydrocodone bubble-pack should have been present because he had administered from it two days earlier. Following this discovery, the facility expanded its search and found that two additional residents each had a missing hydrocodone 5/325 mg bubble-pack of 28 pills, also with missing inventory sheets, and that three more hydrocodone 10/325 mg bubble-packs for the first resident were missing with their inventory sheets. The Administrator reported that the missing inventory sheets were the main reason the hydrocodone losses were not detected for the three residents, because the narcotic count appeared to be correct in the absence of those records. The Administrator also stated that copies of the inventory sheets for resident narcotics are not taken when medications are delivered, which contributed to the inability to track when the narcotics were received and subsequently went missing. A facility five-day report indicated that a total of 164 hydrocodone pills were diverted. The facility’s written Drug Diversion policy states that the facility maintains zero tolerance for narcotic drug diversion and requires secure storage, accurate documentation, and immediate documentation of all narcotic administrations in the MAR and Controlled Substance Record, but these requirements were not effectively carried out in practice for the affected residents.
Failure to Obtain IDT Review and Behavior Monitoring for Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedure on the use of psychotropic medications for a resident who was prescribed Depakote. The resident was admitted with diagnoses including major depressive disorder, history of falling, shortness of breath, and muscle weakness. A physician order dated 1/29/26 directed that the resident start Depakote 250 mg by mouth twice daily for mixed mania and bipolar due to aggressive behaviors, and the medication was initiated that evening and continued thereafter. Record review of the Medication Administration Records (MARs) for January and February showed that the resident received Depakote 250 mg twice daily from 1/29/26 through the end of February. The January MAR indicated the resident started Depakote on the evening of 1/29/26 and continued at 8 a.m. and 6 p.m., but there was no behavior monitoring documented for Depakote use during that time. The February MAR showed that behavior monitoring related to Depakote was not initiated until 2/11/26, despite the resident having been on the medication since 1/29/26. During an interview and concurrent electronic medical record review with the Social Services Director, it was confirmed that the resident was started on Depakote 250 mg twice daily without an Interdisciplinary Team (IDT) meeting having been conducted to determine the appropriateness of initiating this psychotropic medication. The Social Services Director stated that staff were supposed to monitor the resident’s behaviors while on Depakote to determine if the medication and dosage were appropriate, but this was not done initially. The facility’s policies on Use of Psychotropic Medications and the Psychotropic Drug Committee require adequate indications for use, evaluation of nonpharmacological interventions, IDT involvement, and documentation of the resident’s response to psychotropic medications, which were not implemented for this resident at the time Depakote was started and during the initial period of its administration.
Failure to Complete Required Background Reference Check for LVN
Penalty
Summary
The facility failed to follow its Background Investigations policy by allowing a licensed vocational nurse (LVN 2) to work without completion of a required reference check. During an interview and employee file review with the Administrator, it was found that LVN 2’s reference check section in the employee file was not completed, despite LVN 2 having been employed at the facility since 2/13/24. The Administrator acknowledged that, per facility policy and procedure, reference checks should have been completed prior to the nurse beginning work. The written Background Investigations policy stated that job reference checks, drug screenings, licensure verifications, and criminal conviction record checks are to be conducted on all applicants for employment, and that applicants who do not consent to such investigations will not be considered for positions requiring them. The survey finding noted that this failure had the potential to expose residents to abuse, neglect, and mistreatment.
CNA Mocked Resident's Cry for Help, Violating Dignity Standards
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed engaging in unprofessional and inappropriate behavior toward a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 6. The resident, who has a known behavior pattern of yelling and screaming for help in Spanish, was calling out 'ayudame' when the CNA approached, got down to the resident's level, and repeatedly mimicked the resident's cries for help while laughing. This interaction was witnessed by other staff members, including the Director of Staff Development (DSD) and the Administrator, both of whom described the CNA's actions as unprofessional and inappropriate. Facility records, including a 5-day report and policy on promoting and maintaining resident dignity, confirmed that the CNA's behavior did not align with the facility's standards for treating residents with respect and dignity. The policy specifically requires staff to speak respectfully to residents and to maintain or enhance each resident's quality of life by recognizing their individuality. The incident was documented as a failure to provide dignity and respect, with the potential to cause emotional distress to the resident involved.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the resident's records, which showed that the care plan did not comprehensively cover all identified needs, nor did it include clear, measurable goals or interventions.
Failure to Implement Care Plan Intervention for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with a history of physical aggression towards others. The care plan, established due to previous incidents, required staff to monitor the resident and keep him separated from other residents in the dining area. Despite this intervention being documented and known to staff, the resident was able to physically touch another resident on the jaw with a closed fist during a meal. Multiple staff interviews confirmed awareness of the care plan requirement, but acknowledged that the intervention was not followed at the time of the incident. The resident involved had diagnoses including schizoaffective disorder, bipolar disorder, and adjustment disorder, and had previously exhibited physically aggressive behavior. The other resident involved had developmental and mental health diagnoses. The incident was witnessed by a visitor, reported to staff, and resulted in the residents being separated, with no injuries noted. Facility policy required comprehensive care plans to be implemented and for staff to be notified of their responsibilities, but this was not carried out in this instance, leading to the deficiency.
Failure to Address Resident Grievance Regarding Increased Sunlight
Penalty
Summary
The facility failed to implement its policy and procedure on grievances for a resident who had a diagnosis of epilepsy and capsular glaucoma. The resident's admission record indicated that bright light could negatively affect her condition. The resident reported that a new sliding glass door installed in her room lacked tint, which increased the amount of sunlight entering her room and bothered her eyes. She voiced her complaint to the facility's maintenance worker, but no action was taken to address her concern. The maintenance worker confirmed that the resident's sliding glass door was replaced and that the resident had complained about the increased light. He stated that he communicated the resident's concerns to the facility's leadership during daily morning meetings. However, there was no documentation of the complaint or any response from the facility. The Administrator in Training and the Social Services Director were aware of the complaint but were unsure of the process to address grievances and had not completed a grievance form for the resident's complaint. The facility's policy on grievances requires prompt efforts to resolve complaints, including acknowledgment and active resolution efforts. The policy also mandates that the Grievance Official oversee the grievance process, issue written decisions, and maintain confidentiality. Despite these requirements, the facility did not follow its policy, as there was no documentation or written decision regarding the resident's grievance, and the grievance process was not properly executed.
Failure to Use Hoyer Lift Results in Resident Fall and Injury
Penalty
Summary
The facility failed to prevent an avoidable fall for a resident when two Certified Nursing Assistants (CNAs) did not follow the care plan that required the use of a Hoyer lift for transfers. Instead, the CNAs attempted to transfer the resident using a bath towel, which resulted in the resident falling and experiencing pain in the left foot. The resident was later found to have a possible fracture in the left great toe. The resident, who had a history of repeated falls, difficulty walking, and required assistance with personal care, was dependent on staff for transfers. The care plan specifically indicated the use of a Hoyer lift with two staff members for any transfers. However, during the transfer, the CNAs lost control of the bath towel, causing the resident to fall to the floor. The resident reported pain in the left foot following the incident, and subsequent medical evaluations confirmed a nondisplaced fracture. Interviews with the CNAs revealed that they were aware of the requirement to use the Hoyer lift but chose to use a bath towel instead, a method they were not trained to use. The facility's policies emphasized the importance of following the care plan and using mechanical lifts for safe resident handling and transfers. The failure to adhere to these policies and the care plan led to the resident's fall and injury.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to provide education to staff on the prevention and recognition of Legionnaires' Disease, as evidenced by the Infection Preventionist's inability to provide documentation of such education. The Water Management Program indicated that nursing staff should be educated about Legionnaires' Disease to aid in early identification, but the Infection Preventionist admitted to not having conducted this education. This lack of education could hinder early identification and response to potential cases of Legionnaires' Disease among residents. Infection control surveillance activities were inadequately conducted, as the Infection Preventionist could not provide documentation of these activities. Although competencies on hand hygiene and the donning and doffing of PPE were available, there was no evidence of ongoing surveillance for healthcare-associated infections or other significant infections. This lack of documentation and surveillance could impede the facility's ability to track and trend infections effectively, potentially leading to unaddressed infection risks. The facility also failed to adhere to infection prevention and control practices as per CDC guidelines. Observations revealed multiple lapses, including the improper storage and cleaning of resident-care equipment, such as razors, wheelchair footrests, and a Hoyer Lift. Additionally, hand hygiene practices were not consistently followed by staff, as evidenced by instances where staff did not perform hand hygiene after removing gloves or before assisting residents with meals. These failures in maintaining cleanliness and proper hygiene practices could contribute to the transmission of infectious diseases within the facility.
Failure to Inform Residents of Ombudsman Contact Information
Penalty
Summary
The facility failed to adhere to its policy and procedure titled Resident Rights for three of nine sampled residents, specifically Residents 19, 28, and 43. These residents were unaware of how to contact the Ombudsman, an independent advocate for residents in long-term care facilities. During a group interview, all three residents stated they did not know how to contact the Ombudsman office and were unaware of the location of Ombudsman posters. Additionally, Resident 43 mentioned that the contact information for the Ombudsman was not discussed during group meetings. The Activities Director confirmed that she does not provide information on how to contact the Ombudsman during group meetings, which is contrary to the facility's policy that requires residents to receive notice of contact information for advocacy organizations, including the Ombudsman program.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that 12 out of 32 sampled residents had an Advance Directive (AD) documented in their medical records. An AD is a legal document that provides instructions for medical care and only goes into effect if the individual is unable to make decisions for themselves. During interviews and record reviews, it was found that several residents, including new admissions, did not have an AD acknowledgment in their medical records. The Social Services Director (SSD) and Medical Record Director (MRD) confirmed the absence of these documents during their reviews. The facility's policy and procedure, titled 'Residents' Right Regarding Treatment and Advance Directives,' requires that upon admission, the facility determines if a resident has executed an AD and provides information about the right to refuse treatment and formulate an AD. However, the facility did not adhere to this policy, as evidenced by the lack of AD documentation for the residents reviewed. This failure could potentially lead to responsible parties and medical professionals not honoring residents' healthcare wishes in emergency situations.
Failure to Provide Arbitration Agreement in Understandable Language
Penalty
Summary
The facility failed to ensure that the Binding Arbitration Agreement (BAA) was provided in a form and language that six sampled residents and/or their representatives could understand. The Business Office Manager (BOM) admitted that the arbitration agreements were only available in English, despite some residents speaking other languages such as Tagalog, an Indian language, and Spanish. The BOM also acknowledged that she did not explain the full content of the agreement, only the concept of arbitration, and did not ensure that residents or their representatives fully understood the terms and conditions. Additionally, the BOM did not have a process to evaluate the residents' understanding of the agreement, nor could she articulate how disputes would be handled or where arbitration would take place. Specific instances included Resident 34, who had a Brief Interview of Mental Status (BIMS) score indicating severe cognitive impairment, yet signed the BAA herself without a clear understanding. Resident 3's BAA was signed by a niece who did not have legal power of attorney, and the agreement was not provided in a language understood by the resident. Resident 25, with an intact cognitive status, and Resident 149 both expressed that they did not fully understand the agreement they signed during admission. The facility's policy required that the arbitration agreement be explained in a language and manner that the resident or representative understands, which was not adhered to in these cases.
Failure to Obtain Proper Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that physicians provided informed consent for the use of antipsychotic medications for three sampled residents. This deficiency was identified during interviews and record reviews, where it was found that the necessary physician statements of risks, benefits, and alternatives were missing from the Psychoactive Medication Evaluation and Consent (PMEC) forms. Additionally, the forms lacked physician signatures, indicating that the physicians did not provide the informed consent for the prescribed medications. For Resident 1, the facility's records showed that verbal consent for medications such as Lorazepam, Trazodone, and Abilify was obtained from the resident's sister via telephone. However, the verbal consent process was not properly followed, as it required validation by two licensed personnel, but only one Licensed Vocational Nurse (LVN) validated the consent. Similar issues were found with Resident 40 and Resident 149, where the PMEC forms for medications like Zolpidem and Trazodone also lacked the necessary physician statements and signatures. The facility's policy and procedure for informed consent, dated 12/14/17, clearly stated that the healthcare practitioner ordering psychotherapeutic medication is responsible for obtaining informed consent and providing documentation of the risks and benefits. The policy also required telephone verification of informed consent with two witnesses, which was not adhered to in these cases. This failure had the potential to prevent residents from receiving accurate information about their medications and understanding the associated risks, benefits, and alternatives.
Failure to Train Resident in Self-Administration of Suction
Penalty
Summary
The facility failed to ensure that a resident was trained in self-administration of suction, which had the potential to place the resident at risk for respiratory infection and/or complications. During an observation, a suction machine with a plastic container containing tan frothy liquid was noted on the bedside table of the resident, who appeared alert and was able to verbalize his needs. A Licensed Vocational Nurse (LVN) was observed replacing the plastic container on the suction machine. Upon review of the resident's medical record, there was no documentation of an Interdisciplinary Team (IDT) training or assessment for the resident's ability to suction himself. The resident reported using the suction machine up to five times a day. A facility policy and procedure for the use of the suction machine was requested but not provided.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman (OSLTCO) about the transfer of a resident to an acute care facility, as required by regulations. During an interview and record review with the Director of Nursing (DON) and Medical Records Director (MRD), it was found that Resident 25 had been hospitalized multiple times due to medical conditions such as low hemoglobin and high potassium levels. However, there was no documentation indicating that the OSLTCO was informed of these transfers, which is a necessary step to ensure the resident's rights and protections are upheld. The facility's policy and procedure on transfers and discharges require that notices be provided to the resident, their representative, and the Ombudsman in a timely manner, especially in cases of emergency transfers. Despite this, the MRD admitted to not sending the required notifications for the months of October and November 2024. The DON was also unable to provide evidence that the OSLTCO was notified of Resident 25's transfers during this period, highlighting a lapse in compliance with federal regulations and the facility's own policies.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that a baseline care plan (BCP) was completed and provided to a resident within 48 hours of admission. This deficiency was identified for a resident who was admitted with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, and Congestive Heart Failure, and who required assistance with personal care and had difficulty walking. During a review of the resident's admission record, it was found that the BCP was not completed, and a summary was not provided to the resident within the required timeframe. During an interview and record review with the Minimum Data Set (MDS) Coordinator, it was confirmed that there was no documentation of a completed BCP for the resident, and the resident did not receive a summary of the BCP. The facility's policy and procedure for baseline care plans required that a BCP be developed within 48 hours of admission and that a written summary be provided to the resident, with a signature obtained to verify receipt. However, these steps were not followed, leading to the deficiency.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to update and develop comprehensive person-centered care plans for three residents, leading to potential unmet care needs. For Resident 3, observations revealed foot drop, dry and scaly skin, and fungal-like toenail conditions, with no updated care plan addressing these issues. The CNA noted potential pain during repositioning, but the MDS Coordinator confirmed the absence of a documented care plan for foot care. Resident 1 experienced difficulty cutting and chewing meat, consuming only 25% of their meal, yet there was no nursing documentation or updated care plan addressing these eating difficulties. Similarly, Resident 31, who has Type 2 Diabetes Mellitus, lacked a documented care plan for diabetes management, despite having a high A1C level and requiring monitoring for signs of hypo- and hyperglycemia. The resident reported that nursing staff did not inquire about specific diabetes-related symptoms, and the LVN confirmed the absence of a care plan for diabetes management.
Failure to Notify Physician of Psychiatric Recommendation
Penalty
Summary
The facility failed to notify the attending physician of a psychiatrist's recommendation to increase the dosage of Trazodone for a resident experiencing depression. This oversight was identified during observations and interviews with the resident, who appeared unkempt and expressed feelings of depression, impacting his willingness to engage in daily activities and self-care. The resident was observed wearing the same clothes over consecutive days, with signs of poor hygiene and physical neglect, such as oily hair, edematous and dry skin, and long, unkempt toenails. The psychiatric evaluation conducted recommended an increase in Trazodone to address the resident's depression, but there was no documentation indicating that the attending physician was informed of this recommendation. The facility's policy requires that significant changes in a resident's condition be communicated to the physician, but this protocol was not followed. The Minimum Data Set Coordinator confirmed the lack of documentation and communication regarding the psychiatrist's recommendation, highlighting a failure in the facility's process for managing changes in a resident's mental health condition.
Failure to Provide Adequate Foot Care and Documentation
Penalty
Summary
The facility failed to ensure proper foot care for two residents, leading to potential adverse consequences due to delayed treatments. For Resident 3, the facility did not assess and notify the physician about significant foot problems, including foot drop, dry and scaly skin, and discolored, swollen toes with long, thick toenails. Despite observations indicating potential pain, there was no documentation of a nurse's assessment or physician notification. Additionally, a podiatry recommendation for a vascular surgeon referral was not acted upon. Resident 149 also experienced inadequate foot care. During an examination, a medical doctor noted edematous feet due to congestive heart failure, with dry, scaly skin and long, yellowish toenails. The doctor recommended a podiatry referral, but there was no documentation of this recommendation in the progress notes or a physician's order for the referral. The facility's policies on documentation and podiatry services were not followed, as assessments and necessary referrals were not documented or completed. The facility's failure to document and act on the necessary foot care assessments and referrals for these residents indicates a lack of adherence to their own policies and procedures. This oversight in documentation and communication with physicians could lead to delayed treatments and adverse outcomes for the residents involved.
Lack of Physician's Order for Catheter Care
Penalty
Summary
The facility failed to ensure that a physician's order for catheter care was in place for a resident with an indwelling urinary catheter due to neuromuscular dysfunction of the bladder. The resident, who had been using a Foley catheter for three years, reported frequent urinary tract infections. During an observation, the catheter tubing was noted to be cloudy, indicating potential issues with catheter maintenance. Upon review, the Director of Nursing (DON) could not provide documentation of a physician's order for catheter care, including the frequency of catheter changes. The only orders available were for measuring urine intake and output. The last documented catheter replacement occurred when it was dislodged several months prior. The facility's policy requires catheter use to be in accordance with physician's orders, including details on the necessity, size, and change frequency, which were not documented in this case.
Failure to Ensure Full Oxygen Tank for Resident
Penalty
Summary
The facility failed to ensure that Resident 199 had a full portable oxygen tank available for use, which was necessary for her respiratory care. During an observation on the facility's outside patio, Resident 199 was seen sitting in her wheelchair with a nasal cannula attached to an empty oxygen tank. She was observed pursed lip breathing, a technique used to maximize oxygen intake, indicating potential respiratory distress. Licensed Vocational Nurse (LVN) 8 confirmed the oxygen tank was empty and acknowledged the oversight in not checking the tank before taking the resident outside. Resident 199 had a physician's order for continuous oxygen administration at 2 to 4 liters per minute via nasal cannula for shortness of breath. The facility's policy on oxygen administration requires oxygen to be administered under a physician's order, consistent with professional standards of practice.
Failure to Provide Required Annual Abuse Training
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the annual training of staff on recognizing and reporting elder and dependent adult abuse, neglect, and exploitation. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), where it was found that a significant number of Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs) had not received the required annual training. Specifically, twenty-seven out of forty-two sampled CNAs, seventeen out of twenty-two sampled LVNs, and seven out of eight sampled RNs lacked documented evidence of having completed the training. The facility's policy, dated 11/29/24, mandates that existing staff receive annual education through planned in-services and as needed. However, the training records reviewed, covering the period from 1/3/24 to 7/23/24, showed no documented training for the listed staff members. The DSD confirmed the absence of additional training documentation, indicating a systemic failure to ensure compliance with the facility's training policy. This lapse had the potential for abuse incidents to go unnoticed and unreported within the facility.
Failure to Provide Follow-Up for Medically-Related Social Services
Penalty
Summary
The facility failed to ensure that two residents received necessary follow-up for medically-related social services, specifically concerning dental and vision care. Resident 40, who had missing teeth and required full mouth dentures, was seen by a dentist three months prior, but there was no follow-up to ensure the dental recommendations were carried out. Additionally, Resident 40 had an order for vision follow-up, but there was no documentation of a referral to an ophthalmologist. The lack of social services follow-up resulted in delays in addressing these needs. Similarly, Resident 25, who had yellowish, decayed, and missing teeth, had dental x-rays taken, but there was no subsequent follow-up documented by social services. The facility's policy and procedure for social services, which mandates the provision and documentation of medically-related social services, was not adhered to, leading to these deficiencies in care for the residents.
Unattended Medication at Bedside
Penalty
Summary
The facility failed to adhere to its medication storage policy when a medication was left unattended at the bedside of a resident. During an observation, a 30 ml plastic medication cup, 3/4 full of a blue gel-like substance, was found on the bedside table of Resident 99. Licensed Vocational Nurse (LVN) 6 identified the substance as Bio-freeze gel, a medication used to treat minor aches and pains of the muscles/joints. LVN 6 was unaware of how long the medication had been left there and noted that it is typically found on the medication treatment cart. Further observations and interviews with Certified Nursing Assistant (CNA) 3 and the Director of Nursing (DON) confirmed that the medication cup should not have been left in the resident's room. The facility's policy and procedure on Medication Storage, dated 11/29/2024, mandates that all drugs and biologicals be stored in locked compartments and under direct observation during medication passes. The unattended medication at the bedside posed a potential risk for residents to inadvertently use it without supervision.
Failure to Provide Prescribed Meal and Assess Resident's Eating Ability
Penalty
Summary
The facility failed to ensure that a resident received the food items as specified on their meal ticket, which was necessary to meet their nutritional requirements. During a meal observation, it was noted that the resident's lunch tray did not include ice cream, fortified soup, a sandwich, or Nutri juice, all of which were indicated on the meal ticket. The Licensed Vocational Nurse confirmed the absence of these items, and the Certified Dietary Manager acknowledged that these items should have been included. The resident's physician's order also specified that ice cream should be provided twice daily with lunch and dinner. Additionally, the facility did not assess the resident's ability to cut meat into bite-sized pieces and feed themselves. During an observation, the resident struggled to cut the meat, and there was no documentation in the nursing progress notes or care plan regarding this difficulty. The Minimum Data Set Coordinator confirmed the lack of documentation and that the physician was not notified about the resident's difficulty in cutting the meat and eating. The facility's policy indicated that menus should be developed in collaboration with a Registered Dietitian and should adhere to the written menu, which was not followed in this case.
Failure to Provide Assistive Feeding Device
Penalty
Summary
The facility failed to provide an assistive feeding device for a resident who required it, potentially impacting the resident's nutritional status. During an observation and interview, it was noted that the resident's lunch tray contained a regular ceramic plate instead of the required divided plate. The Certified Dietary Manager (CDM) acknowledged that the resident should have been served on a divided plate as indicated on the undated Meal Ticket. The facility's policy on Adaptive Equipment-Feeding Devices, dated 2020, specifies that appropriate assistance and adaptive equipment, such as built-up dishes with inner lips and plate guards, should be provided to residents to aid in meal consumption.
Deficiencies in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by several deficiencies. The Infection Preventionist (IP) did not evaluate or follow up on a resident who was treated with an antibiotic for a fungal infection. Specifically, the IP was unable to provide documentation of any diagnostic tests, such as an X-ray or blood work, to validate the resident's diagnosis of a fungal infection. Furthermore, the IP was not aware of the reason for the resident's prescription of Fluconazole and did not consult with the physician regarding the treatment. Additionally, the facility did not conduct an Antibiotic Stewardship Meeting, which should have been led by the Pharmacist, Medical Director, and Director of Nursing. The IP admitted that the pharmacist was not involved in the antibiotic stewardship program, and there was no consultation with the pharmacist. Moreover, the IP failed to provide evidence of antibiotic stewardship education for the nursing staff, which is a requirement according to the facility's policy and procedure. The lack of these critical components in the antibiotic stewardship program had the potential to lead to inappropriate antibiotic treatment for residents.
Failure to Obtain Consent and Document Vaccine Administration
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the administration of influenza vaccines for five residents. Specifically, Residents 10, 8, and 7 were administered the flu vaccine without obtaining informed consent from the residents or their legal representatives. This oversight was identified during interviews and record reviews with the Infection Preventionist (IP), who confirmed the absence of signed consents in the clinical records of these residents. Additionally, Residents 100 and 2 did not receive explanations of the risks and benefits associated with their refusal of the flu vaccine, and there were no declination statements documented for these refusals. Furthermore, the facility did not maintain proper documentation for the administration of the flu vaccine to Resident 7. The Administration Note for Resident 7 lacked critical information such as the lot number, expiration date, the person administering the vaccine, and the site of injection. These documentation lapses were contrary to the facility's policy, which mandates that such details be recorded in the resident's medical file. The failure to document these details accurately could lead to potential issues in tracking the vaccine in case of adverse reactions or recalls.
Failure to Obtain COVID-19 Vaccination Consent and Inform Residents of Risks
Penalty
Summary
The facility failed to complete the COVID-19 vaccination consent forms for four of 31 sampled residents. Resident 10 and Resident 7 received the COVID-19 vaccine without obtaining consent from the residents or their legal representatives. Additionally, Resident 100 and Resident 2 were not informed of the risks and benefits associated with refusing the COVID-19 vaccine. These deficiencies were identified during interviews and record reviews with the Infection Preventionist, who acknowledged the absence of consent forms and the lack of documentation regarding the risks and benefits of vaccine refusal. The Infection Preventionist admitted to not having updated the vaccination records, and the Nurse Consultant confirmed that the facility lacked a policy on the completion of vaccination consents. These failures resulted in the potential for inaccurate medical records and the spread of infectious diseases.
Unsecured Oxygen Tank Poses Risk in LTC Facility
Penalty
Summary
The facility failed to ensure the proper storage of an oxygen tank for a resident, which posed a potential health hazard. During an observation and interview, a Licensed Vocational Nurse (LVN) found an oxygen tank with an attached gauge meter and oxygen tubing standing unsecured on the right side of a resident's bed. The LVN acknowledged that the oxygen tank should have been secured in a rack. A Respiratory Therapist (RT) confirmed that the director of respiratory care was informed after the fact and stated that the unsecured tank was unacceptable and dangerous, posing a risk to both the resident and staff. The facility's policy and procedure on Oxygen Safety, dated 11/29/24, specifies that oxygen cylinders must be properly chained or supported in racks or other fastenings to prevent them from falling, regardless of whether they are connected, unconnected, full, or empty. Additionally, the policy indicates that oxygen cylinders should not be stored with gauges attached, and liquid oxygen base reservoir containers must be secured to prevent tipping over.
Failure to Account for Resident's Personal Funds
Penalty
Summary
The facility failed to ensure the proper accounting of a resident's personal funds, which were kept secured in the nurse's medication cart. The deficiency involved a resident who initially had $2,600 stored in an envelope within the cart, as documented and signed by both the resident and an LVN. Over time, the amount in the envelope decreased without proper documentation or explanation, leaving only $50 when the resident reported the funds missing. The facility's policy required that any removal of funds be documented with the date, amount, and signatures of both the nurse and the resident, which was not adhered to in this case. Interviews with the Director of Nursing and the Administrator revealed that the responsibility for documenting the removal of funds lay with the nurses who had access to the medication cart. However, there was no documentation indicating when or who removed the total of $2,550 from the envelope. The facility's policies on resident personal funds and abuse prevention were not followed, leading to the unaccounted funds and potential emotional distress for the resident.
Failure to Administer Physician-Ordered Treatments
Penalty
Summary
The facility failed to provide physician-ordered treatments for four sampled residents, leading to potential adverse effects on their health. Resident 1 did not receive Mupirocin External Ointment for a skin infection on multiple occasions and missed a Medi-honey Wound/Burn Dressing treatment for a diabetic ulcer. Resident 2 did not receive Santyl External Ointment for a wound on the left shin during several shifts. Resident 3 missed multiple treatments, including antifungal powder, Betadine Solution, barrier cream, Hydrogel External Gel, and zinc oxide ointment for various skin conditions and wounds. Resident 4 did not have the dressing on the left foot kept dry and intact as ordered. The Director of Nursing (DON) confirmed these findings, acknowledging that the staff failed to document the treatments, implying they were not administered. The facility's policy on wound treatment management, dated November 2023, mandates that treatments be provided according to physician orders and documented in the Treatment Administration Record or electronic health record. The lack of documentation and adherence to physician orders represents a significant deficiency in the facility's care practices.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by the actions of a Certified Nursing Assistant (CNA). On one occasion, the CNA told the resident that they were lucky to receive three meals a day because there are starving children in the world. This comment was made after the resident expressed a lack of appetite due to recovering from surgery. The resident, who was cognitively intact with a BIMS score of 14, felt demeaned by the CNA's remark. The following day, the same CNA failed to deliver the resident's breakfast tray while serving other residents in the room, despite having been recently in-serviced on the proper procedure for meal distribution. The resident did not receive their meal until another staff member noticed the oversight and provided the tray. This incident left the resident feeling confused and wondering if they were being punished for the previous day's interaction. The facility's policy on promoting and maintaining resident dignity emphasizes treating residents with respect, which was not upheld in this situation.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by the actions of a Licensed Vocational Nurse (LVN) who repeatedly closed the resident's door during episodes of yelling. The resident, who has a diagnosis of anxiety disorder and paraplegia, reported that staff placed a towel in her rectal area, causing her to scream. The LVN, identified as LVN 2, responded to the resident's yelling by closing the door to her room, which was not an intervention discussed or care planned by facility leadership. The Director of Nursing (DON) was not informed of the resident's behavior, and no appropriate interventions, such as redirection or speaking in a calm manner, were attempted before closing the door. The resident's Minimum Data Set (MDS) indicated intact cognition, and the Progress Notes documented multiple instances of the resident yelling out about alleged incidents involving towels and chili. Despite the resident's repeated claims, LVN 2 continued to close the door without consulting the resident's roommates or neighboring residents. The facility's policy on promoting and maintaining resident dignity emphasizes treating residents with respect and dignity, which was not upheld in this situation. The DON acknowledged that closing the door was not an appropriate response and that the situation should have been investigated with proper interventions implemented.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to adhere to its policy and procedure on reporting allegations of abuse for a resident, resulting in a deficiency. The resident, who has a diagnosis of anxiety disorder and paraplegia, made multiple allegations that staff were inserting chili and towels into her rectum. Despite these serious allegations, staff members, including CNAs and LVNs, did not report the incidents as required by the facility's policy. The resident's Minimum Data Set indicated she had intact cognition and required maximum assistance for personal hygiene, showering, lower body dressing, and toileting. Interviews with various staff members revealed a pattern of inaction regarding the resident's allegations. A CNA admitted to not reporting the allegations because of the resident's history of making similar claims. An LVN, who was aware of the allegations, also failed to report them, citing uncertainty about whether a report had been made. The Social Services Director was informed of verbal aggression by another staff member but could not recall taking any action. Progress notes from May to July documented the resident's repeated claims and instances of blood in her stool, yet these were not reported as abuse allegations. The facility's policy mandates immediate investigation and reporting of all abuse allegations to the Administrator, state agency, and other required agencies within specified timeframes. However, the Administrator, who was aware of the allegations, did not report them due to the resident's history of false claims. This failure to follow established procedures placed the resident and potentially other residents at risk for further abuse.
Inaccurate Fall Risk Assessment Leads to Deficiency
Penalty
Summary
The facility failed to accurately assess a resident for fall risk, which had the potential to prevent appropriate interventions from being implemented. The resident, who had a history of Parkinson's disease, convulsions, schizophrenia, difficulty in walking, and required assistance with personal care, experienced ten fall incidents since the beginning of 2024. Despite these incidents, the fall risk assessments conducted by the nursing staff were inconsistent and inaccurate, leading to inappropriate fall risk scores and interventions. The Director of Nursing (DON) acknowledged that the fall risk evaluations were not conducted correctly, resulting in fluctuating fall risk scores that did not reflect the resident's actual risk. The facility's policy required accurate fall risk assessments to ensure a safe environment and appropriate supervision, but the assessments were not completed correctly, as evidenced by the incorrect answers inputted by the nursing staff. This failure to accurately assess and address the resident's fall risk was a significant deficiency in the facility's care provision.
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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