Vermont Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 22035 S. Vermont Avenue, Torrance, California 90502
- CMS Provider Number
- 056433
- Inspections on file
- 55
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Vermont Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, schizoaffective disorder, psychosis, seizures, high elopement risk, and high fall risk was discharged to a recuperative care center (RCC) without proper discharge planning. The conservator, identified as the responsible party, was not involved in selecting the RCC or consenting to the discharge, and no IDT meeting was held to assess the resident’s cognitive, medical, physical, or psychosocial needs before transfer to a lower level of care. Nursing staff did not complete required steps such as effective communication with the receiving facility, medication reconciliation, or a direct nurse-to-nurse handoff, and only a voicemail was left for the conservator after the resident had already been transferred. EMS and hospital records later documented that the resident was found wandering in the community, disoriented, and was admitted to a GACH with acute psychosis and altered mental status, leading surveyors to cite noncompliance with F-627 for failure to ensure a safe discharge.
A resident with a Foley catheter was observed in a wheelchair in the hallway without a dignity bag covering the catheter bag. The resident confirmed not having or using a dignity bag. Staff interviews revealed that the CNA was unaware of the catheter and did not cover it, and the LVN did not notice the catheter bag. Facility policy requires Foley catheters to be covered to maintain privacy and dignity.
A resident with severe cognitive impairment and multiple medical conditions was involved in an altercation with another resident. Following this incident, the facility did not conduct an IDT meeting to review and revise the care plan, as required by policy. Staff interviews confirmed the absence of an IDT meeting after the change in condition, resulting in a delay in addressing the resident's care needs.
A resident with diabetes, chronic kidney disease, and quadriplegia did not receive consistent blood sugar monitoring or insulin coverage as required by facility policy and physician orders. Staff were unaware of the resident's diabetes diagnosis and did not monitor for symptoms of hyperglycemia or hypoglycemia. The resident's PCP was not informed about the lack of blood sugar checks, leading to a critical event where the resident developed diabetic ketoacidosis with coma and required emergency hospitalization.
A resident with severe cognitive impairment and total dependence for ADLs was not promptly readmitted after hospital stabilization due to reported lack of bed availability, resulting in a three-day delay despite facility policy requiring return to the first available bed.
A resident with severe cognitive impairment and physical limitations was not assisted with showers at least twice weekly, despite care plan directives and facility policy. Documentation and staff interviews confirmed the lack of required ADL support, resulting in unmet hygiene needs.
A tube of Diclofenac Sodium Topical Gel, 1% that was not part of a resident's current physician-ordered medications was found left on the resident's nightstand. Both an RN and the DON confirmed that medications should not be stored at the bedside and should only be accessible to authorized staff, in accordance with facility policy.
A resident with a history of falls and multiple fractures did not receive the required visual checks as outlined in their care plan, and staff failed to document these interventions. This lapse resulted in an unwitnessed fall causing pelvic fractures and hospitalization, despite facility policies mandating comprehensive care planning and documentation.
A resident with paraplegia, dependent for transfers, was manually moved from bed to a shower chair by a CNA and RNA without using a mechanical lift as recommended by PT and required by facility policy. The resident, who was cognitively intact, requested not to use the lift due to discomfort, and staff did not escalate the refusal. During the manual transfer, the resident was assisted to the floor and sustained a minimally displaced impacted femur fracture. The facility lacked a care plan intervention for mechanical lift use and staff did not follow fall prevention and transfer policies.
A resident with a tracheostomy and severe cognitive impairment experienced bleeding and severe pain at the stoma site after a tracheostomy tube change. Despite a physician's order to notify the physician for severe pain, an LPN administered Tylenol but did not contact the physician. Documentation and staff interviews confirmed the lack of required notification, leaving the physician unaware of the resident's change in condition.
The facility failed to conduct Change in Condition (CIC) evaluations for three residents exposed to COVID-19, despite orders for novel respiratory precautions. These residents, with varying levels of cognitive impairment and dependency on assistance for daily activities, did not receive the required assessments following their exposure. Interviews with staff confirmed the absence of CIC evaluations, contrary to the facility's policy for significant changes in condition.
Staff at the facility failed to wear proper PPE when entering rooms under Novel Respiratory Precautions for COVID-19 exposure. A housekeeping staff member, a CNA, and a Charge Nurse entered the rooms of three residents without the required gown, eye protection, filtered mask, and gloves. The facility's policy mandates full PPE for such precautions, which was not followed, as confirmed by the Infection Preventionist and DON.
A resident at high risk for pressure injuries developed deep tissue injuries on the right lateral foot and right buttock due to the facility's failure to turn and reposition the resident every two hours as per the care plan and physician orders. Additionally, regular skin assessments were not conducted, and preventive measures like Prevalon boots were not applied in a timely manner, leading to the deterioration of the resident's skin condition.
The facility failed to administer morning medications on time in the SAU, with delays due to the lengthy process of administering via G-tubes. Additionally, two residents received Zosyn IV medications that did not match physician orders due to uncommunicated changes by the pharmacy. The emergency drug usage log was also incomplete, lacking essential details.
Two residents in an LTC facility received intravenous antibiotics not in accordance with physician orders, with Zosyn administered in normal saline instead of dextrose, potentially affecting their health due to existing conditions. Additionally, a resident with hypothyroidism missed doses of Liothyronine, as confirmed by medication records and staff interviews. The facility's Medication Administration Policy was not followed, increasing the risk of adverse health outcomes.
The facility failed to provide adequate ROM and mobility services to residents, as evidenced by inconsistent adherence to physician orders and therapy recommendations. A resident with hemiparesis did not receive PROM exercises for both arms, and AAROM exercises for both legs were inconsistently documented. Another resident with anoxic brain damage did not receive consistent PROM exercises or have prescribed splints applied regularly, leading to potential contractures. Additionally, a resident with cerebral infarction did not receive prescribed Omni-cycle exercises and ambulation assistance, affecting joint and muscle integrity.
The facility failed to provide adequate staffing of Restorative Nursing Aides (RNAs) and licensed nurses, resulting in missed treatments for residents with limited range of motion and delayed medication administration in the subacute unit. Several residents did not receive their prescribed RNA services due to insufficient staffing, and medication administration was delayed for some residents due to a lack of licensed nurses.
The facility exceeded the 5% medication error rate threshold, with errors involving two residents. A resident received Mucinex DM instead of Mucinex (guaifenesin) as ordered, and another received Zosyn in normal saline instead of dextrose. The errors were due to incorrect medication preparation and administration by nursing staff.
The facility failed to ensure IV antibiotic medications were labeled according to physician orders for two residents. One resident received piperacillin sodium and tazobactam sodium (Zosyn) in normal saline, contrary to the order for the medication in dextrose for a UTI. Another resident's medication label also did not match the order for Zosyn in dextrose for pneumonia. These discrepancies could lead to medication errors.
The facility failed to ensure the ice machine had an air gap for backflow prevention, as required by the FDA Food Code. Observations revealed black grime and dirt on the ice machine pipe, with no air gap present. Staff, including the Assistant Dietary Supervisor, Registered Dietician, and Maintenance Supervisor, were unaware of the regulation. The Administrator acknowledged the potential risk of contaminated water backflowing into the ice machine, posing a risk of waterborne illness to residents.
The facility failed to accurately document care for several residents, leading to deficiencies in treatment. A resident's AAROM exercises were not documented for the right leg, another's PROM for the left arm was incorrectly scheduled, and Omni-cycle exercises for both arms were omitted. Additionally, a clinical record error persisted for months, and splint applications and speech-language pathology treatment attempts were not documented, resulting in inaccurate care provision.
The facility failed to maintain proper infection control practices, including maintaining appropriate dryer temperatures, performing hand hygiene, and disinfecting cloth gait belts. A dryer was operating below the required temperature to kill germs, a CNA did not perform hand hygiene between resident rooms, and a Laundry Aid handled clean linens without washing hands after sorting dirty ones. Additionally, cloth gait belts were improperly disinfected with wipes meant for non-porous surfaces, risking infection spread among residents with serious health conditions.
The facility failed to maintain operational washer temperature gauges, with staff using incorrect methods to check temperatures, risking infection spread. The Maintenance Supervisor and Laundry Aide used sink water temperatures instead of the non-functional gauges, contrary to the facility's policy requiring 160°F for linen washing. The Director of Nursing highlighted the importance of accurate washer temperatures to prevent resident infections.
The facility failed to notify the physician and complete a Change of Condition (COC) for two residents. One resident expressed a desire to die, and another missed thyroid medication doses. Staff acknowledged the oversight, and the facility's policies require immediate physician notification for significant changes.
A resident with serious mental illness was admitted without a required PASARR Level II evaluation, despite a Level I screening indicating its necessity. The oversight was confirmed by the MDS coordinator and DON, acknowledging the potential for missed specialized mental health services.
A facility failed to implement a care plan for a resident with paranoid schizophrenia and major depressive disorder who expressed a desire to die. Despite staff acknowledging the need for a care plan to address the resident's suicidal ideation, none was in place, contrary to the facility's policy on comprehensive care plans.
A resident admitted with multiple fractures did not have an Interdisciplinary Team (IDT) meeting scheduled within the required 72 hours, as per facility policy. This oversight left the resident unaware of his care plan. Interviews with staff confirmed the failure to schedule the meeting, and the Social Services Director acknowledged the lapse. The facility's policies emphasize the importance of involving residents in care planning, which was not adhered to in this case.
A resident with multiple diagnoses, including Stage 4 pressure injuries and functional quadriplegia, did not receive scheduled showers or bed baths as required, leading to inadequate hygiene care. Facility records and staff interviews confirmed the absence of skin inspection sheets and failure to provide necessary care, despite policies outlining the need for regular bathing and skin inspections to prevent further skin breakdown.
A resident with hearing impairment did not receive necessary hearing aids due to the facility's failure to follow up on the resident's report of missing aids. Despite the resident's intact cognition and dependency on assistance for daily activities, the Social Services Director did not arrange for replacement aids, leading to communication difficulties. Facility policies on accommodating needs were not followed.
A resident's IV catheter site was not rotated for nine days, contrary to the care plan requiring rotation every 96 hours. The site was observed to be leaking and lacked a time or date on the dressing, essential for tracking rotations. Interviews confirmed the absence of documentation, which is crucial for preventing infections. The facility's policy required dressings to be changed with each rotation or every seven days, with proper labeling.
A resident receiving hemodialysis was not provided with an emergency dialysis kit at their bedside, as required by the facility's protocols. The absence of the kit, which should contain essential items like gauze and a tourniquet, was confirmed by a Registered Nurse Supervisor. The resident, who has end-stage renal disease and is at risk for bleeding due to heparin administration, was left vulnerable to potential complications. The Director of Nursing acknowledged the oversight, highlighting a lapse in the facility's adherence to its dialysis care policy.
The facility failed to maintain accurate staffing records on multiple occasions, leading to discrepancies between the required and actual number of RNs and LVNs present. This issue was confirmed by the DSD and highlighted by the DON, emphasizing the importance of accurate staffing to ensure timely resident care.
A resident with paranoid schizophrenia and major depressive disorder expressed suicidal ideation, but the LTC facility failed to document these comments or notify the appropriate medical professionals. Staff interviews revealed a lack of communication and adherence to the facility's policy on behavioral health services, resulting in the resident not receiving necessary care and interventions.
A resident was not provided with lower dentures, impacting their ability to chew and potentially affecting their nutrition. Despite being evaluated for dentures, no follow-up was made due to insurance issues, and the facility did not adhere to its policy of timely dental referrals. The resident's care plan highlighted the risk of decreased food intake due to missing dentures, but the facility failed to ensure the resident received the necessary dental care.
The facility's QAA Committee failed to effectively oversee and implement corrective actions for deficiencies identified in a previous survey, resulting in repeat issues. These included inadequate care for dependent residents, failure to maintain residents' mobility, and problems with pharmacy services, such as high medication error rates and improper drug storage. The Administrator acknowledged the deficiencies and stressed the need for staff accountability.
A resident with an indwelling catheter was prescribed two antibiotics for a UTI, despite a urine culture showing resistance to both. The facility's antibiotic stewardship program was not followed, as the resident did not exhibit symptoms warranting antibiotic use. The IPN and DON acknowledged the failure to ensure appropriate antibiotic use, which could lead to unnecessary and harmful treatment.
A resident with a history of falls, dementia, and legal blindness was found without a functional call light system, violating facility policy. The resident, requiring substantial assistance, was unable to signal for help, as confirmed by staff interviews. The facility's policy mandates routine maintenance of the call system, but it was not followed, leading to potential delays in assistance and increased risk of falls.
A resident at high risk for falls was not provided with necessary safety interventions, resulting in a fall and serious injuries. Despite a high fall risk score, the facility failed to implement measures like landing pads and bed alarms. Staff were unaware of the resident's fall risk, and the resident attempted tasks independently, leading to the fall. The facility's policy on safety and supervision was not followed, contributing to the incident.
A resident with a history of falls and significant medical conditions experienced a fall that was not accurately documented in the MDS assessments. The MDS Coordinator acknowledged the error, which could affect the facility's quality metrics and the resident's care plan. The DON confirmed that inaccurate assessments could impact resident care due to incorrect health information.
A facility failed to enforce infection control measures for a resident on droplet precautions. A visitor entered the resident's room without wearing PPE, despite signage and an isolation cart being present. Staff interviews indicated that licensed nurses were responsible for educating visitors on PPE use, but this was not done, posing a risk of spreading infectious diseases.
A resident's medical records were found to be illegible and incomplete, leading to potential medication errors. The MAR contained unclear documentation of vital signs necessary for administering Metoprolol, and wound care notes were missing. Both an LVN and an RN confirmed the illegibility, and the DON acknowledged the need for organized and legible records as per facility policy.
A resident with a tracheostomy did not receive proper care after a shower, leading to a wet tracheostomy tie and dressing. The facility's protocol required the respiratory therapist to be informed and present during showers to ensure the tracheostomy site remained clean and dry. However, due to a communication lapse, this protocol was not followed, compromising the resident's care.
A resident with severe cognitive impairment and multiple diagnoses was found to have a skin tear on her forearm. The facility failed to notify the responsible party of this change in condition, as required by the care plan. An LVN mistakenly assumed visiting family members were the responsible party and did not verify their identities, leading to a lapse in communication.
A resident was denied re-admission to a facility after hospitalization despite being cleared for return and having an available bed. The facility cited lack of experience with hospice residents in the Subacute Unit and concerns about the resident's CRPA infection. A family dispute also influenced the decision. The facility's policy and CMS guidelines indicated that residents with MDROs should not be denied admission, but the resident remained at the hospital for 16 days.
The facility failed to implement Enhanced Standard Precautions (ESP) for three residents with gastrostomy tubes and tracheostomies, resulting in staff not using isolation gowns during high-contact care. Observations revealed a lack of ESP signage and PPE availability, and interviews confirmed that staff were not properly educated on ESP protocols.
A resident with severe cognitive impairment was slapped by a CNA during a bed bath, and the RNS failed to immediately separate the CNA from the resident, allowing the CNA to continue providing care. The incident was reported by another CNA, and the facility's policies on abuse and neglect were not followed.
The facility failed to document a resident's agitation in the Medication Administration Record (MAR) as required, despite the resident being observed as agitated by the Registered Nurse Supervisor (RNS). This lapse was confirmed by the Director of Nursing (DON) and was against the facility's policy for charting and documentation.
The facility failed to protect a resident from physical abuse by another resident. Despite witnessing the incident and receiving multiple reports, staff did not immediately separate the residents, placing the victim at further risk. The delay in action and failure to follow facility policies led to a deficiency in ensuring resident safety.
The facility failed to report an allegation of abuse within the required timeframe. A resident with major depressive disorder and other conditions reported being slapped by another resident. Despite staff witnessing the incident, it was not reported immediately, and the residents were not separated promptly, contrary to the facility's policy.
The facility failed to ensure an LVN received required abuse training, leading to unreported aggressive behavior between two residents. The LVN had not attended in-service training since October 2023, placing residents at risk for abuse, neglect, and exploitation.
Failure to Involve Conservator and IDT in High-Risk Resident’s Discharge to RCC
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate discharge planning for a resident who was a Regional Center client with schizoaffective disorder bipolar type, unspecified psychosis, anxiety disorder, seizures, anemia, and severe cognitive impairment. The resident’s face sheet identified a conservator as the responsible party, and the MDS dated 11/19/2025 documented severely impaired cognitive skills for daily decision-making and dependence on staff for ADLs, with no ability to ambulate independently. The resident had documented high elopement risk and fall risk, including balance problems and decreased muscular coordination. Social Services documentation from 11/10/2025 indicated the resident came from a homeless environment and might need additional help once discharged home with the support of the conservator. An IDT conference on 11/14/2025 included the conservator by phone, but no discharge planning was discussed at that time, and the notes indicated the bed hold policy and discharge plan would be reviewed with the responsible party/conservator. On 1/28/2026, a physician’s order was obtained to discharge the resident to a recuperative care center (RCC). A progress note timed at 1:20 p.m. on that date documented that the resident was discharged and picked up by EMT personnel, with standard safety checks such as identity verification, confirmation of transfer destination, attachment of transfer documents, and securing the resident on a gurney. The same note indicated that a voicemail was sent to the conservator notifying them of the transfer, but there was no documentation of prior discussion, involvement, or consent from the conservator regarding the discharge plan or the choice of RCC. Social Services Staff stated that the resident was conserved under a Public Guardian and that the facility did not discuss the discharge planning or transfer to the RCC with the conservator, and that no IDT meeting was held related to the discharge plan prior to discharge. The DON stated that she and Social Services decided to transfer the resident to the RCC because the resident did not meet skilled criteria and needed a lower level of care where medications would be managed, and acknowledged that the conservator was not involved in the discharge planning or discharge and that there was no IDT meeting conducted for this discharge. The facility also failed to ensure adequate communication and clinical handoff to the receiving RCC. LVN 1 described the expected discharge process as including obtaining a physician’s order, performing a skin assessment, notifying the family or conservator, preparing discharge paperwork, printing the face sheet and medication summary, and contacting the receiving facility. LVN 1 stated these steps were not fully completed for this resident’s discharge, that he was unable to communicate with the conservator or the receiving facility, did not communicate with a receiving nurse, did not perform medication reconciliation, and did not endorse the resident’s medical history to the receiving facility. He reported that paperwork was handed to EMT personnel at the time of discharge and that he failed to verify the type of setting at the RCC to ensure it could meet the resident’s needs. Subsequently, EMS and hospital records documented that the resident was found wandering in the street in the early morning hours, not alert or oriented, with insect eggs on her clothes and hands, and was transported to a general acute care hospital where she was admitted with acute psychosis and altered mental status. Interviews with the conservator, CNA staff, and review of the facility’s discharge planning policy further confirmed that the resident’s discharge occurred without the required involvement of the conservator, without an IDT discharge planning process, and without appropriate clinical communication to the receiving RCC. The facility’s own policy on discharge planning required the Social Services Director or designee to be involved in discharge planning to ensure a safe discharge and successful transition to the next level of care or return home, working with the IDT, physician, resident, and resident’s representative. The policy specified that discharge planning services and any changes to the discharge plan were to be discussed with the resident and, if indicated, the resident’s representative, and documented in the medical record. In this case, interviews and record review showed that the conservator was not involved in selecting the RCC or consenting to the discharge, that no IDT meeting was held to assess the resident’s cognitive, medical, physical, and psychosocial needs prior to discharge to a lower level of care, and that the RCC was not properly notified of the resident’s diagnoses, medications, history of wandering, and risk for falls and seizures prior to transfer. These actions and omissions constituted the deficient practice cited under F-627 for failure to ensure a safe and appropriate discharge for this resident.
Removal Plan
- The DON/designee conducted an immediate clinical review of Resident 1’s status in collaboration with the GACH, including medication reconciliation and continuity of care.
- The IDT (Social Service, DOR, DON, ADON/QA Nurse, DSD, MDS Nurse) met to review root cause analysis and ensure discharge planning criteria/process compliance.
- The IDT (SSD, DON, ADON) conducted a facility-wide review of discharges, focusing on level of care determination, IDT involvement, legal representative notification/consent, safe discharge destination, and medication reconciliation/continuity.
- Require licensed nursing staff to notify the SSD of all resident discharges and have discharge information communicated to the SSD and reviewed during the weekly discharge planning meeting (including assessment of cognitive impairment, elopement risk, behavioral symptoms, conservatorship/legal representative involvement, and discharge planning), with variances corrected immediately.
- Require DON or designee to provide final authorization prior to discharge.
- During weekends/when SSD and DON are not physically present, require the Nursing Supervisor to review discharge documentation, confirm completion of required steps, and notify the SSD and DON for follow-up review.
- Implement a Hard Stop Discharge Protocol using a standardized interdisciplinary discharge checklist; no resident may be discharged until all checklist steps are completed.
- Require final approval by the Administrator or DON for all planned discharges to lower levels of care (including RCFE, ALF, ILF, and recuperative care) upon completion of the Hard Stop checklist.
- Require discharge planning to begin at baseline admission and be reviewed at least 30 days prior to projected discharge, again 7 days prior, and prior to the day of discharge.
- Assign QA Nurse responsibility for resident assessment and participation in the discharge process.
- Assign IDT (SSD, DOR, DON, DSS, QA) responsibility for reviewing discharge planning.
- Assign DON/QA/DON designee responsibility for reviewing clinical readiness and safety prior to discharge.
- Require licensed nursing staff to provide a complete handoff to the receiving provider/facility at discharge (clinical status, medications, care needs, follow-up requirements) and document the handoff in the medical record.
- Require SSD and licensed nursing staff to notify the resident’s guardian/responsible party regarding discharge planning, provide discharge destination options, and document preferences/consent in the medical record.
- Assign SSD responsibility for all discharge notices and documentation (notify resident/guardian/responsible party, document discharge plan and chosen destination, maintain related forms/communications in the medical record, ensure timely completion).
- Require Nursing Supervisor or licensed nursing staff to provide a complete handoff report to the receiving facility at discharge (clinical status, medications, care needs, behavioral considerations, follow-up requirements) and document it in the medical record.
- Require SSD to complete post-discharge follow-up/wellness check within 72 hours to confirm safe arrival, medication/care management, identify concerns, and document follow-up actions.
- Provide in-service training to the DON and Administrator on the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety considerations, and compliance monitoring.
- Provide 1:1 in-service and competency validation with the SSD on the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety requirements, and documentation expectations.
- Educate all licensed nurses, Social Services staff, and IDT members on CMS discharge requirements, resident rights, safe transitions of care, documentation expectations, legal representative notification, and high-risk discharge criteria; provide training by DON and SSD with attendance logs; include in new hire orientation.
- Audit all resident discharges using the Hard Stop Discharge Checklist (daily for first 2 weeks, weekly for next 4 weeks, then monthly) through QAPI to ensure ongoing compliance.
- Ensure on the day of discharge the licensed nurse provides a complete report/handoff to the receiving facility prior to transfer.
- Have Medical Records review audit findings and report results to DON/ADON/QA team; correct discrepancies timely; report results to the QAPI Committee by DON and SSD.
- Incorporate the discharge process into the facility’s QAPI program, including tracking/trending discharge variances, identifying root causes, implementing corrective actions, and reporting findings to leadership, with a performance goal of 100% compliance.
Failure to Maintain Resident Dignity by Not Covering Foley Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with a Foley catheter was observed seated in a wheelchair in the hallway without a dignity bag covering the catheter bag. The resident confirmed that he did not have or use a dignity bag for his Foley catheter. The resident's medical history included hemiplegia and hemiparesis following a stroke, difficulty walking, anemia, and the use of a Foley catheter as indicated by physician orders and assessment records. The Minimum Data Set showed the resident was able to make himself understood, understand others, and was independent in several activities of daily living, requiring only supervision for personal hygiene. Interviews with facility staff revealed that the CNA was unaware the resident had a Foley catheter and therefore did not cover the catheter bag. The LVN also did not notice the Foley catheter bag during her shift. The Director of Nursing stated that the resident should have had the Foley catheter covered at all times to maintain privacy and dignity, in accordance with facility policy. Review of facility policies confirmed the requirement to treat residents with respect and dignity and to ensure Foley catheters are covered with a dignity bag.
Failure to Initiate IDT Meeting After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) initiated a care conference for a resident following an alleged resident-to-resident altercation. The resident involved had a history of unspecified dementia, generalized anxiety disorder, unspecified psychosis, and hemiplegia/hemiparesis following a cerebral infarction. The Minimum Data Set (MDS) indicated the resident had severely impaired cognitive skills and required supervision or assistance with transfers. After the incident, where the resident allegedly pushed another resident's shoulder multiple times, there was no documented IDT meeting to address the change in condition or to develop a collaborative plan of care. Interviews with facility staff, including the Social Worker, Assistant Administrator, and Director of Nursing, confirmed that no IDT meeting was conducted after the incident, despite facility policy requiring such a meeting following a significant change in a resident's condition. The facility's policy and procedure indicated that the IDT, along with the resident and their representative, should develop and review a comprehensive, person-centered care plan when there is a significant change. The lack of an IDT meeting resulted in a delay in addressing the resident's care needs and implementing necessary interventions.
Failure to Implement Diabetic Management and Insulin Administration Protocols
Penalty
Summary
The facility failed to follow its own policy and procedure for diabetic management and insulin administration for a resident diagnosed with type 2 diabetes mellitus, chronic kidney disease, and quadriplegia. The resident was admitted and readmitted to the facility with orders for diabetes medications, including oral medication and insulin, but there were no consistent orders for blood sugar (BS) monitoring or insulin coverage as indicated by the resident's condition. The care plan for the resident specified monitoring for signs and symptoms of hyperglycemia and regular BS checks, but these interventions were not implemented by the staff. Licensed staff assigned to the resident were not aware of the resident's diabetes diagnosis and did not monitor BS levels or observe for symptoms of hyperglycemia or hypoglycemia. The resident's primary care provider (PCP) was not informed that there were no orders for BS monitoring or insulin coverage, and the PCP was unaware that BS checks were not performed for an extended period. The Medication Administration Record showed that insulin was administered inconsistently, and there were gaps in BS monitoring, particularly from one date to another, during which no BS checks were documented. As a result of these failures, the resident experienced a significant change in condition, presenting with high BS that could not be registered on the glucometer, altered level of consciousness, tachypnea, oxygen desaturation, and hypotension. The resident was transferred to a general acute care hospital, where a critically high blood glucose level was recorded, and the resident was diagnosed with diabetic ketoacidosis with coma, requiring intubation and intensive insulin therapy. Interviews with facility staff, including the RN Supervisor and DON, confirmed that the facility did not implement the care plan or ensure appropriate monitoring and treatment for the resident's diabetes.
Delay in Readmission Following Hospitalization Due to Bed Availability
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for all activities of daily living and had severe cognitive impairment, was promptly readmitted after being stabilized at a general acute care hospital. The resident, who had diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, and multiple pressure injuries, was transferred to the hospital for evaluation and treatment. Hospital records indicated the resident was ready for discharge back to the facility, but the facility initially reported no bed availability on two separate occasions. Despite the facility's policy stating that residents should be permitted to return to their previous room or the first available bed, the resident remained at the hospital for three additional days after being deemed appropriate for return. The Director of Nursing confirmed that a bed was available on the second attempt, and acknowledged that the resident should have been readmitted at that time, as the facility was the resident's home. This delay in readmission was not in accordance with the facility's stated procedures for bed holds and returns.
Failure to Provide Required Shower Assistance for Resident with Severe Cognitive Impairment
Penalty
Summary
A review of facility records and interviews revealed that a resident with severe cognitive impairment and a history of muscle weakness, difficulty walking, and traumatic brain injury was not assisted with showers at least twice a week as required. The resident's Minimum Data Set (MDS) assessment indicated a need for partial assistance with showering and toileting hygiene, and supervision with oral and personal hygiene. The care plan, initiated in April 2022, specified that the resident required assistance with activities of daily living (ADLs), including a directive to ensure showers two to three times per week. During a review of shower documentation and Point of Care (POC) response history for the month of July, it was confirmed by a registered nurse that the resident did not receive the required number of showers. The Director of Nursing also acknowledged that residents are to be assisted with showers at least twice weekly for personal hygiene. Facility policies reviewed indicated that staff are to assist residents with ADLs and promote cleanliness and comfort, but these were not followed in this instance.
Medication Improperly Stored at Bedside
Penalty
Summary
A tube of Diclofenac Sodium Topical Gel, 1% was found on a resident's nightstand during an observation conducted with an RN. The medication was identified as a used, old medication that was not part of the resident's current physician-ordered medications. Both the RN and the DON confirmed that medications should not be stored at the bedside for resident safety, and that only staff authorized to administer medications should have access to them. The resident involved had diagnoses including hemiplegia and hemiparesis affecting the left side, type 2 diabetes, and low back pain. The resident's cognitive skills for daily decision-making were intact, and they required supervision with eating and partial assistance with personal and oral hygiene. The facility's policy stated that medications must be stored safely, securely, and only accessible to authorized staff, which was not followed in this instance.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and document care plan interventions for a resident identified as high risk for falls. The resident had a history of multiple fractures and repeated falls, and the care plan specifically required visual checks to be performed and documented every shift. However, there was no documentation that these visual checks were completed as required. This omission was confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged that the care plan interventions were not followed or recorded as part of the nursing measures. As a result of the failure to implement and document the required visual checks, the resident experienced an unwitnessed fall that led to multiple pelvic fractures and required hospitalization. The facility's own policies and procedures mandated comprehensive care planning with measurable objectives and documentation of all services provided, but these were not adhered to in this case. The lack of adherence to the care plan and documentation requirements directly contributed to the resident's fall and subsequent injuries.
Failure to Use Mechanical Lift Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident with paraplegia was transferred safely from bed to a shower chair, resulting in a fall and injury. The resident was dependent for transfers and required the use of a mechanical lift as recommended by the Physical Therapy (PT) department. Despite this, two staff members, a Certified Nursing Assistant (CNA) and a Restorative Nursing Assistant (RNA), attempted to transfer the resident manually without the mechanical lift, contrary to the PT recommendation and facility policy. The resident, who had no cognitive impairment and was able to make her own decisions, insisted on being transferred without the mechanical lift because the sling caused her discomfort. The CNA and RNA attempted the transfer manually, realized the resident was too heavy, and assisted her to the floor. During the transfer, the resident experienced pain and, after being assisted to the floor, was later found to have sustained an acute minimally displaced impacted fracture of the distal left femur. Staff interviews confirmed that the mechanical lift should have been used and that the resident's refusal should have been escalated to nursing supervisors. Further review revealed that the facility did not have a care plan intervention specifying the use of a mechanical lift for this resident, despite the PT and Occupational Therapy (OT) recommendations and the resident's high risk for falls. The staff also failed to follow the facility's policies on mechanical lift use and fall prevention, which require all departments to contribute to fall prevention efforts. The lack of a care plan intervention and failure to follow established procedures directly contributed to the resident's injury during the transfer.
Failure to Notify Physician of Resident's Change in Condition After Tracheostomy Tube Change
Penalty
Summary
The facility failed to notify a resident's physician when the resident experienced scant bleeding and significant pain at her tracheostomy stoma site following a tracheostomy tube change. The resident, who had a history of cerebral infarction, tracheotomy status, and acute respiratory failure, was documented as having severe cognitive impairment. Despite a physician's order specifying that the physician should be notified for severe pain, the licensed nurse administered Tylenol Extra Strength for pain rated at eight out of ten but did not contact the physician. Documentation in the Pain Assessment Flow Sheet and Medication Administration Record confirmed the administration of pain medication without physician notification. Interviews with facility staff, including the DON, respiratory therapist, and the nurse involved, revealed that the nurse did not notice the requirement to notify the physician as stated in the pain order. The facility's policy and procedure for change of condition, as well as the job description for licensed nurses, required prompt physician notification for changes in condition. The failure to notify the physician resulted in the physician being unaware of the resident's change in condition and unable to provide further instructions for care.
Failure to Conduct Change in Condition Evaluations for COVID-19 Exposed Residents
Penalty
Summary
The facility failed to complete a Change in Condition (CIC) evaluation for three residents who were exposed to COVID-19. Resident 2, admitted with a diagnosis of Hemophilus influenzae, was cognitively intact and required maximal assistance with daily activities. Despite an order for novel respiratory precautions due to COVID-19 exposure, the facility did not complete a CIC evaluation for Resident 2 in March 2025. Similarly, Resident 3, who was readmitted with pneumonia and influenza and had severely impaired cognitive skills, also did not receive a CIC evaluation following COVID-19 exposure, despite being dependent on assistance for daily activities. Resident 5, admitted with chronic respiratory failure and pneumonia, had moderately impaired cognitive skills and was dependent on assistance for daily activities. Like the other residents, Resident 5 was placed under novel respiratory precautions due to COVID-19 exposure, but the facility failed to conduct a CIC evaluation. Interviews with RN 1 and the Director of Nursing confirmed the absence of CIC evaluations for these residents, which was against the facility's policy requiring comprehensive assessments for significant changes in a resident's condition.
Failure to Use Proper PPE in Precaution Rooms
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) by staff members entering rooms designated for Novel Respiratory Precautions. Specifically, Housekeeping staff and a Certified Nurse Aid entered the rooms of two residents without wearing the required PPE, which includes a gown, eye protection, filtered mask, and gloves. These residents were under novel respiratory precautions due to COVID-19 exposure. The staff members acknowledged the requirement for full PPE but did not comply, citing reasons such as not providing direct patient care or not touching anything in the room. Additionally, a Charge Nurse entered another resident's room, also under novel respiratory precautions, wearing only a mask and not the full PPE as required. The Charge Nurse admitted to the oversight. The facility's policy mandates full PPE for contact and droplet isolation, which was not adhered to in these instances. The Infection Preventionist and Director of Nursing confirmed the necessity of full PPE for entering precaution rooms, aligning with the facility's policy.
Failure to Prevent Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to prevent the development of deep tissue injuries (DTIs) in a resident who was at high risk for pressure injuries. The resident, who was admitted with conditions such as cerebral infarction, chronic respiratory failure, and functional quadriplegia, was dependent on staff for all activities of daily living and was always incontinent of bowel. Despite a care plan and physician orders to turn and reposition the resident every two hours, this was not consistently done, leading to the development of DTIs on the resident's right lateral foot and right buttock. The facility also failed to conduct regular skin assessments as required. The resident's care plan specified that skin assessments should be done daily by CNAs and weekly by licensed nurses, particularly during shower days or bed baths. However, the resident did not receive showers or skin inspections on multiple scheduled days, and there was a lack of documentation indicating that these assessments were performed. This oversight contributed to the resident's skin condition deteriorating without timely intervention. Additionally, the facility did not implement necessary interventions such as the use of Prevalon boots to relieve pressure on the resident's feet until after the DTIs had developed. The lack of adherence to the care plan and physician orders, combined with inadequate skin assessments and failure to apply preventive measures, resulted in the resident developing significant pressure injuries that could have been avoided with proper care and attention.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure timely administration of morning medications in the subacute unit (SAU) for several residents. On two separate days, a number of residents received their morning medications after the designated time window, which was between 8 a.m. and 10 a.m. The delay was attributed to the time-consuming process of administering medications via gastrostomy tubes, which took approximately 30 minutes per resident. With the available staff, the time required to administer medications exceeded the regulatory window, leading to late administration for some residents. The facility also failed to ensure the accuracy of medications upon delivery and before administration. Two residents received Zosyn IV medications that did not match the physician's orders. The facility's pharmacy changed the IV fluid from dextrose to normal saline without notifying the facility or the prescriber. This change was not communicated, and the discrepancy was not identified by the nursing staff before administration. The facility's policy required that medications be administered as prescribed, but this was not adhered to in these cases. Additionally, the facility did not maintain a complete emergency drug usage log. An entry in the log was missing critical details such as the date, time, quantity removed, and the licensed nurse's initials. This lack of documentation could lead to potential medication errors and adverse effects. The facility's policy required a complete record of emergency drug usage, but this was not followed, indicating a lapse in maintaining accurate records.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. Resident 22 and Resident 44 received intravenous antibiotic Zosyn in a manner not consistent with the physician's orders. Resident 22 was supposed to receive Zosyn 3.375 gm in Dextrose 50 ml, but instead received it in 100 ml of normal saline, which was not in accordance with the physician's order. This discrepancy was observed during a medication administration observation and confirmed through interviews and record reviews. Similarly, Resident 44's physician order indicated Zosyn 3.375 gm in Dextrose 50 ml, but the medication label did not match this order. Both residents had conditions that could be adversely affected by incorrect fluid administration, such as heart failure and hypernatremia. Additionally, the facility failed to administer Liothyronine to Resident 361 as per the physician's orders. Resident 361, who had a diagnosis of hypothyroidism, did not receive her thyroid medication on two occasions in March 2025. This was confirmed through interviews and medication reconciliation record reviews. The resident reported not always receiving her thyroid medications in the morning, and the Licensed Vocational Nurse assigned to her on one of the missed days was unsure how the medication was missed. The facility's policy requires medications to be administered in accordance with the orders, including any required time frame. The facility's Medication Administration Policy, which mandates that medications be administered as prescribed, was not adhered to in these cases. The Director of Nursing acknowledged the potential negative effects of administering incorrect IV fluids to residents with certain conditions. The failure to administer medications as ordered increased the risk of adverse health outcomes for the residents involved.
Failure to Provide Adequate ROM and Mobility Services
Penalty
Summary
The facility failed to provide adequate services to residents with limited range of motion (ROM) and mobility, as evidenced by the lack of adherence to physician orders and occupational therapy recommendations. Resident 62, who was admitted with hemiparesis and dementia, did not receive passive range of motion (PROM) exercises for both arms as recommended in the occupational therapy discharge summary. Additionally, active assistive range of motion (AAROM) exercises for both legs were inconsistently documented and not performed as ordered, leading to potential decline in joint mobility and increased pain in the left shoulder. Resident 109, diagnosed with anoxic brain damage and epilepsy, did not receive consistent PROM exercises for both arms and legs, nor were the prescribed splints and orthoses applied regularly. Documentation revealed multiple instances where these interventions were not performed, increasing the risk of contractures and further ROM limitations. The joint mobility screen for Resident 109 was also inaccurately assessed, failing to reflect the true extent of ROM limitations in the shoulders. Resident 112, with a history of cerebral infarction and diabetes, was not provided with the prescribed Omni-cycle exercises and ambulation assistance using a front-wheeled walker (FWW) with an ankle foot orthosis (AFO). The documentation showed several dates where these interventions were not carried out, potentially affecting the resident's joint and muscle integrity. Similar deficiencies were noted for Residents 40 and 121, who did not receive the required ROM exercises and ambulation support as per their physician orders, further highlighting the facility's failure to maintain and improve residents' mobility and ROM as required.
Staffing Deficiencies Lead to Missed Treatments and Delayed Medications
Penalty
Summary
The facility failed to ensure sufficient staffing of Restorative Nursing Aides (RNAs) to provide necessary treatments to residents with limited range of motion and mobility. Specifically, on multiple occasions, there were not enough RNAs available to cover all nursing stations, leading to missed RNA treatments for several residents. For instance, on certain days, only one RNA was available to cover multiple stations, making it impossible to provide the required treatments to all residents. This staffing issue was compounded by RNAs being pulled from their duties to cover Certified Nursing Assistant (CNA) roles when CNA staff were absent. The deficiency affected several residents, including Resident 62, who had physician orders for active assistive range of motion exercises five times per week. Documentation revealed numerous dates where these exercises were not provided, indicating a failure to meet the resident's care plan. Similarly, Resident 109, who required passive range of motion exercises and the application of various splints, also missed treatments on multiple occasions. The lack of RNA services was documented over several months, highlighting a persistent staffing issue. Additionally, the facility failed to provide sufficient licensed nurses in the subacute unit, resulting in delayed medication administration for several residents. On specific dates, a Licensed Vocational Nurse (LVN) was responsible for 12 residents, and at least three residents did not receive their morning medications on time. This delay in medication administration further underscores the facility's staffing challenges, impacting the timely delivery of care to residents.
Medication Administration Errors Exceed 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below the 5% threshold, resulting in a 6.25% error rate during medication administration. One incident involved a Licensed Vocational Nurse (LVN) administering Mucinex DM to a resident via a gastrostomy tube, despite the physician's order specifying Mucinex (guaifenesin) without DM. The LVN crushed the extended-release tablet, which should not have been crushed, and administered it incorrectly. The resident had a history of malignant neoplasm of the hypopharynx and esophagus, and chronic obstructive pulmonary disease. Another incident involved the administration of Zosyn to a resident via intravenous infusion. The Registered Nurse (RNS) prepared and administered the medication in 100 ml of normal saline, contrary to the physician's order, which specified Zosyn in 50 ml of dextrose. The Director of Nursing confirmed that the medication was not administered according to the five rights of medication administration, which could potentially affect residents with certain conditions sensitive to specific fluid types.
Medication Labeling Discrepancies for IV Antibiotics
Penalty
Summary
The facility failed to ensure that intravenous (IV) antibiotic medications were labeled in accordance with physician orders for two residents. During an observation, a Registered Nurse Supervisor (RNS 4) was administering an IV medication to Resident 22. The label on the medication indicated it was piperacillin sodium and tazobactam sodium (Zosyn) 3.375 grams in 100 milliliters of normal saline. However, the physician's order for Resident 22 specified the medication should be piperacillin sodium-tazobactam sodium in dextrose 3-0.375 grams/50 milliliters, to be infused at 25 cubic centimeters per hour for four hours every eight hours for a urinary tract infection. Similarly, for Resident 44, the IV medication label did not match the physician's order. The label indicated Zosyn 3.375 milligrams in 100 milliliters of normal saline, while the physician's order specified Zosyn intravenous solution 3-0.375 grams/50 milliliters in dextrose, to be administered for pneumonia. These discrepancies in medication labeling had the potential to lead to medication errors, as the labels did not align with the prescribed orders for the residents.
Ice Machine Lacks Air Gap for Backflow Prevention
Penalty
Summary
The facility failed to ensure the ice machine had an air gap for backflow prevention, which is a requirement according to the FDA Food Code 5-202.13. During an observation on March 11, 2025, it was noted that the ice machine pipe leading to the drain had black grime and dirt on it, and there was no air gap between the pipe and the ice machine drain. This was confirmed during a subsequent observation and interview on March 14, 2025, with the Assistant Dietary Supervisor, who acknowledged the presence of black dirt on the pipe and was unaware of the air gap regulation. Further observations and interviews on the same day with the Registered Dietician and the Maintenance Supervisor revealed that both were unaware of the air gap requirement and noted the presence of dirt and black grime on the pipe. The Maintenance Supervisor, who had worked at the facility for several years, admitted the possibility of residents getting sick from contaminated ice. The Administrator was aware of the federal regulation and acknowledged the potential for contaminated water to backflow into the ice machine, posing a risk of waterborne illness to residents.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to provide accurate documentation for five residents with limited range of motion and mobility, leading to deficiencies in care. For Resident 62, the facility did not include a task for the Restorative Nursing Aide (RNA) to perform active assistive range of motion (AAROM) exercises on the right leg, as per the physician's order. This omission was confirmed during an interview with the Director of Medical Records, who acknowledged the lack of documented evidence for AAROM exercises on the right leg over a year. Resident 40's documentation was also incomplete, as it did not include a task for the RNA to perform passive range of motion (PROM) on the left arm during the day shift, despite physician orders. The Director of Staff Development confirmed this was a documentation error, as the task was incorrectly assigned to the night shift, which the RNA would not see. Similarly, Resident 112's documentation failed to include Omni-cycle exercises for both arms, as required by the physician's order, and the facility lacked evidence of these exercises being performed. For Resident 133, there was a clinical record error in the physician's order, which inaccurately required AAROM for the right leg, despite the resident's inability to move the right side of the body. This error persisted for eight months before being corrected. Additionally, Resident 109's treatment notes did not document the application of various splints during physical and occupational therapy sessions, and there was no evidence of speech-language pathology treatment attempts, as the therapist did not document these due to system access issues. These documentation failures resulted in inaccurate care provision for the residents involved.
Infection Control Deficiencies in Linen Handling and Gait Belt Disinfection
Penalty
Summary
The facility failed to maintain proper infection control practices in several areas, leading to potential cross-contamination and risk of infection spread among residents. One of the deficiencies involved the failure to maintain the recommended temperature in one of the linen dryers. During an observation, the dryer was found to be operating at 130 degrees Fahrenheit, below the required 160-170 degrees Fahrenheit necessary to kill germs. The Maintenance Supervisor was unable to explain the discrepancy, which could contribute to the spread of infection throughout the facility. Another deficiency was observed in hand hygiene practices. A Certified Nurse Assistant (CNA) was seen moving between resident rooms without performing hand hygiene, which is crucial to prevent the transmission of germs from one resident to another. The CNA acknowledged the lapse in protocol, and the Infection Prevention Nurse confirmed that such practices could lead to the spread of infections. Additionally, a Laundry Aid was observed handling clean linens without performing hand hygiene after sorting dirty linens, further breaching infection control protocols. The facility also failed to properly disinfect cloth gait belts used by residents. The belts, made of porous cotton, were cleaned with disinfecting wipes intended for hard, non-porous surfaces, rendering the cleaning ineffective. This improper disinfection practice was observed with multiple residents, including those with cancer, coronary artery disease, heart failure, and diabetes mellitus, who required assistance with transfers and walking. The Infection Prevention Nurse confirmed that the use of inappropriate disinfecting methods on porous surfaces could lead to the transmission of infections between residents.
Non-Functional Washer Temperature Gauges in Laundry
Penalty
Summary
The facility failed to ensure that laundry washers were maintained in operational condition, specifically regarding the functionality of the washer temperature gauges. During an observation and interview, it was noted that three out of three washer temperature gauges were not functioning properly. The Maintenance Supervisor (MS) admitted that the gauges do not always work and instead used a thermometer to check the sink water temperature, which he believed shared the same water pipeline as the washers. The MS had reported this issue to the previous Administrator but not to the current one. Additionally, the Laundry Aide (LA) 1 confirmed that the washer temperature gauges had been non-functional for several weeks but had not reported it to anyone. LA 1 also used a thermometer to check the sink water temperature, believing it should be at 160 degrees Fahrenheit to prevent the spread of infection. The Director of Nursing (DON) stated that checking the washer temperatures via the sink is incorrect and emphasized the importance of having functioning washer temperature gauges to prevent infections and potential illnesses among residents. The facility's policy and procedure for laundry and linen, revised in 2014, indicated that linens should be washed in water at least 160 degrees Fahrenheit for a minimum of 25 minutes. The Maintenance Supervisor's job description included the responsibility to identify, report, and schedule repairs for any equipment malfunctions, which was not adequately fulfilled in this instance.
Failure to Notify Physician and Complete Change of Condition
Penalty
Summary
The facility failed to complete a Change of Condition (COC) and notify the physician for two residents, leading to a deficiency in care. Resident 48, who was diagnosed with paranoid schizophrenia and major depressive disorder, expressed a desire to die. Despite this significant change in mental status, the facility did not notify the physician or complete a COC, which would have facilitated closer monitoring and psychological intervention. Licensed Vocational Nurse (LVN) 1 acknowledged the oversight, stating that the physician should have been informed to prevent potential self-harm. Additionally, Resident 362, who has a diagnosis of hypothyroidism, missed scheduled doses of thyroid medication on two occasions. The Registered Nurse Supervisor (RNS) 2 confirmed that the physician was not notified, and a COC was not completed, which could have led to a deterioration in the resident's thyroid condition. The Director of Nursing (DON) emphasized the importance of notifying the physician and completing a COC in such situations to ensure proper monitoring and care. The facility's policies also mandate immediate physician notification and documentation of any significant changes in a resident's condition.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) Level II was completed for a resident with serious mental illness, which is a requirement for appropriate placement and service provision. The resident, who was admitted and readmitted with diagnoses of major depressive disorder and schizoaffective disorder, was taking antipsychotic medication. The Minimum Data Set (MDS) indicated moderate cognitive impairment, and the resident's PASARR Level I screening had identified the need for a Level II evaluation due to the presence of a serious mental illness. Despite the PASARR Level I screening indicating the necessity for a Level II evaluation, no such evaluation was found in the resident's records. Interviews with the MDS coordinator and the Director of Nursing confirmed the oversight, acknowledging that the resident could have missed out on specialized mental health services. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, and if indicated, referred for a Level II evaluation. However, this process was not followed, leading to the deficiency.
Failure to Implement Care Plan for Suicidal Ideation
Penalty
Summary
The facility failed to implement a care plan for a resident, identified as Resident 48, who was admitted with diagnoses including paranoid schizophrenia, major depressive disorder, and cerebral infarction. The resident was moderately cognitively impaired and required substantial assistance with daily activities. During an observation, the resident expressed a desire to die in the presence of an LVN, who stated she would notify her charge nurse immediately. However, it was found that there was no care plan addressing the resident's verbalization of wanting to die. Interviews with facility staff, including an LVN, a Registered Nurse Supervisor, and the Director of Nursing, confirmed that a care plan should have been in place for Resident 48's expression of suicidal ideation. The facility's policy on comprehensive care plans indicated that each resident's care plan should incorporate identified problem areas and risk factors to prevent or reduce declines in functional status. The absence of a care plan for Resident 48's suicidal ideation was a deficiency that could potentially delay care and treatment for the resident.
Failure to Schedule Timely IDT Meeting for Resident
Penalty
Summary
The facility failed to ensure that an Interdisciplinary Team (IDT) meeting was scheduled within 72 hours after the admission of a resident, identified as Resident 218. This resident was admitted with multiple injuries, including fractures from a motor vehicle accident, and was dependent on staff for various activities of daily living. Despite the facility's policy requiring an IDT meeting within 72 hours to discuss the resident's plan of care, no such meeting was scheduled or documented, leaving the resident unaware of his care plan. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse Supervisor (RNS), and the Social Services Director (SSD), confirmed the oversight. The SSD acknowledged the failure to schedule the IDT meeting and noted that attempts to contact the resident's family were made only after the deficiency was identified. The Director of Nursing (DON) also confirmed that the resident was alert and oriented and emphasized the importance of the resident being informed about his care plan to prevent potential refusal of care. The facility's policies and procedures outlined the necessity of involving residents in care planning and ensuring they are informed about their treatment and discharge plans. However, the lack of documentation and scheduling of the IDT meeting for Resident 218 indicates a deviation from these policies, resulting in the resident not being involved in his care planning process.
Failure to Provide Scheduled Showers and Skin Inspections
Penalty
Summary
The facility failed to provide necessary care and services for Resident 154, who was dependent on assistance for activities of daily living (ADLs) such as bathing, dressing, and toileting. Resident 154, who was admitted with multiple diagnoses including Stage 4 pressure injuries and functional quadriplegia, did not receive scheduled showers or bed baths as required. The facility's records indicated that Resident 154 was only showered twice since admission, despite being scheduled for showers twice weekly. This lack of proper hygiene care was confirmed through interviews with staff members, who acknowledged the absence of skin inspection sheets and the failure to provide scheduled showers or bed baths. The deficiency was further highlighted by the absence of skin inspection sheets for certain months, indicating that Resident 154 did not receive the necessary skin inspections during showers or bed baths. Certified Nursing Assistant (CNA) 3, who was responsible for assisting with ADLs and conducting skin inspections, confirmed that Resident 154 did not receive showers on scheduled days and that skin inspections were not performed. The Director of Staff Development and other nursing staff corroborated these findings, emphasizing the importance of regular bathing and skin inspections to prevent further skin breakdown and pressure injuries. The facility's policy and procedure documents, as well as the CNA job description, outlined the requirement for providing assistance with ADLs, including bathing and skin inspections. However, these procedures were not followed, resulting in Resident 154 not receiving the necessary care to maintain good grooming and personal hygiene. The failure to adhere to the established care plan and shower schedule contributed to the resident's ongoing pressure injuries and potential delay in wound healing.
Failure to Provide Hearing Aids to Resident
Penalty
Summary
The facility failed to assist a resident in maintaining their hearing abilities by not ensuring the resident had access to necessary hearing aids. The resident, who was admitted with diagnoses including hyperlipidemia and major depressive disorder, was found to have intact cognition but was dependent on assistance for toileting and bathing. The resident's care plan, initiated upon admission, identified a communication deficit due to hearing impairment. Despite this, the resident reported missing hearing aids to the Social Services Director (SSD) on multiple occasions, but no follow-up actions were taken to address the issue. Interviews with the resident, SSD, Director of Nursing (DON), and Administrator (ADM) revealed a lack of follow-up and coordination in providing the resident with the necessary hearing aids. The SSD acknowledged the oversight in not arranging an appointment for the resident to obtain new hearing aids. The facility's policies on caring for hearing-impaired residents and accommodating individual needs were not adhered to, resulting in the resident experiencing communication difficulties and frustration due to the inability to hear adequately during conversations.
Failure to Rotate IV Catheter Site as Required
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, identified as Resident 22, by not rotating the IV catheter site as required. Resident 22, who was admitted with an IV catheter placed at a general acute care hospital, had the catheter in place for nine days without rotation, contrary to the care plan which specified rotation every 96 hours. During an observation, the IV site was found to be leaking and lacked a time or date on the dressing, which is essential for tracking when the site needs to be rotated. Interviews with the Registered Nurse Supervisor (RNS3) and the Director of Nurses (DON) confirmed the absence of documentation regarding the time and date on the IV site, which is crucial for communication and preventing potential infections. The facility's policy required transparent dressings to be changed with each site rotation or at least every seven days, and to label the dressing with the date, time, and nurse's initials. The failure to adhere to these protocols had the potential to cause an infection at the insertion site.
Failure to Provide Emergency Dialysis Kit for Resident
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis treatments was provided with an emergency dialysis kit at their bedside. This deficiency was identified during an observation and interview with a Registered Nurse Supervisor, who confirmed the absence of the kit, which should contain essential items such as gauze, a tourniquet, and a bandage. The resident in question, who has end-stage renal disease and is dependent on hemodialysis, was at risk for bleeding due to heparin administration during dialysis. The resident's care plan specifically indicated the need for an emergency dialysis kit to manage potential bleeding from the dialysis access site. The Director of Nursing acknowledged the oversight and confirmed that all residents on dialysis should have an emergency kit at their bedside to address potential complications such as bleeding from the access site. The facility's policy on dialysis care mandates that shunt care be provided by a licensed nurse and that any complications be immediately reported to a physician. However, the absence of the emergency kit at the resident's bedside indicates a lapse in adhering to these protocols, potentially delaying treatment in case of an emergency.
Inaccurate Staffing Records in Facility
Penalty
Summary
The facility failed to ensure that staffing information was accurate and current on several occasions, specifically on 1/13/25, 2/12/25, 3/9/25, and 3/10/25. During these dates, discrepancies were found between the facility's census and the Nursing Staffing Assignment and Sign-In Sheets. For instance, on 1/13/25 and 2/12/25, the facility's census indicated the need for 2 Registered Nurses (RNs), but only 1 RN was signed in according to the records. Similarly, on 3/9/25, the census required 4 Licensed Vocational Nurses (LVNs), but only 3 were signed in, and on 3/10/25, 3 LVNs were needed, but only 2 were signed in. These inaccuracies in staffing records were confirmed by the Director of Staff Development (DSD), who acknowledged the importance of posting accurate staffing information to ensure adequate care for residents. The Director of Nursing (DON) also emphasized the necessity of maintaining accurate and updated staffing records, as they reflect the number of staff available to provide care to residents. The facility's policy and procedure on staffing, dated 2017, states that the facility should provide sufficient numbers of staff with the necessary skills and competency to care for all residents according to their care plans and the facility assessment. The failure to maintain accurate staffing records had the potential to affect the care of all residents, as it could lead to delays in care, such as unanswered call lights and late medication administration.
Failure to Address Resident's Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident who expressed suicidal ideation. The resident, diagnosed with paranoid schizophrenia and major depressive disorder, verbalized feelings of wanting to die, which were observed by staff members, including an LVN and a CNA. Despite these observations, the comments were not documented, and the resident's physician, psychiatrist, or interdisciplinary team were not notified. The resident's care plan did not include interventions for these expressed feelings, and there was no change of condition report or monitoring initiated. Interviews with staff revealed a lack of communication and documentation regarding the resident's suicidal ideation. An LVN admitted to not informing anyone about the resident's comments, and the Registered Nurse Supervisor was unaware of the situation. The Director of Nursing acknowledged that the resident's comments should have been reported immediately, and appropriate measures should have been taken, including notifying the doctor and implementing a care plan. The facility's policy on behavioral assessment and monitoring was not followed, resulting in the resident not receiving the necessary care and interventions for their emotional and psychosocial needs.
Failure to Provide Lower Dentures to Resident
Penalty
Summary
The facility failed to provide a resident, identified as Resident 10, with lower dentures, which was necessary for effective chewing and maintaining adequate nutrition. Resident 10 was admitted with diagnoses including protein calorie malnutrition, muscle weakness, dementia, and diabetes mellitus. The resident's care plan indicated a risk for decreased food intake due to dental problems, as all natural teeth were missing and the resident relied on full upper and lower dentures. Despite an order for a finely chopped mechanical soft texture diet until dentures were available, the resident was observed without bottom dentures, expressing dissatisfaction with the taste of food without them. The Social Services Director and Social Services staff confirmed that Resident 10 was evaluated for dentures on a previous date, but no follow-up appointment was made, and insurance issues delayed further action. The Director of Nursing acknowledged the facility's responsibility to ensure the resident had dentures, regardless of insurance coverage. The facility's policy required referrals for dental services within three days if dentures were lost or damaged, with documentation of actions taken to ensure adequate nutrition in the interim. However, this policy was not followed, as evidenced by the lack of timely follow-up and documentation in Resident 10's case.
Repeat Deficiencies in Resident Care and Medication Management
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to provide effective oversight and implement the plan of correction for deficiencies identified during the previous recertification survey. This failure led to repeat deficiencies in several areas, including the care provided for dependent residents in activities of daily living, maintaining and improving residents' range of motion and mobility, pharmacy services, and medication management. Specifically, the facility continued to have issues with medication error rates exceeding five percent and improper labeling and storage of drugs and biologicals. During an interview, the Administrator acknowledged the presence of deficiencies from the previous survey and emphasized the need for accountability among staff. The facility's policy and procedure for Quality Assurance & Performance Improvement (QAPI) outlined responsibilities for identifying and addressing quality deficiencies, but these were not effectively executed. The QAPI Committee was tasked with routine monitoring of various aspects of resident care, including medication administration and prevention of adverse health outcomes, yet these areas still showed deficiencies.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for one of the residents, identified as Resident 91. The resident was admitted with several diagnoses, including atrial fibrillation, urinary retention, benign prostatic hyperplasia, and obstructive and reflux uropathy. The resident had an indwelling catheter and was dependent on staff for toileting hygiene, bathing, and dressing. A Change in Condition Evaluation indicated abnormal urine, but the resident had no fever or pain. Despite this, the resident was prescribed Keflex and Macrobid for a urinary tract infection. A urine culture revealed that the bacteria present were resistant to both antibiotics prescribed. The Infection Preventionist Nurse confirmed that the resident's antibiotic use did not follow established criteria, as the resident did not exhibit symptoms such as chills, new onset of delirium, dysuria, suprapubic pain, or fever. The IPN acknowledged that it was the responsibility of the licensed nurses and the IPN to ensure the appropriateness of antibiotic use, and that the nurse who carried out the order should have verified the necessity of using two antibiotics. The Director of Nursing also stated that using two antibiotics could be unnecessary and harmful. The facility's policy on antibiotic stewardship, revised in 2016, indicated that antibiotics should be prescribed and administered under the guidance of the stewardship program, with laboratory results communicated to the prescriber to determine the appropriate course of action.
Failure to Maintain Functional Call Light System for Resident
Penalty
Summary
The facility failed to maintain a functional call light system for Resident 139, which was a violation of the facility's policy and procedure regarding the call light system. Resident 139, who had a history of repeated falls, muscle weakness, unspecified dementia, and legal blindness, was observed pressing the call light without any response, as there was no audible sound or visible light on the resident's doorway. This deficiency was confirmed during an interview with a Licensed Vocational Nurse (LVN 3), who verified that the call light was not working. The resident required substantial assistance with activities of daily living and was at high risk for falls and accidents, making a functional call light system crucial for timely assistance. Interviews with facility staff, including a Certified Nursing Assistant (CNA 6), Maintenance Supervisor (MS), Registered Nurse Supervisor (RNS4), and Director of Nursing (DON), highlighted the importance of a working call light system for resident safety and communication. The facility's policy indicated that the call system should be routinely maintained and tested by the maintenance department to ensure functionality. However, the Maintenance Supervisor admitted that call lights were not routinely checked unless reported by staff, which contributed to the deficiency. The failure to maintain a functional call light system had the potential to delay assistance to Resident 139, increasing the risk of falls and accidents.
Failure to Implement Fall Risk Prevention Leads to Resident Injury
Penalty
Summary
The facility failed to implement a fall risk prevention program for a resident identified as high risk for falls, resulting in the resident falling and sustaining serious injuries. The resident, who had a history of falls and was diagnosed with conditions such as muscle weakness and osteoarthritis, was not provided with necessary safety interventions like landing pads, bed alarms, and a bed in the low position as outlined in their care plan. Despite being assessed with a high fall risk score, these preventive measures were not in place at the time of the incident. Interviews with staff revealed that the resident's high fall risk was not communicated effectively among the care team. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) were unaware of the resident's fall risk status and did not implement the required interventions. The resident attempted to perform tasks independently, such as removing pants, which led to the fall. The lack of communication and failure to follow the care plan contributed to the incident. The facility's policy on safety and supervision was not adhered to, as the interdisciplinary care team did not adequately analyze and address the resident's specific fall risks. The Director of Nursing acknowledged that the resident's fall risk assessment score should have been communicated to ensure the implementation of the fall risk prevention program. The oversight in identifying and addressing the resident's fall risk resulted in the resident sustaining a right femoral neck fracture and a right humerus fracture, necessitating surgical intervention.
Inaccurate MDS Assessment of Resident Falls
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status on the Minimum Data Set (MDS), specifically regarding falls. Resident 4, who had a history of falls and was at high risk for injury, experienced a fall on January 4, 2024, as documented in the Nursing Progress Notes. However, the MDS assessments dated February 23, 2024, and May 23, 2024, incorrectly indicated that no falls had occurred. This inaccuracy was acknowledged by the Minimum Data Set Coordinator (MDSC 1), who confirmed that the MDS assessments were not correct and that this could affect the facility's quality metrics. Resident 4's medical history included a fracture of the right femur, right humeral fracture, history of falling, muscle weakness, and bilateral primary osteoarthritis of the hip. The resident required substantial assistance with daily activities and had moderately impaired cognitive skills. Despite these conditions, the MDS assessments failed to reflect the fall that occurred, which could negatively impact the resident's plan of care and the delivery of necessary services. The Director of Nursing (DON) also stated that inaccurate MDS assessments could affect resident care and services due to inaccurate health information.
Inadequate Infection Control Measures for Resident on Droplet Precautions
Penalty
Summary
The facility failed to observe infection control measures for a resident on droplet precautions. A visitor entered the room of a resident who was on droplet precautions without wearing the required personal protective equipment (PPE), such as a surgical mask, gown, and gloves. This occurred despite the presence of droplet precaution signage and an isolation cart with PPE outside the resident's room. The resident had been exposed to influenza, as indicated by their care plan and physician's order for Tamiflu prophylaxis. Interviews with facility staff, including Licensed Vocational Nurses and the Infection Preventionist Nurse, revealed that it was the responsibility of licensed nurses to inform and educate visitors about the need to wear PPE before entering the room. The facility's policy and procedure documents also indicated that education regarding transmission-based precautions should be provided by the infection preventionist or designee. However, the visitor was not informed or reminded to wear PPE, leading to a potential risk of spreading infectious diseases to other residents, visitors, and staff.
Illegible and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete, legible, and organized, as required by their policy and procedure titled Health Information Record Manual - Chapter III Legal Health Record. This deficiency was identified during a review of the resident's Medication Administration Record (MAR) and other medical documents. The MAR contained illegible documentation of vital signs, such as heart rate and blood pressure, which are critical for administering medications like Metoprolol. Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 both confirmed the illegibility of these records, which hindered their ability to make informed decisions regarding medication administration. Additionally, the facility's Director of Nursing (DON) acknowledged that written records should be legible and organized to facilitate proper care planning. The review also revealed that wound care notes for the resident were missing from both the electronic medical record and the physical chart, with RN 1 unsure of where these records might be stored. The facility's policy mandates that documentation in manual records must be legible and that the professional designation of the person writing or signing the record must be clearly shown, which was not adhered to in this case.
Failure in Tracheostomy Care Post-Shower
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for a resident, identified as Resident 3, who had a tracheostomy and was dependent on a respiratory ventilator. The deficiency occurred when the tracheostomy tie and dressing were not changed after the resident's shower, resulting in them becoming wet. This oversight was discovered when the head of respiratory care was informed by a family member about the resident's shower, and upon checking, found the tracheostomy tie and dressing wet. The facility's protocol required the tracheostomy site to be kept clean and dry to prevent skin breakdown, which was not adhered to in this instance. Resident 3 had a complex medical history, including acute respiratory failure, pneumonitis, and an altered level of consciousness following a cerebrovascular accident. The resident was entirely dependent on nursing staff for daily activities, including showering. The physician's orders specified that tracheostomy care should be performed daily and as needed, with particular attention to changing the tracheostomy tie and assessing skin integrity. However, on the day of the incident, the certified nursing assistant (CNA) responsible for the resident's care did not inform the respiratory therapist about the shower, leading to the failure in changing the tracheostomy tie and dressing. Interviews with facility staff, including the head of respiratory care, a registered nurse supervisor, and a CNA, revealed that the standard procedure involved notifying the respiratory therapist before a resident with a tracheostomy was showered. The respiratory therapist was expected to be present during the shower to monitor the resident's oxygen levels and change the tracheostomy tie and dressing afterward. However, due to a lapse in communication, this protocol was not followed, resulting in the deficiency. The facility's policy on tracheostomy care emphasized the importance of maintaining skin integrity and preventing infection, which was compromised in this case.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for a resident who was found to have a skin tear on her left forearm. The resident, who was admitted with diagnoses including unspecified dementia with psychotic disturbance, schizophrenia, psychosis, and glaucoma, was noted to have severely impaired cognitive skills and lacked the capacity to make decisions. The care plan for the resident included notifying the physician and resident representative for significant changes in condition. However, when the skin tear was discovered, the responsible party was not informed. During an interview, an LVN stated that two visitors inquired about the dressing on the resident's arm, which led to the discovery of the skin abrasion. The LVN mistakenly assumed the visitors were the responsible party and did not verify their identities, resulting in a failure to notify the actual responsible party. The facility's policy on charting and documentation required notification of family and physician, but this was not adhered to in this instance.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to re-admit a resident who was transferred to a General Acute Care Hospital (GACH) due to unresponsiveness. The resident, who had severe cognitive impairment and was under the care of a surrogate decision maker, was cleared by the GACH to return to the facility after being placed on hospice care. Despite having an available bed in the Subacute Unit, the facility denied readmission, citing that they had never had a hospice resident in that unit before and concerns about the resident's Carbapenem-resistant Pseudomonas Aeruginosa (CRPA) infection. The facility's policy indicated that residents should be allowed to return to an available bed, but this was not followed. The decision to deny readmission was influenced by a family dispute, where a family member who was not the resident's responsible party did not want the resident to return to the facility. The facility's Director of Nursing confirmed that the family feud was a factor in the decision. The facility's policy and a letter from the Centers for Medicare & Medicaid Services (CMS) indicated that residents with Multidrug-resistant Organisms (MDROs) should not be denied admission based on their need for Enhanced Barrier Precautions (EBP). Despite this, the facility did not readmit the resident, resulting in the resident remaining at the GACH for 16 days after being cleared for transfer back to the facility.
Failure to Implement Enhanced Standard Precautions
Penalty
Summary
The facility failed to implement Enhanced Standard Precautions (ESP) to prevent the spread of multidrug-resistant organisms (MDROs) for three residents who had gastrostomy tubes and tracheostomies. The facility did not ensure that Licensed Vocational Nurses (LVNs) had a proper understanding of ESP, did not post proper signage on the doors of residents requiring ESP, and did not ensure that LVNs used isolation gowns when providing high-contact resident care. Additionally, personal protective equipment (PPE) was not available outside the residents' rooms, and comprehensive ESP care plans were not developed for the three residents. These deficiencies were observed during a survey, where LVNs were seen providing care without wearing gowns and were unaware of the need for ESP for residents with indwelling devices. Resident 1, 3, and 4 were all admitted with diagnoses including chronic respiratory failure, gastrostomy, and tracheostomy. Their Minimum Data Sets (MDS) indicated that their cognitive skills for daily decision-making were severely impaired, and they were dependent on staff for various activities, including hygiene, bathing, and dressing. Despite these conditions, the facility did not implement ESP protocols, which include the use of gowns and gloves during high-contact care activities. Observations revealed that there were no ESP signs or isolation carts outside the residents' rooms, and LVNs were not wearing gowns while providing care. Interviews with the LVNs and the Director of Nursing (DON) confirmed that there was a lack of understanding and implementation of ESP protocols. The DON acknowledged that the facility's policy on ESP was not properly implemented and that all residents with indwelling devices should have ESP signs and isolation carts outside their rooms. The facility's policies and procedures indicated that ESP should be used for all residents with wounds or indwelling devices, and staff should be trained on these protocols. However, the facility failed to develop care plans reflecting ESP for the affected residents, putting them at risk for infections.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to ensure that a resident was free from abuse by facility staff. A Certified Nursing Assistant (CNA) was observed slapping a resident's left forearm during a bed bath. The resident, who has severe cognitive impairment and requires substantial assistance with personal hygiene, was agitated and screaming during the incident. The Registered Nurse Supervisor (RNS) witnessed the abuse but did not immediately separate the CNA from the resident, allowing the CNA to continue providing care to the resident and other residents before leaving the facility. The incident was reported by another CNA who heard a slapping sound and observed the resident pointing to her cheek in distress. The RNS, upon entering the room, saw the resident agitated and the CNA slapping the resident's forearm. Despite witnessing the abuse, the RNS only called for another CNA to assist and did not remove the abusive CNA from the resident's care immediately. The RNS later acknowledged that this was the wrong course of action and that the CNA should have been removed immediately to prevent further harm. Interviews with the facility's Director of Nursing (DON) and Administrator confirmed that the RNS should have separated the CNA from the resident immediately upon witnessing the abuse. The facility's policy on abuse and neglect prohibition clearly states that residents must be protected from harm during an investigation, and the RNS's failure to act accordingly was a violation of this policy. The facility's policies emphasize the importance of treating all residents with kindness, dignity, and respect, which was not upheld in this incident.
Failure to Document Resident's Change in Condition
Penalty
Summary
The facility failed to document accurately and completely for one resident when there was a change in condition. Specifically, the resident, who had diagnoses including unspecified dementia, mood disturbance, and anxiety, was noted to be agitated on a particular date. However, this episode of agitation was not documented in the Medication Administration Record (MAR) as required. The Registered Nurse Supervisor (RNS) observed the resident's agitation but did not record it in the MAR, which was confirmed during a review and interview with the Director of Nursing (DON). The facility's policy and procedure for charting and documentation require that all services provided, progress towards care plan goals, and any changes in the resident's condition be documented in the medical record. The failure to document the resident's agitation in the MAR meant that the psychiatrist would not have accurate information to prescribe medication correctly. This lapse in documentation was acknowledged by the DON, who confirmed that the RNS did not chart the episodes of agitation as required by the facility's policy.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On 4/13/2024, a CNA witnessed Resident 2 hit Resident 1 on the face but did not separate the two residents. The incident was reported to an LVN, who did not take immediate action to separate the residents or inform the RN and physician about the aggressive behavior exhibited by Resident 2. The residents remained in the same room, which placed Resident 1 at risk for further harm. On 4/15/2024, Resident 1's representative reported the incident to an RN, who also did not take immediate action to separate the residents. The RN informed the administrator, and an investigation was initiated on 4/16/2024. Despite the ongoing investigation, Resident 2 was not moved to another room until 4/16/2024, three days after the initial incident. This delay in action further compromised Resident 1's safety and well-being. Interviews with various staff members, including the Social Service Director, Director of Nursing, and Administrator, revealed a consensus that the residents should have been separated immediately to prevent further abuse. The facility's policies and procedures also indicated that immediate action should be taken to protect residents from abuse. However, the failure to promptly separate the residents and report the aggressive behavior led to a deficiency in ensuring the safety and protection of Resident 1.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe, as mandated by state regulations. Resident 1, who has major depressive disorder, transient ischemic attack, and heart failure, reported to her representative that she was slapped by Resident 2 while being assisted by CNA 1. Despite CNA 1 witnessing the incident and informing LVN 1, the incident was not reported to the appropriate authorities immediately. The Social Service Director (SSD) and other staff members were informed of the incident days later, and the investigation was initiated three days after the incident occurred. Resident 2, who has dementia and uropathy, was involved in the incident but was not separated from Resident 1 immediately after the alleged abuse. The SSD, upon being informed, conducted assessments and interviews but did not report the incident to the ombudsman until three days later. The Director of Nursing (DON) and the Administrator were also informed of the incident days after it occurred, and the residents were not separated until the next day, contrary to the facility's policy. The facility's policy requires immediate reporting of abuse to the administrator and other officials, but this protocol was not followed. Staff members, including the SSD, DON, and Administrator, acknowledged that the incident should have been reported immediately and that the residents should have been separated to prevent further harm. The delay in reporting and failure to separate the residents constituted a deficiency in the facility's handling of the abuse allegation.
Failure to Provide Abuse Training for LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) had received training on preventing all forms of abuse and the procedures for reporting incidents of abuse. This deficiency was identified during a review of the LVN's employee file, which revealed that the LVN had not attended any in-service training sessions since October 2023 and did not have any documented abuse training. The Director of Staff Development (DSD) and the Director of Nursing (DON) both confirmed that abuse training is required upon hire, annually, and as needed, and that the LVN's lack of training placed residents at risk for abuse, neglect, and exploitation. The Administrator also emphasized the importance of abuse training for all staff to ensure resident safety and compliance with mandated reporting requirements. The deficiency was further highlighted by an incident involving two residents. Resident 1, who had major depressive disorder, transient ischemic attack, and heart failure, required partial assistance with transfers and used a wheelchair. Resident 2, diagnosed with dementia and uropathy, was dependent on staff for transfers and also used a wheelchair and walker. LVN 1 failed to report aggressive behavior exhibited by Resident 2, which included hitting Resident 1, to the RN or doctor. This failure to report and address the aggressive behavior was a direct result of the LVN's lack of abuse training, as confirmed by interviews with the DSD and DON. The incident underscored the critical need for proper training to prevent and report abuse, ensuring the safety and well-being of all residents.
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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