Veterans Home Of California - Chula Vista
Inspection history, citations, penalties and survey trends for this long-term care facility in Chula Vista, California.
- Location
- 700 East Naples Court, Chula Vista, California 91911
- CMS Provider Number
- 555795
- Inspections on file
- 37
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Veterans Home Of California - Chula Vista during CMS and state inspections, most recent first.
A resident with nicotine dependence and a PRN order for nicotine lozenges was found in bed with a medication cup containing a white tablet left unattended on the bedside drawer, with no staff present. The resident reported it was a nicotine wafer left by the nurse and ingested it, hoping it was the nicotine lozenge. The RN reported having given two lozenges but only saw the resident take one and believed direct observation was unnecessary for PRN doses. Review showed no evaluation or MD order for the resident to self-administer medications, despite facility policy requiring medications to be promptly administered as part of the complete act of administration.
A resident was readmitted with an order for IV Zosyn to treat an abdominal infection, but the facility did not have the medication available and could not obtain it from their contracted after-hours pharmacy. This resulted in delayed treatment and the resident being transferred to another facility for care.
Staff, including CNAs and an LVN, did not wear surgical masks as required in a unit with active Covid-19 cases, despite the facility's mitigation plan mandating source control masking during outbreaks. Interviews confirmed staff were aware of the policy, but masks were not consistently worn, increasing the risk of viral transmission.
The facility failed to maintain food safety and sanitation in the kitchen, with unlabeled and undated food items, expired meat substitute, and broken tiles creating unsanitary conditions. These deficiencies could expose residents to contaminated food and unsanitary practices.
The facility failed to notify the ombudsman of the transfer of three residents to the hospital, as required. One resident with diabetes and skin damage, another with a recent amputation, and a third with osteomyelitis were transferred without notification. The ADON was unaware of the requirement, and the facility's policy did not address notifying the ombudsman.
A facility failed to provide a written bed hold policy notification to a resident and/or his representative upon transfer to a hospital. Despite the facility's policy requiring such notification, there was no evidence of it in the resident's medical records. Interviews with RNs confirmed the oversight, potentially leaving the resident uninformed about their rights to return.
A resident experienced significant weight loss, and the facility failed to update the nutrition care plan to reflect necessary interventions. Despite the resident's moderate impairment and awareness of weight loss, the care plan was not revised to include dietary needs and preferences. The facility's policies on care plan updates were not followed, leading to a deficiency in providing appropriate nutrition interventions.
A resident experienced significant unintentional weight loss due to the facility's failure to implement a comprehensive approach for monitoring nutrition interventions. The RD did not update the care plan to address the resident's ongoing weight loss, and there was a lack of communication between dietary and nursing teams, hindering effective intervention.
The facility failed to ensure safe pharmaceutical services, with expired medications found in medication rooms and carts, and inadequate controlled drug records for a resident. Expired Procrit, Mantoux, insulin, and nitroglycerin were available for use, violating facility policy. Additionally, mismatched prescription numbers for a resident's narcotic medication indicated poor record-keeping, risking drug diversion or misuse.
A LTC facility experienced a medication error rate of 7.14% due to errors involving two residents. One resident received glipizide without the required 30-minute pre-meal interval, and another resident was given fexofenadine with fruit juice, contrary to guidelines. Additionally, a medication was omitted for the second resident. The errors occurred due to non-adherence to the facility's medication administration policies and guidelines.
The facility failed to ensure proper labeling and storage of medications. An outdated insulin vial was found in the Unit 700 Medication Room, and a bulk bottle of atovaquone oral suspension was improperly stored in the Unit 300 Medication Room. The pharmacist acknowledged these issues, which were contrary to the facility's policy and manufacturer's instructions.
A resident with dysphagia was not scheduled for a dental appointment despite a physician's order and facility policy requiring an initial dental screening upon admission. The resident had not seen a dentist since October 2023 and reported discomfort with ill-fitting dentures. The charge nurse failed to notify the office assistant to arrange the appointment, and there was no documentation of a request for dental evaluation.
The facility failed to serve food at acceptable temperatures, with observations showing meals below the required 130°F. Residents reported meals, especially breakfast, were often cold. The Director of Dietetics acknowledged the issue, and the facility's policy emphasized serving food at required temperatures.
The facility failed to follow Enhanced Barrier Precautions for two residents, leading to potential infection control issues. Staff did not wear required PPE during high-contact activities for residents with gastrostomy tubes. Additionally, improper storage of a single-use syringe and an unsealed saline spray in the medication room posed contamination risks. These actions were contrary to the facility's infection prevention policies.
A facility failed to implement a comprehensive care plan for a resident with mental health diagnoses, as their aggressive behaviors were not documented or communicated to the IDT. The resident's behavior towards staff was not monitored as required, leading to a lack of awareness among the care team until a meeting months later.
A resident with cognitive impairments eloped from an LTC facility, resulting in a fall and injury. The facility failed to assess the resident's supervision needs and did not conduct an Elopement Risk Assessment despite previous incidents. Staff did not adhere to monitoring protocols, leading to the resident being unsupervised for nine hours.
The facility failed to report suspected financial abuse within 24 hours for a resident with severe cognitive impairment. Despite multiple indications of delinquent payments by the resident's DPOA, the facility delayed reporting to APS and CDPH, resulting in a year-long delay in oversight and investigation.
Unattended Nicotine Lozenge Left at Bedside Without Self-Administration Authorization
Penalty
Summary
Nursing staff failed to ensure medications were properly administered and not left unattended at the bedside for a resident with an order for nicotine lozenges. The resident had a diagnosis of nicotine dependence and a physician’s order for nicotine 2 mg lozenges to be given as needed. During observation, the resident was found lying in bed with a clear plastic medication cup containing a single white circular tablet on the bedside drawer, with no nursing staff present. The resident stated the tablet was a nicotine wafer that the nurse had left there and then ingested the tablet, stating he hoped it was the nicotine lozenge. Further review showed that the MAR documented administration of one 2 mg nicotine lozenge earlier that morning, while the RN reported having given two lozenges and only witnessing the resident take one. The RN stated that because the lozenges were ordered as needed, she did not believe she had to see the resident take them. The supervising RN confirmed that medications should not be left unattended at the bedside and that the resident had not been evaluated for self-administration of medications. Another RN confirmed there was no physician order for the resident to self-administer medications. The facility’s medication administration policy required that medications be promptly given to the proper resident as part of the complete act of administration.
Failure to Provide Ordered IV Antibiotic Upon Readmission
Penalty
Summary
The facility failed to provide necessary treatment for a resident who was readmitted with an order for intravenous (IV) Zosyn, an antibiotic required for an abdominal infection following acute appendicitis with abscess. The hospital had communicated the need for IV Zosyn prior to the resident's transfer, and the facility staff, including the RN Case Manager and Director of Nursing, were aware of the requirement. However, upon the resident's arrival, the facility did not have IV Zosyn available, and the in-house pharmacy was closed. Attempts to obtain the medication from the contracted after-hours IV pharmacy were unsuccessful, as the pharmacy was not open during the weekend hours. The facility's process for reviewing new admissions or readmissions included determining whether the facility could meet the resident's care needs. Despite this, the staff did not verify the availability of IV Zosyn before accepting the resident for readmission. The emergency medication kit did not contain IV Zosyn, and the pharmacy manager was not informed in advance about the need for this medication. The facility's after-hours pharmacy contract indicated that emergency or expedited orders could be delivered on weekends and holidays upon mutual agreement, but this process was not successfully executed in this case. As a result of the facility's inability to provide the ordered IV antibiotic, the resident experienced a delay in receiving necessary medication and was subsequently transferred to another facility that could provide the required treatment. The failure to ensure medication availability prior to readmission directly led to the deficiency identified in the report.
Failure to Enforce Masking Protocols During Covid-19 Outbreak
Penalty
Summary
Staff on Unit 300 failed to adhere to the facility's infection prevention and control program by not wearing surgical masks as required in an area where residents with active Covid-19 infections resided. During an observation, two CNAs were seen with their surgical masks around their necks, not covering their nose and mouth, while passing nourishments to residents. Additionally, an LVN was observed at the nurse's station without a mask. Interviews with the involved staff confirmed their awareness of the masking requirement, and the Infection Preventionist stated that surgical masks were required on the units, with N-95 masks needed for direct care of Covid-19 positive residents. The facility's mitigation plan, reviewed during the investigation, specified that source control masking is required during a VRI outbreak or surge in cases, which was the current situation with multiple residents and staff testing positive for Covid-19. Despite this, staff, including visiting hospice nurses, were not consistently following the masking procedures as outlined in the mitigation plan. The DON and Standard Compliance Coordinator acknowledged the expectation for all staff and visitors to adhere to the masking requirements during the outbreak.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain food safety and sanitation measures in the kitchen, as observed during a survey. A plastic bin containing a white powdered substance, identified as a thickening agent for pureed foods, was found unlabeled and undated under a food preparation counter. Additionally, a bag of opened frozen peanut butter cookies and three sandwiches in the refrigerator were also found without labels or dates. These items were not in compliance with the 2022 Federal Food and Drug Administration Food Code, which requires proper labeling and dating of food items to ensure safety and prevent foodborne illnesses. Further observations revealed a bag of meat substitute in the walk-in freezer that was past its expiration date, which should have been discarded according to the facility's policy and the FDA Food Code. Additionally, five broken tiles were found at the base of the wall next to the dish drying racks, creating unsanitary conditions. The facility's policy requires that kitchen areas be kept clean and in good repair, which was not adhered to in this instance. These deficiencies had the potential to expose residents to contaminated food and unsanitary practices, increasing the risk of foodborne illnesses.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the ombudsman of the transfer or discharge of three residents, which is a requirement to ensure residents' rights are protected. Resident 19, who had diabetes mellitus and sacral moisture-associated skin damage, was transferred to a hospital for further evaluation and treatment of buttocks wounds. There was no documented evidence that the ombudsman was notified of this transfer. Similarly, Resident 47, who was readmitted to the facility after a right above-knee amputation, was transferred to a hospital without the ombudsman being informed. Resident 99, diagnosed with osteomyelitis, was also transferred to a hospital for further evaluation and treatment without notifying the ombudsman. Interviews with the Assistant Director of Nursing (ADON) revealed that the facility did not have a practice of notifying the ombudsman when residents were transferred or discharged. The ADON was unaware of the requirement to notify the ombudsman, and the facility's policy and procedure on transfer/discharge did not address this requirement. This oversight in communication and policy led to the deficiency identified by the surveyors.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a written bed hold policy notification to a resident and/or his representative upon the resident's transfer to an acute care hospital. This deficiency was identified during a review of the resident's medical records and interviews with facility staff. The resident was transferred to the hospital on August 27, 2024, and was readmitted to the facility on December 7, 2024, after a prolonged hospitalization. Despite the facility's policy requiring a bed hold notification to be provided and documented, there was no evidence of such notification in the resident's medical records. Interviews with Registered Nurses 5 and 6 confirmed that a bed hold notification was not completed for the resident at the time of transfer. The facility's policy, dated January 29, 2025, mandates that a licensed nurse must notify the resident or their representative about the bed hold policy and document this in the medical record. The failure to adhere to this policy potentially left the resident and/or his representative uninformed about the resident's rights to return to the facility following hospitalization.
Failure to Update Nutrition Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a person-centered care plan for weight loss was updated for a resident, identified as Resident 20, who experienced significant weight loss. Resident 20 was admitted with diagnoses including hypertension, rheumatoid arthritis, and chronic obstructive pulmonary disease. The resident had a BIMS score indicating moderate impairment and experienced a weight loss of over 7% from August 2024 to January 2025, without being on a physician-prescribed weight-loss regimen. Despite the resident's awareness of his weight loss and food preferences, the care plan was not updated to reflect necessary nutrition interventions. Observations and interviews revealed that Resident 20 consumed less than 55% of meals on average, and although there was an order for a Prostat supplement, it was not consistently administered. The Registered Nurse confirmed that the supplement was not given on a specific date, and the Registered Dietitian acknowledged that the care plan was not updated to include additional food items recommended. The care plan had not been revised to reflect the resident's ongoing weight loss and dietary needs, despite the dietitian's awareness and quarterly assessments. The facility's policies required care plans to be reviewed and updated quarterly or as necessary, but this was not adhered to in Resident 20's case. The Assistant Director of Nursing stated that dietary notes were separate from nursing notes, which may have contributed to the lack of communication and updates in the care plan. The failure to update the care plan as per the facility's policy and the resident's needs led to a deficiency in providing appropriate nutrition interventions for Resident 20.
Failure to Monitor Nutrition Interventions Leads to Significant Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive systematic approach for monitoring nutrition interventions for a resident, leading to significant unintentional weight loss. The resident, who had a history of hypertension, rheumatoid arthritis, and chronic obstructive pulmonary disease, experienced a weight loss of 10.84% from July 2024 to January 2025. Despite the resident's weight loss being documented, the facility did not adequately update or follow through with the nutrition care plan to address the issue. The Registered Dietitian (RD) was responsible for updating the nutrition care plans and attending Nutritional At Risk (NAR) meetings. However, the RD did not consistently update the care plan to reflect the resident's ongoing weight loss and failed to implement recommended interventions such as a fortified diet. The RD acknowledged that the resident's nutrition assessment did not include additional foods recommended, and the care plan lacked a weight loss goal. Interviews with facility staff revealed a lack of communication and coordination between the dietary and nursing teams. The Assistant Director of Nursing (ADON) stated that dietary notes were separate from nursing notes, hindering the nursing staff's ability to carry out interventions. The facility's policies required the RD to monitor significant weight changes and update care plans, but these actions were not effectively executed, contributing to the resident's continued weight loss.
Expired Medications and Inadequate Drug Records Found in Facility
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for its residents, as evidenced by the presence of expired medications in the medication rooms and carts. During an inspection of the Unit 300 Medication Room, outdated Procrit, Mantoux vial, and insulin pen were found stored and available for resident use. The pharmacist acknowledged that these medications were expired and should have been removed from the medication refrigerator. The facility's policy clearly stated that drugs should not be kept in stock after their expiration date, yet these expired medications were still present. In another instance, an expired nitroglycerin vial was found in the Unit 700 Medication Cart. The Assistant Director of Nursing confirmed the expiration and acknowledged that the vial should have been removed according to the facility's policy. This oversight in managing medication expiration dates posed a risk of residents receiving outdated and potentially ineffective medications. Additionally, the facility failed to maintain organized and orderly controlled drug records for Resident 5. The prescription numbers on the resident's PRN hydrocodone/acetaminophen did not match the corresponding Controlled Drug Record, leading to discrepancies in narcotic accountability. The Director of Pharmacy and Supervising Registered Nurse acknowledged the mismatch and the delay in the use of the narcotic supply. This lack of proper record-keeping could result in drug diversion, abuse, or misuse, further compromising resident safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate due to three medication errors involving two residents. For one resident, the medication glipizide, which is used to manage blood sugar levels, was not administered 30 minutes before meals as required. The Licensed Vocational Nurse (LVN) prepared and administered the medication without adhering to the timing guidelines specified in both the facility's drug handbook and Lexi-comp, the facility's reference for drug information. The Director of Pharmacy confirmed that the medication should be given 30 minutes before the first main meal, but this protocol was not followed. Another resident experienced two medication errors. One medication was omitted, and the allergy medication fexofenadine was administered with fruit juice, contrary to the guidelines in Lexi-comp, which state that fexofenadine should not be given with fruit juices. The Registered Nurse (RN) responsible for administering the medications acknowledged the omission and the incorrect administration method. The facility's policy and procedure for medication pass and administration were not adhered to, as special considerations and timing were not properly noted or followed in the Medication Administration Record (MAR). The facility's policies, including those for medication pass and drug administration, emphasize the importance of administering medications as prescribed and noting special considerations in the MAR. However, these policies were not followed, leading to the medication errors. The Director of Pharmacy and nursing staff acknowledged the discrepancies between the facility's practices and the established guidelines, which contributed to the increased medication error rate.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were labeled and stored according to accepted standards and manufacturer's instructions. During an inspection of the Unit 700 Medication Room, an outdated insulin vial was found stored in the refrigerator, despite a pharmacy label indicating it should not be used after January 22, 2025. The pharmacist acknowledged the outdated insulin vial and stated it should not have been returned to the medication room refrigerator. The facility's policy, reviewed with the Director of Pharmacy, indicated that drugs should not be kept in stock after their expiration date, and no contaminated or deteriorated drugs should be available for use. In another instance, during an inspection of the Unit 300 Medication Room, a bulk bottle of atovaquone oral suspension for a resident was stored in the medication refrigerator at 38 degrees Fahrenheit, contrary to the manufacturer's instructions to store it at room temperature between 68 to 77 degrees Fahrenheit. The pharmacist acknowledged the discrepancy between the storage conditions and the manufacturer's labeling. The facility's policy, reviewed with the Director of Pharmacy, stated that nursing staff should review manufacturer's recommendations to ensure drugs are stored at appropriate temperatures.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to ensure a dental appointment was scheduled for a resident, identified as Resident 72, who was admitted with a diagnosis of dysphagia. During an observation and interview, it was noted that Resident 72 was without teeth or dentures and expressed discomfort with wearing dentures due to their fit. The resident had not been seen by a dentist since October 2023, despite a physician's order from November 2024 for a dental evaluation and treatment. The registered nurse confirmed that the charge nurse should have notified the office assistant to arrange a dental appointment and documented this in the resident's record, which was not done. The facility's policy required an initial dental screening examination upon admission, which was not adhered to in this case.
Failure to Serve Food at Acceptable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at an acceptable temperature, which could affect the meal and food intake of residents, potentially impairing their nutritional status. During a test tray observation, it was noted that the entree of carne with tortilla was served at 128 degrees Fahrenheit, and the milk was at 50.8 degrees Fahrenheit, both below the acceptable temperature as per the FDA Food Code, which requires food to be held at 130 degrees Fahrenheit or above. Additionally, the beans served as a side item were dried out, indicating a lack of proper food handling and temperature maintenance. Interviews with residents and observations further confirmed the issue, as nine residents reported that meals, particularly breakfast, were often served cold. One resident specifically mentioned that his food was often cool and expressed a preference for hotter meals. The Director of Dietetics acknowledged the low food temperatures and stated that food should be served at an acceptable temperature and palatability. The facility's policy on food preparation also emphasized the importance of serving food at required temperatures to conserve nutrients, flavor, and appearance.
Inadequate Infection Control Practices and Medication Storage Issues
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for two residents, leading to potential infection control issues. Resident 84, who was admitted with dysphagia and a gastrostomy tube, was observed receiving perineal hygiene care, medication administration, and tube feeding without the staff wearing the required personal protective equipment (PPE). Despite the presence of EBP signage, both a Certified Nursing Assistant and a Licensed Vocational Nurse did not wear gowns during these high-contact activities, which are essential to prevent the spread of multidrug-resistant organisms. Similarly, Resident 25, diagnosed with multiple sclerosis and dysphagia, was also subject to inadequate infection control practices. During medication administration via a gastrostomy tube, a Licensed Vocational Nurse failed to wear a gown, contrary to the EBP requirements indicated by the signage outside the resident's room. The Infection Control Nurse confirmed that gowns and gloves should have been worn to prevent the transmission of multidrug-resistant organisms. Additional deficiencies were noted in the medication room, where a single-use syringe labeled as sterile was improperly stored attached to a medication bottle, and an unsealed bottle of saline spray was found without its printed neckband. These practices posed a risk of contamination and were acknowledged by the facility's pharmacist and infection control nurse. The facility's policies on drug storage and infection prevention were not followed, contributing to the potential spread of infections and use of compromised medical supplies.
Failure to Document and Monitor Resident's Aggressive Behavior
Penalty
Summary
The facility failed to implement an accurate comprehensive person-centered care plan for a resident, who was admitted with diagnoses including Major Depressive Disorder, Panic Disorder, and Post-Traumatic Stress Disorder. The resident exhibited aggressive behaviors towards staff, which were not monitored or documented as required. The Director of Physical Therapy reported being verbally harassed by the resident over the past two years but did not document these behaviors in the medical record or notify the Interdisciplinary Team (IDT) until July 2024. This lack of documentation and communication resulted in the IDT being unaware of the resident's behavior issues until a meeting on July 22, 2024. The Social Services Director and Supervising Registered Nurse were also unaware of the resident's aggressive behavior until shortly before the IDT meeting. The facility's policy required behavior monitoring to be documented every shift, but this was not done. The Medical Doctor emphasized the importance of documentation for accurate assessment and treatment planning. The failure to document and communicate the resident's behaviors compromised the ability to address the resident's mental health needs effectively.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident, resulting in injury. The resident, who had a history of dementia and paranoid schizophrenia, left the facility unsupervised and was missing for approximately nine hours. During this time, the resident fell and sustained a two-centimeter forehead laceration that required five sutures. The facility staff did not assess the level of supervision required for the resident's safety, despite previous incidents indicating a risk of elopement. The resident had a documented history of attempting to leave the facility unsupervised, as evidenced by a previous fall at the facility's back gate. Despite this, the facility did not conduct an Elopement Risk Assessment or update the resident's care plan to address the risk of elopement. The facility's policy required staff to monitor residents' whereabouts every two hours, but this was not adhered to, as the resident's location was documented without direct visualization. Interviews with facility staff revealed a lack of adherence to established protocols for monitoring residents. The Certified Nurse Assistant (CNA) responsible for the resident's care did not visually confirm the resident's location, relying instead on routine assumptions. The Director of Nursing acknowledged the failure to conduct an Elopement Risk Assessment and the absence of policies to prevent elopements, citing the facility's status as an unlocked facility where residents have the right to leave.
Failure to Report Suspected Financial Abuse in a Timely Manner
Penalty
Summary
The facility failed to implement their policy and procedure for reporting suspected financial abuse within 24 hours for a resident with severe cognitive impairment. The resident's Durable Power of Attorney (DPOA) had not paid the monthly residential fees for an extended period, leading to a significant outstanding balance. Despite multiple indications and internal communications about the delinquent payments, the facility did not report the suspected financial abuse to Adult Protective Services (APS) or the California Department of Public Health (CDPH) in a timely manner. The Financial Case Worker (FCW) and other staff members were aware of the issue but did not take the necessary steps to report it immediately, resulting in a year-long delay in oversight and investigation. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, was financially dependent on the DPOA. The facility's internal records showed multiple attempts to contact the DPOA and discussions about the need to report the suspected abuse. However, the actual report to APS was not made until much later, despite clear signs of financial mismanagement. The Facility Administrator acknowledged the oversight and confirmed that the suspected abuse should have been reported immediately as per the facility's policy and state law.
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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