Villa Del Rio
Inspection history, citations, penalties and survey trends for this long-term care facility in Bell Gardens, California.
- Location
- 7002 Gage Avenue, Bell Gardens, California 90201
- CMS Provider Number
- 555781
- Inspections on file
- 45
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Villa Del Rio during CMS and state inspections, most recent first.
Two residents did not receive timely, physician-ordered care for fungal skin rashes. One resident with intact decision-making capacity and no cognitive impairment had standing orders for twice-daily cleansing and application of Triamcinolone cream, and later Nystatin powder plus Triamcinolone to breast, buttock, and perineal areas for candidiasis; TAR review and staff interviews confirmed multiple missed evening doses across two months. Another resident with pneumonia, epilepsy, and moderate cognitive impairment reported an itchy, red, raised groin rash, with documentation that the physician was called and staff were awaiting treatment orders, but records showed no successful physician contact or treatment orders in place until six days later. The DON confirmed that ordered treatments were not fully administered and that the delay in obtaining orders for the rash constituted a delay of care, contrary to facility policies on medication administration and change in condition.
A resident with dermatitis of the trunk and a history of cardiac arrhythmias had physician orders for daily topical ketoconazole and triamcinolone for 30 days, with a care plan goal that symptoms such as scaly, flaky, itchy, red skin would resolve within that period and a specified re-evaluation date. On observation, the resident still had a generalized rash and reported ongoing itchiness, yet review of progress notes showed no documented re-evaluation of the treatment or care plan on the target date. The treatment nurse and DON confirmed that the care plan was not reassessed or revised as required by facility policy, resulting in a failure to update the plan of care based on the resident’s ongoing skin condition.
A resident with muscle weakness, hypertension, and dependence for most ADLs and mobility was care planned to have a call light within reach, but surveyors found the call light not within reach and the resident unable to use it due to limited arm and hand movement. The resident reported not knowing where the call light was, being unable to press it, feeling powerless and ignored, and having to yell or wait for staff, including times when the resident was dirty and wanted to be cleaned. A CNA acknowledged she had not assessed whether the resident could use the call light and recognized that lack of access could lead to feelings of neglect and delayed care. The MDS nurse stated he was unaware the resident could not use the call light, despite facility policy requiring evaluation of each resident’s unique needs and provision of appropriate call system accommodations.
A resident with muscle wasting, atrophy, and lack of coordination was readmitted with a bilateral lower extremity rash documented in the progress notes. An LVN who completed the readmission observed the rash but did not notify the physician, did not complete a Change of Condition assessment, and did not initiate a care plan, resulting in the rash not being properly assessed or treated. This was inconsistent with facility policy requiring prompt physician notification for changes in a resident’s condition.
A resident with muscle weakness, hypertension, impaired decision-making capacity, and high dependence for ADLs received incontinence care from an LVN who failed to perform hand hygiene before donning gloves and did not remove contaminated gloves before applying a clean brief and touching the resident. The LVN cleaned the resident’s pubic area and buttocks, placed soiled towels on the bed, then immediately handled clean items and continued resident contact with the same gloves. The LVN acknowledged not following hand hygiene practices, despite facility policy requiring hand hygiene before applying and after removing PPE and before resident care.
The facility failed to maintain functional ceiling-suspended privacy curtains in two shared rooms, resulting in inadequate visual privacy for two residents who required assistance with ADLs. One resident, with mental health and physical impairments and partial/moderate ADL dependence, had a curtain that was too short and did not close completely, allowing others to see the resident during care, as reported by a CNA. Another resident, with muscle weakness, hypertension, impaired decision-making capacity, and total ADL dependence, had a shortened curtain with tangled strings that did not provide sufficient privacy, as reported by an LVN. These conditions did not comply with the facility’s written policy requiring resident bedrooms to be equipped to assure full visual privacy with ceiling-suspended curtains around each bed in non-private rooms.
Nursing staff failed to follow professional standards when administering medications to three residents, including not identifying medications to residents with cognitive impairment, administering all medications at once without explanation, and crushing multiple medications together for administration via gastrostomy tube. Nurses acknowledged these practices did not align with facility policy, which requires explaining medications and administering them in accordance with professional standards.
Two residents were not provided with a safe, clean, and homelike environment due to unresolved maintenance issues, including a damaged bathroom door and a broken toilet seat. Staff were aware of these hazards but failed to document or report them according to facility procedures, resulting in ongoing risks to resident safety and comfort.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in residents receiving drugs without adequate justification or in a manner that could limit their functional abilities.
The facility did not complete or retain required background check documentation for multiple staff, including RNs, LPNs, a treatment nurse, and a CNA. Several employee files lacked background reports, some checks were delayed for years after hire, and some were incomplete or missing due to misplaced records after a change in ownership. The DSD and DON confirmed that background checks should have been done upon hire and that missing documentation was a failure to follow facility policy.
A resident with a history of COPD, hemiplegia, and aphasia was observed receiving G-tube feeding while lying with the head of bed at a 20-degree angle, below the required 30-45 degrees specified in both the care plan and facility policy. The LVN confirmed the improper positioning during the feeding, despite clear orders and protocols for enteral feeding safety.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident with severe mental illness, impaired cognition, and a history of exit-seeking behavior was able to leave the facility through an unarmed exit door due to lack of staff supervision, failure to communicate elopement risk among staff, and failure to follow care plan interventions and facility policy regarding door alarms. The resident was not monitored as required, and staff were unaware of the resident's risks, leading to the resident's elopement and subsequent death offsite.
Staff did not ensure the shower room floor was dry and free of dirty linen after use, and the toilet was left uncleaned with visible soiling and no lid. Maintenance staff, a CNA, and the DON all confirmed these conditions did not meet infection control standards and violated facility policies for cleanliness.
Multiple Geri chairs and shower chairs were found to be broken or ripped, with missing cushions, exposed padding, and damaged parts, creating an unsafe and uncomfortable environment for residents. The Maintenance Supervisor and DON confirmed the deficiencies, and facility policies and equipment manuals required regular inspection and repair to ensure resident safety and comfort.
A resident with metabolic encephalopathy and type 2 DM had a care plan requiring monitoring of rash treatment effectiveness, but nursing staff did not document any monitoring after the care plan was established. The DON confirmed the absence of documentation, which was inconsistent with facility policy requiring comprehensive, measurable care plans.
A resident with metabolic encephalopathy and diabetes did not have their pain reassessed in a timely manner after receiving Norco for moderate to severe pain. On one occasion, pain was reassessed five hours after administration, and on another, there was no documentation of reassessment. The DON confirmed these lapses, which were not in accordance with facility policy.
A LVN failed to document the administration of a PRN dose of Hydrocodone-Acetaminophen for a resident with metabolic encephalopathy and diabetes, despite facility policy requiring immediate documentation on the MAR after medication administration. The nurse stated the omission occurred due to being called away to assist another resident.
The facility did not provide a refrigerator for storing food brought in by visitors for residents, leading to the disposal of leftover perishable food items. Staff and policy confirmed that only shelf-stable foods could be kept at the bedside, while foods requiring refrigeration were thrown out due to the absence of a dedicated storage option.
Multiple infection control deficiencies occurred, including the lack of Enhanced Barrier Precautions for residents with indwelling medical devices or MDROs, absence of a documented water management program, a resident consuming food from another's used tray, and a nurse failing to perform hand hygiene during wound care. These lapses were confirmed through observation, interviews, and record reviews.
Multiple residents received psychotropic medications without proper informed consent, including cases where residents lacked decision-making capacity or had appointed representatives who were not consulted. Consent forms were often incomplete, outdated, or missing entirely, and staff acknowledged that required procedures for obtaining and documenting informed consent were not followed.
The facility failed to accurately complete and document MDS assessments for several residents, including not reflecting therapeutic diets, dialysis status, language preferences, interpreter needs, and oral/dental conditions. These inaccuracies were identified through record review, observation, and interviews with residents, family, and staff, revealing that assessments did not match residents' actual health status or communication needs.
Three residents did not have their care plans reviewed or revised after significant changes in their conditions, including a fall, a hospital transfer for bleeding, and the initiation of continuous cardiac monitoring. The facility did not hold required IDT meetings or update interventions, resulting in delays and omissions in care planning and communication with responsible parties.
Four residents with limited ROM and mobility did not receive appropriate restorative services, including RNA, PT, or OT, as recommended or ordered. One resident with stroke and hemiplegia lacked a care plan and RNA services despite assessment recommendations. Another resident with cognitive impairment and brain dysfunction was not provided RNA services, and a third with severe contractures and a pressure ulcer did not receive ROM exercises due to miscommunication between rehab and wound care staff. Additionally, RNA services were not resumed for a resident after hospital readmission, contrary to previous orders and facility policy.
Three residents were placed at risk due to staff failing to keep a call light within reach and provide non-slip footwear for a resident at risk for falls, not conducting an IDT meeting after an unwitnessed fall for another resident, and allowing a resident with dysphagia to access and eat food from another resident's tray, contrary to her prescribed diet. These actions and inactions resulted in unsafe conditions and increased risk of harm.
Two residents with significant physical and cognitive impairments did not receive physician-ordered PT and OT evaluations or restorative services. Both were dependent on staff for ADLs and had documented limitations in range of motion, but only brief assessments were performed instead of comprehensive therapy evaluations. Facility staff and records confirmed the absence of required rehabilitative interventions, contrary to facility policy.
Several residents with complex medical and behavioral needs did not have individualized care plans addressing their diagnoses, medication use, behaviors, or refusals of care. Staff confirmed that care plans were missing or incomplete for issues such as aggression, high-risk medications, use of dentures, and risk of ADL decline, despite facility policy requiring comprehensive, measurable care plans.
The facility did not timely initiate conservatorship referrals for two residents lacking decision-making capacity, resulting in improper oversight and notification. Additionally, the MDS did not accurately reflect language preferences or interpreter needs for two residents, and a non-verbal resident was not provided with a communication board, limiting participation in care and staff understanding of needs.
A resident with multiple medical and mental health conditions was not provided with dentures despite documented need and delivery to the facility. The resident remained edentulous, experienced embarrassment, and had difficulty chewing food while on a regular diet. Staff were unaware of the missing dentures, did not communicate the issue, and failed to adjust the resident's diet, resulting in a negative impact on the resident's quality of life.
Two residents at risk for falls were found to have their call lights out of reach, despite care plans and facility policy requiring accessibility. One resident, needing assistance for mobility, was observed getting out of bed without supervision to access the call button, while another non-ambulatory resident in a wheelchair could not reach her call light and was unable to request help. Staff confirmed the call lights were not accessible, in violation of established protocols.
A resident with schizoaffective disorder and moderately impaired cognition was admitted without a properly completed Advance Directive Acknowledgement form. The form was left blank, and the Social Services Director confirmed the resident was not given the opportunity to discuss or formulate an advance directive, contrary to facility policy requiring this determination and discussion upon admission.
Two residents experienced significant changes in condition, including transfer to a hospital and abnormal heart rate readings, but the facility failed to notify the appropriate public guardian, responsible party, or physician as required by policy and physician orders. Staff did not update records or communicate changes, resulting in a lack of timely notification and potential delays in care.
A resident with multiple medical conditions and requiring moderate ADL assistance was observed on multiple occasions with long, dirty fingernails. The resident expressed a desire for nail care, and both CNA and DON interviews confirmed that daily nail cleaning and trimming were required duties. Facility policy and CNA job descriptions also specified this responsibility, but the resident's fingernails remained unaddressed.
A resident with severe cognitive impairment and total dependence for ADLs was found undressed and covered in feces after a breakdown in shift hand-off communication. A newly hired CNA did not receive a report about the resident's behaviors or care needs and was instructed by the charge nurse to delay care, leading to the resident being left soiled and exposed. Facility leadership confirmed that shift reporting procedures were not followed, contributing to the incident.
A resident with end stage renal disease who required hemodialysis did not receive post-dialysis monitoring on two occasions after returning from treatment. Documentation and staff interview confirmed the absence of required monitoring, despite facility policy mandating assessment after dialysis.
Two residents with dementia and additional mental health diagnoses did not have individualized care plans addressing their dementia, despite severe cognitive impairment and the need for assistance with ADLs. Staff confirmed that care plans were necessary to guide care and meet facility policy requirements, but these were not developed.
A resident with diabetes and moderate cognitive impairment was given Glipizide on several occasions when their blood sugar was below the physician-ordered threshold. An LVN confirmed the medication was administered despite orders to hold it for low blood sugar, contrary to facility policy.
A resident with COPD and atrial fibrillation, who had moderately impaired cognition and required assistance with most ADLs, was not offered a pneumococcal vaccine as required by facility policy. The Infection Preventionist confirmed there was no documentation of the vaccine being offered or education provided, despite the policy mandating that all residents be offered the vaccine.
A registry LVN was allowed to provide direct care without receiving required abuse prevention and reporting training. The nurse did not receive this training from either the agency or the facility, and facility leadership confirmed there was no process to ensure registry staff were trained on abuse policies before starting work. This resulted in the LVN being unaware of the facility's abuse reporting requirements.
A facility failed to create a care plan for a resident at risk of elopement, despite the resident's history of wandering and cognitive impairment. The resident, with conditions including COPD and dementia, was identified as having exit-seeking behavior, yet no care plan was developed to address this risk. The absence of a care plan was confirmed by both the MDS-LVN and the DON, and the resident was later reported missing, highlighting the deficiency.
A resident with dementia and a history of elopement left the facility unsupervised due to inadequate supervision. Despite being identified as at risk for elopement, staff were unaware of this risk, leading to the resident's unsupervised departure. The facility's policies on assessing and managing elopement risks were not effectively communicated or implemented.
The facility failed to maintain safe water temperatures in three resident restrooms and one shower room, with temperatures exceeding the maximum limit of 120 degrees Fahrenheit. Observations revealed temperatures of 125, 126, and 122 degrees Fahrenheit in various areas, posing a risk of burns to residents. The facility's policy required temperatures not to exceed 120 degrees Fahrenheit, but discrepancies were found between recorded and actual temperatures.
A resident's bathroom sink in an LTC facility was not functioning properly, lacking hot water and leaking onto the floor. Despite being reported, the issue persisted, causing discomfort and potential safety hazards. The resident, who required supervision for ADLs, had to use alternative means for hygiene. Facility staff acknowledged the problem and the need for immediate repairs to ensure resident safety and comfort.
A resident with Alzheimer's and other conditions was unable to have their rights exercised by their responsible party due to the facility's failure to maintain accurate contact information. The resident experienced falls, and the responsible party was not notified, as the facility did not have the correct phone number on the resident's Face Sheet. Staff interviews revealed a lack of communication and failure to refer the resident to the Public Guardian office.
A resident with Alzheimer's and other conditions experienced falls, but the facility failed to notify the responsible party (RP) as required. The resident's Nurses Notes lacked documentation of any attempts to contact the RP, and the absence of the RP's phone number on the Face Sheet contributed to the issue. The facility's policy mandates notifying the resident's physician and RP of changes in condition, which was not followed.
A resident with a history of UTI and neuropathy experienced severe abdominal pain, but the LTC facility failed to assess the pain or the suprapubic catheter, as required by their policy. Despite the resident's complaints and requests for hospital transfer, the facility did not conduct timely assessments or notify the physician. The resident suffered severe pain for an extended period and was eventually transferred to a hospital, where a blocked catheter was identified and treated, and sepsis was diagnosed.
The facility failed to provide physician-ordered pressure ulcer treatments for three residents, as no treatment nurse was assigned on multiple dates. This resulted in missed wound care treatments, as confirmed by blank treatment administration records. Residents with existing pressure ulcers did not receive necessary care, leading to potential worsening of their conditions. The Director of Nursing was unaware of the missed treatments, despite facility policies requiring documentation of wound care.
The facility failed to provide sufficient nursing staff, resulting in inadequate care and missed medication doses for residents. CNAs were often assigned to care for 20 or more residents, leading to delays in hygiene care and increased risk of pressure ulcers. Residents missed critical medications due to staffing shortages, and wound care treatments were not performed as ordered. The facility did not meet the required minimum of 2.4 DHPPD by CNAs, contributing to these deficiencies.
The facility did not ensure that nurse staffing information, including actual hours worked, was completed and posted for two days. Observations showed incomplete Direct Care Service Hours Per Patient Day (DHPPD) forms, and interviews revealed that actual hour calculations had not been done since 2023. This failure left residents, staff, and visitors unaware of the accurate number of clinical staff available.
The facility failed to ensure resident privacy during ADL care for four residents, who were exposed due to open privacy curtains or doors. CNAs acknowledged the need for privacy, but issues such as forgetting to close curtains or broken equipment were cited. The DON confirmed the requirement for privacy, aligning with the facility's policy on Residents Rights.
Failure to Administer Ordered Antifungal Treatments and Delay in Obtaining Rash Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered treatments for fungal skin infections were administered as prescribed for one resident. One resident with intact decision-making capacity and no cognitive impairment had physician orders dated 1/26/2026 for cleansing a rash with normal saline, patting dry, and applying Triamcinolone 0.5% cream topically under both breasts every day and evening shift for 14 days to treat candidiasis. Review of the Treatment Administration Record (TAR) for January 2026 showed that the evening doses on 1/27, 1/28, 1/29, and 1/31 were not documented as given. Subsequent physician orders dated 2/9/2026 directed cleansing with normal saline and application of Nystatin powder and Triamcinolone cream to the buttocks and perineal area every day and evening shift for candidiasis. The February 2026 TAR showed missed evening treatments on 2/11, 2/12, and 2/19. During interviews, an LVN and the treatment nurse confirmed that the resident did not receive all ordered evening treatments and doses of Nystatin and Triamcinolone during these periods. The deficiency also includes the facility’s failure to promptly obtain treatment orders for another resident who reported a new itchy rash. This resident, with pneumonia and epilepsy and moderate cognitive impairment, complained on 1/31/2026 of itchiness to the groin area with red, raised rashes. A progress note documented that the physician was called and that staff were awaiting a response on needed treatment. Review of progress notes, TARs for January and February 2026, and the 24-hour report sheet showed no documentation that the physician was successfully reached regarding the rash on that date, and no treatment orders were in place at that time. In a subsequent interview and record review, an LVN stated there was no supporting documentation that nurses were able to reach the physician about the rash identified on 1/31/2026 and that treatment orders were not obtained until 2/6/2026, six days after the initial complaint. The DON, upon review of the TARs, progress notes, and 24-hour report, stated that nurses did not administer all ordered doses of Nystatin and Triamcinolone for the first resident in January and February 2026 and acknowledged that all treatments should have been administered as ordered. The DON also stated that staff should have communicated to the upcoming shift when waiting for physician orders and characterized the six-day delay in obtaining orders for the second resident’s rash as a delay of care. Facility policies on medication administration and change in condition required medications to be administered as ordered and prompt physician notification when there is a need to significantly alter a resident’s medical treatment.
Failure to Re-Evaluate and Revise Dermatitis Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to re-evaluate and revise a resident’s care plan for dermatitis as scheduled. A resident with a history of atrial fibrillation and atrial flutter, who had capacity to make decisions per a prior H&P and later showed moderate cognitive impairment on the MDS, was observed with a generalized rash on the back and reported having the rash for about a year with itchiness, especially at night. Physician’s orders dated 11/21/2025 directed cleansing the rash with normal saline and applying ketoconazole cream every shift and triamcinolone cream on day shift to the trunk for 30 days. A corresponding care plan for dermatitis of the trunk, initiated on 11/21/2025, set a goal that the resident would have no complaints of scaly, flaky, itchy, red skin for 30 days and no allergic reaction to the topical medications, and specified that a re-evaluation should occur on 12/21/2025. Review of the resident’s progress notes for 12/2025 showed no documentation that the treatment and plan of care were re-evaluated on the 12/21/2025 target date. During interviews, the treatment nurse stated that skin assessments are done daily and at the end of treatment, and that when treatment ends staff should notify the wound consultant to determine whether orders should be continued or changed, but acknowledged that this resident’s plan of care was not revised or re-evaluated on 12/21/2025 to determine if the dermatitis had resolved. The DON similarly stated that the treatment nurse should reassess whether a resident’s plan of care and treatment are working and document the re-evaluation in the progress notes, and confirmed that if the care plan was not re-evaluated after the target date, the resident’s skin condition could have worsened. The facility’s comprehensive care plan policy requires measurable objectives, timeframes, and documentation of alternative interventions as needed, but the required re-evaluation and potential revision of the dermatitis care plan were not completed or documented for this resident.
Failure to Ensure Functionally Accessible Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not providing an appropriate and usable call light. The resident, who had diagnoses including muscle weakness and hypertension, was care planned to have a call light within reach and answered promptly. The resident’s H&P documented that he did not have the capacity to understand and make decisions, while the MDS indicated he was usually able to understand and be understood, and was dependent for most ADLs and mobility, including transfers and toileting. During interview, the resident reported not knowing where his call light was, being unable to press it because he could not move his arms and hands, and stated he sometimes felt powerless and ignored, resorting to yelling or waiting until someone entered the room, and that when he called, he would be dirty and wanted to be cleaned. On observation with a CNA, the resident’s call light was found not within reach, and the CNA then placed it within reach. The resident reiterated he could not use the call light due to inability to move his arms and hands. The CNA acknowledged she had not asked the resident if he could use the call light and stated that not being able to use and access the call light could lead to feelings of neglect, delay in care, and in assisting the resident’s needs. The MDS nurse stated he was not aware the resident could not use the call light. The facility’s policy on call lights required that each resident be evaluated for unique needs and preferences to determine any special accommodations needed to utilize the call system and that the facility be adequately equipped with a call light at each resident’s bedside, toilet, and bathing area to allow residents to call for assistance.
Failure to Notify Physician and Assess Rash on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and obtain treatment orders when a resident was readmitted with a rash on both lower extremities. The resident’s admission record showed an initial admission and a later readmission, with diagnoses including muscle wasting, atrophy, and lack of coordination. A History and Physical indicated the resident did not have the capacity to understand and make decisions, while a subsequent MDS documented that the resident was able to understand and be understood, and required varying levels of supervision and moderate assistance with ADLs and transfers. Progress notes from the readmission documented that the resident returned with a bilateral lower extremity rash. During an interview and concurrent record review, an LVN stated she admitted the resident on the readmission date, observed the bilateral lower extremity rash, but did not call the physician to notify him. She further stated she did not complete a Change of Condition assessment and no care plan was created related to the rash. The LVN acknowledged that the rash was not properly assessed and was not treated. Review of the facility’s policy titled “Change in a Resident’s Condition or Status” indicated the facility should promptly notify the attending physician of changes in the resident’s medical condition or status, which was not followed in this case.
Failure to Perform Hand Hygiene and Proper Glove Use During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to hand hygiene and glove use during incontinence care for one resident. The resident had diagnoses including muscle weakness and hypertension, lacked capacity to make decisions per a recent H&P, and was highly dependent on staff for activities of daily living according to the MDS, requiring extensive assistance for mobility, toileting, and personal hygiene. During an observed care episode, an LVN donned gloves without performing hand hygiene, opened the resident’s soiled diaper, cleaned the pubic area with a towel, turned the resident, and cleaned the buttocks with another towel, placing the used towels on the resident’s bed. Without changing gloves or performing hand hygiene, the LVN then placed a clean diaper on the resident, covered the resident with a blanket, and touched the resident’s knees with the same contaminated gloves. In a concurrent interview, the LVN acknowledged not washing or sanitizing her hands before putting on gloves, not removing the used/dirty gloves prior to placing the clean diaper, and not performing hand hygiene after cleaning and before further contact with the resident. The LVN stated she should have washed or sanitized her hands prior to putting on gloves and before cleaning and touching the resident, and recognized that not doing so could lead to infections, including urinary and wound infections that could result in hospitalization. Review of the facility’s hand hygiene policy and hand hygiene table showed that staff are required to perform hand hygiene before applying and after removing PPE, including gloves, and before performing resident care procedures, which was not followed in this instance.
Failure to Maintain Functional Privacy Curtains in Shared Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide functional ceiling-suspended privacy curtains in shared resident rooms, resulting in a lack of full visual privacy for two residents. For Resident 1, review of the admission record showed diagnoses including anxiety disorder, paranoid schizophrenia, muscle wasting and atrophy, and lack of coordination. A History and Physical dated 10/9/2025 documented that Resident 1 did not have capacity to understand and make decisions, while an MDS dated 10/16/2025 indicated the resident usually could understand and be understood and required partial/moderate assistance with ADLs such as toileting hygiene, showering, lower body dressing, transfers, and walking. During an observation and interview on 2/10/2026 at 1:50 p.m., CNA 1 stated that Resident 1’s curtain was short, did not close completely, and did not provide enough privacy, allowing another resident to walk in and see the resident being changed. CNA 1 stated the short curtain could not offer full privacy and that it was the facility’s responsibility to ensure full privacy. For Resident 2, the admission record showed diagnoses of muscle weakness and hypertension, and an H&P dated 5/23/2025 indicated the resident did not have capacity to understand and make decisions. An MDS indicated Resident 2 usually was able to understand and be understood and was dependent for ADLs including eating, personal hygiene, toileting hygiene, showering, dressing, footwear, and transfers. During an observation and interview on 2/11/2026 at 1:18 p.m., LVN 2 reported that Resident 2’s curtain was shortened, did not provide enough privacy, and that the curtain strings appeared tangled; LVN 2 did not know how long the curtain had not been functional and stated that not having full privacy with the curtain placed the resident at risk of being exposed to other residents. Review of the facility’s policy titled “Resident Rooms,” dated 1/2025, showed that resident bedrooms must be designed and equipped for comfort and privacy and that all resident bedrooms will be equipped to assure full visual privacy, including ceiling-suspended curtains extending around each bed in non-private bedrooms. The observed conditions for Residents 1 and 2 did not meet this policy requirement.
Failure to Meet Professional Standards in Medication Administration
Penalty
Summary
The facility failed to meet professional standards in the preparation and administration of medications for three of five sampled residents. In one instance, a nurse prepared all of a resident's medications in a single cup and provided them without identifying the medications, despite the resident's request for information. The resident, who had moderate cognitive impairment and required assistance with activities of daily living, reported that nurses never informed her about the medications she was given. Another resident, also with moderate cognitive impairment and dependent on staff for daily activities, received all medications in a plastic cup without explanation from the nurse. The nurse acknowledged that medications should be administered one at a time and that it was the resident's right to know what medications were being given. The resident confirmed that nurses did not explain the medications and expressed that it was his right to be informed about what he was taking. A third resident, who had cognitive impairment and was dependent on staff, received all medications crushed together in a plastic bag and administered via gastrostomy tube. The nurse stated that he typically crushed all medications together and was unaware of the facility's policy regarding separate crushing. The nurse also acknowledged that medications should be administered separately to identify any adverse reactions. The facility's policy indicated that medications should be administered by licensed nurses in accordance with professional standards and that the purpose of medication administration should be explained.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents. In one instance, a resident's bathroom wall had black and red spots, and the bathroom door panel was damaged. The resident reported that the maintenance supervisor had been notified about the broken door two weeks prior, but no repairs had been made. The resident stated that the broken door panel posed a safety risk, as it had previously caused injury to his foot. Housekeeping staff confirmed the door had been broken for several weeks and that the issue was not documented in the maintenance repair book. The housekeeping supervisor acknowledged the risk of injury and stated that it was the facility's responsibility to ensure resident safety. In another instance, a resident's toilet seat cover was observed to be broken in half. The maintenance supervisor agreed that the toilet seat should have been fixed to maintain a safe and homelike environment. Housekeeping staff observed the broken toilet seat the previous day but did not document it in the maintenance book or inform the maintenance supervisor. The certified nursing assistant stated that a broken toilet placed the resident at risk for skin injuries and falls. The director of nursing confirmed that the facility must keep bathrooms, doors, toilet seats, and walls in good condition to provide a safe environment. Facility policies reviewed indicated that the maintenance department is responsible for keeping the building in good repair and free from hazards.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were administered psychotropic drugs without adequate justification or in a manner that could limit their functional abilities. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Complete and Retain Staff Background Checks
Penalty
Summary
The facility failed to complete and retain documentation of background reports for five out of six sampled staff members, including registered nurses, licensed vocational nurses, a treatment nurse, and a certified nursing assistant. During interviews and record reviews, it was found that several employee files lacked background check documentation, with some background checks either missing, incomplete, or conducted years after the staff member's hire date. In some cases, background reports were still processing or had not been printed and reviewed once completed. The Director of Staff Development (DSD) confirmed that background checks should have been completed upon hire and that missing documentation was partly attributed to a change in facility ownership, during which some records were misplaced. The Director of Nursing (DON) stated that it was the responsibility of the Human Resources Department or the DSD to ensure background checks were completed for newly hired nurses. Both the DSD and DON acknowledged that background checks were necessary to confirm staff eligibility to provide care and to ensure resident safety. The facility's policy and procedure required background checks and verification of employment eligibility status to be conducted in accordance with established policies, but these procedures were not consistently followed, resulting in incomplete or missing background check documentation for multiple staff members.
Failure to Maintain Proper Head of Bed Elevation During G-Tube Feeding
Penalty
Summary
A deficiency occurred when a resident receiving gastrostomy tube (G-tube) feeding was observed lying in bed with the head of bed (HOB) at a 20-degree angle, which was below the required 30-45 degree elevation specified in the facility's policy and the resident's care plan. The assigned LVN confirmed that the HOB was lower than the required angle during the feeding. The resident was receiving Glucerna 1.2 at 60 cc per hour via G-tube at the time of observation. The resident had a medical history including chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis following a stroke, and aphasia. The care plan and physician orders both specified that the HOB should be elevated at least 30-45 degrees during and for at least one hour after tube feeding to reduce the risk of complications. The facility's policy also required staff to be trained and competent in enteral feeding safety precautions, including maintaining proper HOB elevation. Despite these requirements, the resident was not positioned as directed during the feeding.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Supervise and Secure Exit for Elopement Risk Resident
Penalty
Summary
A facility failed to ensure the safety and adequate supervision of a resident with a known risk for elopement and multiple complex medical and psychiatric diagnoses, including paranoid schizophrenia, COPD, hypertension, and epilepsy. The resident had a documented history of exit-seeking behavior, restlessness, agitation, and impaired cognition, and required supervision for activities of daily living and ambulation. Despite these risks, the resident was able to leave the facility through an unlocked and disarmed exit door without staff noticing, as there was no staff present in the hallway at the time and the door alarm had not been activated as required by facility policy and the resident's care plan. The lack of communication among staff and the interdisciplinary care team contributed to the deficiency. The social services director was aware of the resident's prior elopement attempts and exit-seeking behaviors, as reported by the responsible party, but this information was not shared with the care team or nursing staff. As a result, the care plan interventions for elopement risk were not effectively communicated or implemented. Licensed nurses and other staff members were not made aware of the resident's specific risks, and shift huddles intended to communicate such information were not conducted. Staff assigned to the resident did not read or were not informed of the care plan interventions, and did not provide the necessary supervision or monitoring. Additionally, there were no systems in place to ensure that exit door alarms were armed at the required times, and staff were not consistently checking or activating the alarms. Multiple staff members, including licensed nurses and supervisors, did not verify the status of the alarms or ensure that the environment was secure, as required by both facility policy and the resident's care plan. This failure to supervise, communicate, and implement safety measures resulted in the resident eloping from the facility and subsequently being found deceased off the premises.
Failure to Maintain Cleanliness in Shower Room and Toilet
Penalty
Summary
The facility failed to implement proper infection control practices by not ensuring that the shower room and toilet were cleaned after use. During an observation in Building A Shower Room B3, the shower floor was found to be wet, and staff interviews confirmed that the floor should have been dry and cleaned after use to prevent cross-contamination. Maintenance staff and a CNA acknowledged that leaving the floor wet and dirty linen on the floor posed infection control risks. The Director of Nursing also stated that a wet floor could lead to mold and respiratory issues among residents. Additionally, the toilet in the same shower room was observed to contain yellow and brown fluid and lacked a lid, which was confirmed by both the Maintenance Supervisor and the DON as being dirty and inappropriate for resident use. The facility's own policies and procedures require routine cleaning of environmental surfaces and maintaining a clean, homelike environment, but these were not followed in this instance.
Failure to Maintain Safe and Comfortable Resident Equipment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents by not ensuring that essential equipment such as Geri chairs and shower chairs were in good repair. Observations revealed that six out of eight Geri chairs in Building A were either broken or had ripped upholstery, with issues including missing cushions, broken footrests, handrests, and backrests, as well as exposed padding, wood, and metal parts. Two out of eight shower chairs were also found to be broken or ripped, with missing or damaged seat pads and backrests. These deficiencies were confirmed through interviews with the Maintenance Supervisor, who acknowledged the need for repairs to ensure resident comfort and safety. Further interviews with the DON confirmed that the damaged equipment compromised resident comfort and posed a risk of skin injury. Review of the manufacturer's manual for the Geri chair indicated the need for regular inspection and replacement of damaged parts, while the maintenance job description and facility policy emphasized the importance of maintaining equipment for resident safety and comfort. The facility's failure to adhere to these guidelines resulted in an environment that was not safe or comfortable for residents.
Failure to Monitor Effectiveness of Rash Treatment per Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident by not monitoring the effectiveness of treatment for the resident's rash. The resident, who had diagnoses including metabolic encephalopathy and type 2 diabetes mellitus, was cognitively intact and required supervision or assistance with activities of daily living such as upper body dressing and personal hygiene. The care plan specifically directed staff to monitor the effectiveness of the rash treatment and to notify the physician as needed. A review of nursing progress notes after the care plan was established showed no documentation that nurses monitored the effectiveness of the rash treatment. During interviews and record reviews, the Director of Nursing confirmed that there was no supporting documentation to indicate that the required monitoring had occurred, as outlined in the resident's care plan. Facility policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed in this instance.
Failure to Timely Reassess Pain After Administration of Pain Medication
Penalty
Summary
The facility failed to provide effective pain management for one resident by not reassessing the resident's pain in a timely manner after administering Hydrocodone-Acetaminophen (Norco) on two separate occasions. On one occasion, the nurse reassessed the resident's pain approximately five hours after medication administration, rather than within the expected timeframe. On another occasion, there was no documentation that the resident's pain was reassessed at all after receiving the medication. The facility's policy required pain to be reassessed and documented with adequate detail to gauge the effectiveness of interventions. The resident involved had diagnoses including metabolic encephalopathy and type 2 diabetes mellitus, and was cognitively intact, requiring some assistance with activities of daily living. The resident reported receiving pain medication but stated that no nurse returned to check if the medication was effective. Review of the medical record and interviews with the Director of Nursing confirmed that pain reassessment was either delayed or not documented, contrary to facility policy.
Failure to Document PRN Pain Medication Administration
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to document the administration of Hydrocodone-Acetaminophen (Norco) for a resident who was cognitively intact and required some assistance with activities of daily living. The resident, who had diagnoses including Metabolic Encephalopathy and Type 2 Diabetes Mellitus, reported receiving a dose of Norco around 9 a.m. on the specified date. Upon review, the LVN confirmed administering the medication but did not document it at the time, stating that he became occupied with another resident and forgot to complete the documentation. The facility's policy and procedure for medication administration required that medications be administered by licensed nurses as ordered and that the Medication Administration Record (MAR) be signed immediately after administration, ensuring the six rights of medication administration, including right documentation. The Director of Nursing confirmed that nurses are expected to document medication administration immediately after giving the medication to prevent errors.
Lack of Refrigeration for Resident Food from Visitors
Penalty
Summary
The facility failed to provide a refrigerator for the storage of residents' food brought in by visitors, resulting in staff disposing of leftover food that required refrigeration. Interviews with the Dietary Supervisor and Infection Preventionist confirmed that there was no dedicated refrigerator available for residents' personal food items, and that per facility policy, only shelf-stable foods could be stored at the resident's bedside. Foods needing refrigeration were discarded if not consumed immediately, as there was no appropriate storage option available. The facility's policy indicated that staff would determine if food items were shelf stable and could be stored in the resident room or under refrigeration, but in practice, the lack of a refrigerator led to the disposal of perishable foods.
Failure to Implement Infection Control Measures and Precautions
Penalty
Summary
The facility failed to implement and maintain infection control measures for multiple residents, specifically by not applying Enhanced Barrier Precautions (EBP) for twelve residents who met the criteria due to the presence of indwelling medical devices such as gastrostomy tubes, open wounds, or multidrug-resistant organisms (MDROs). Observations revealed that there was no signage or personal protective equipment (PPE) available outside the rooms of these residents, and the Infection Preventionist (IP) confirmed that EBP was not being used for any residents, despite facility policy requiring it for those with certain risk factors. Documentation reviews for each affected resident confirmed the presence of conditions necessitating EBP, yet the required precautions were not in place. The facility also failed to maintain and implement a water management system designed to reduce the risk of Legionella and other opportunistic pathogens. The Maintenance Supervisor was unable to provide records of the water management plan or documentation describing the facility's water system, and the IP had not participated in any water management activities, despite being listed as a team member in the facility's policy. The policy required regular verification of the system's implementation and annual evaluation of its effectiveness, but there was no evidence these activities had occurred. Additional infection control lapses were observed, including an incident where a resident with moderate cognitive impairment ate food from another resident's partially consumed tray left on a hallway food cart. Staff interviews confirmed that residents should be monitored to prevent such occurrences, but monitoring was not consistently in place. Furthermore, a Treatment Nurse did not perform hand hygiene between glove changes while providing wound care to a resident with a Stage 4 pressure ulcer, contrary to facility policy and best practices. The nurse acknowledged the lapse and its potential to introduce bacteria during wound care.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain proper informed consent prior to administering psychotropic medications to multiple residents. In several cases, residents who lacked the capacity to make medical decisions were either asked to provide consent themselves or did not have a legally authorized representative involved in the consent process. For example, one resident with severe cognitive impairment and no listed emergency contact or next of kin was administered antipsychotic, antidepressant, and anticonvulsant medications after the facility obtained consent directly from the resident, despite documentation indicating the resident could not understand or make decisions. The Social Services Director and Director of Nursing both confirmed that the resident should not have been consenting and that a conservator should have been appointed to make such decisions. Another resident with an appointed Public Guardian (PG) received multiple psychotropic medications without the facility obtaining informed consent from the PG. The consent forms for these medications were incomplete, lacking documentation of who provided consent and the date it was obtained. The DON acknowledged that the PG was not given the opportunity to make an informed decision regarding the resident's care, as required. Additionally, a resident with severe cognitive impairment and no current emergency contacts had an outdated psychotropic consent form that was not renewed every six months as required, and a new consent was not obtained when a new medication order was placed. Further deficiencies included a resident who received a monthly antipsychotic injection without any signed or completed informed consent form, and another resident whose consent form for an antipsychotic medication was incomplete, missing the resident's name, date, and verification that consent was obtained. In each of these cases, facility staff acknowledged the failures to properly document and obtain informed consent, as required by facility policy and procedure. These actions resulted in residents or their representatives not being fully informed or able to make decisions regarding the use of psychotropic medications.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy and completeness of Minimum Data Set (MDS) assessments for five residents, resulting in the transmission of inaccurate data to CMS and the potential for unmet care needs. For one resident with end stage renal disease and dependence on hemodialysis, the MDS did not accurately reflect the resident's therapeutic diet or the presence of a Permacath for dialysis, despite clear documentation in the medical record and direct observation. The MDS nurse acknowledged these inaccuracies and confirmed that the assessment should have included these details, as the MDS guides the resident's care plan. Another resident with chronic obstructive pulmonary disease, diabetes, and depression was assessed in the MDS as preferring English and not needing an interpreter, even though the resident primarily spoke Cantonese and used a communication board with Cantonese translations. Interviews with the resident, family, and staff revealed that the resident preferred Cantonese and had difficulty communicating in English, but this was not verified or accurately documented in the MDS. Similarly, a resident whose preferred language was Korean was documented in the MDS as not needing an interpreter, but interviews revealed that staff communicated with the resident in English or Spanish, which the resident did not understand well, and no interpreter or translation services were used. Additional deficiencies were found in the assessment of oral and dental status. One resident was documented in the MDS as having no oral or dental issues, despite not having natural teeth and using dentures, which the resident reported as loose and difficult to use during meals. Another resident was also incorrectly assessed as having no dental issues, even though observation confirmed the absence of natural teeth. The facility's policies required comprehensive and accurate assessments, including direct observation and communication with residents, but these were not followed, leading to inaccurate MDS documentation.
Failure to Revise and Update Care Plans After Changes in Resident Condition
Penalty
Summary
The facility failed to review and revise care plans for three residents following significant changes in their conditions or care needs. For one resident with a history of depression, schizophrenia, and bipolar disorder, the care plan addressing fall risk was not updated after the resident experienced an unwitnessed fall resulting in minor injuries. The Director of Nursing confirmed that the care plan should have been revised with additional interventions to guide staff in preventing further falls and injuries. Another resident, diagnosed with dementia, stroke, aphasia, and hemiplegia, did not have quarterly Interdisciplinary Team (IDT) meetings as required, nor was an IDT meeting held after the resident was sent to a general acute hospital due to bleeding gums. The Social Services Designee acknowledged that the absence of regular and post-hospitalization IDT meetings led to a year-long delay in care plan revision, re-evaluation, and implementation, excluding input from the IDT and the resident’s responsible party or public guardian. A third resident, with diagnoses including bradycardia, syncope, hypertension, and major depressive disorder, had a care plan that was not updated to reflect the use of a new continuous cardiac monitor device after returning from a cardiovascular appointment. The care plan continued to focus on routine heart rate assessments without addressing the specific interventions required for the new device. Both the Licensed Vocational Nurse and the Director of Nursing confirmed that the care plan should have been revised to include the updated interventions related to the cardiac monitor.
Failure to Provide and Implement Restorative Services for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide appropriate services to maintain or improve range of motion (ROM) and mobility for four residents with limited ROM and mobility needs. For one resident with a history of stroke and hemiplegia, the facility did not implement the recommendations from a Joint Mobility Assessment for Restorative Nursing Aide (RNA) services, nor did they develop or implement a care plan addressing the resident's risk for activities of daily living (ADL) decline and stroke diagnosis. This resident was observed to be non-verbal, dependent on staff for all ADLs, and positioned in bed with bent limbs, but had no orders or documentation for PT, OT, or RNA services after initial evaluations were ordered. The Director of Rehabilitation (DOR) confirmed that RNA services were recommended but not provided, and the Minimum Data Set Nurse (MDSN) acknowledged the absence of required care plans for stroke and ADL decline. Another resident with severe cognitive impairment and non-traumatic brain dysfunction was not ordered RNA services, despite requiring moderate assistance for ADLs and bed mobility. The resident was observed in bed and, according to their representative, had not received PT or RNA services and was experiencing decline. The DOR stated that the resident was not placed on RNA services due to age and cognitive limitations, but also acknowledged that these were not valid reasons per facility policy, and that such residents should receive RNA therapy to prevent further decline. A third resident with multiple sclerosis, encephalopathy, and a stage four pressure ulcer had severe joint mobility limitations but was not receiving PT, OT, or RNA services. The DOR stated that ROM exercises were withheld due to the presence of wounds, but the wound specialist confirmed there was no directive to restrict ROM. The DOR admitted that a collaborative plan should have been developed. Additionally, a fourth resident with osteoarthritis and encephalopathy did not have RNA services resumed after readmission from a hospital stay, despite previous orders for ambulation with a walker. The DOR and RNA staff confirmed that RNA services were not restarted, and the DON stated that residents are re-evaluated for services upon readmission, but nursing staff were not responsible for notifying rehabilitation. Facility policies reviewed indicated that residents should receive restorative services as needed to prevent decline in ROM.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for three of five sampled residents, resulting in multiple deficiencies. For one resident with osteoarthritis and psychosis, staff did not ensure the call light was within reach or that the resident was wearing non-slip footwear, as required by the fall risk care plan. Observations showed the call light was disconnected and placed out of reach, and the resident was seen getting out of bed without assistance and with bare feet, despite being at risk for falls. Staff interviews confirmed awareness that the call light should have been accessible and that the resident required supervision and appropriate footwear to minimize fall risk. Another resident with schizophrenia and bipolar disorder experienced an unwitnessed fall, but the facility did not conduct an Interdisciplinary Team (IDT) meeting within 24 hours as required by facility policy. The resident was found on the floor with minor injuries after attempting to use the restroom while not fully awake. The Director of Nursing acknowledged that the IDT meeting, which is intended to review the incident and develop preventative interventions, did not occur, leaving the resident at risk for repeat falls. A third resident with diabetes, congestive heart failure, and dysphagia was observed taking and consuming food from another resident's tray on a food cart in the hallway. This resident was on a mechanical soft diet due to swallowing difficulties and was at risk for aspiration. Staff confirmed that the resident's care plan required monitoring during meals and that eating from another tray posed a choking and infection risk. The food cart was accessible, and staff acknowledged that it should have been secured to prevent residents from accessing inappropriate food.
Failure to Provide Ordered PT/OT Evaluations and Rehabilitative Services
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services as required for two residents, resulting in a year-long delay in the initiation of physical therapy (PT) and occupational therapy (OT) evaluations that were ordered by physicians. For one resident with diagnoses including dementia, stroke, aphasia, and hemiplegia, there was no evidence of a formal PT or OT evaluation or restorative nursing assistant (RNA) services after the initial order. The resident was entirely dependent on staff for activities of daily living (ADLs) and was observed to be non-verbal and positioned in bed with bent limbs. Care plans did not address the resident's stroke diagnosis or risk for ADL decline, and the Director of Rehabilitation acknowledged that the resident should have received a formal evaluation and RNA services to maintain functional status. Another resident with encephalopathy, multiple sclerosis, and a stage four pressure ulcer also did not receive the ordered PT and OT evaluations. The resident had severe joint mobility limitations and was dependent on staff for all ADLs. Despite a physician's order for therapy evaluations, only a Joint Mobility Assessment was performed, which the Director of Rehabilitation later stated was not a substitute for a full PT or OT evaluation. The resident confirmed not receiving therapy services, and medical records supported the absence of formal evaluations or RNA services. Facility policies required that residents with limitations in range of motion be referred to therapy for focused assessment and that specialized rehabilitative services be provided as indicated by comprehensive assessment and care plans. The failure to conduct the ordered evaluations and implement appropriate care planning for both residents was confirmed through interviews, record reviews, and direct observation.
Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for several residents with complex medical and behavioral needs. For one resident with paranoid schizophrenia and a history of aggression, there was no care plan addressing verbal and physical aggression until after an incident where the resident struck another resident. Staff interviews confirmed that aggressive behaviors were known but not care-planned in a timely manner, leaving staff without guidance on interventions to prevent further incidents. Another resident with multiple psychiatric and medical diagnoses, including schizoaffective disorder, diabetes, and atrial fibrillation, was receiving several high-risk medications such as antipsychotics, antidepressants, anticoagulants, and insulin. However, there were no care plans addressing the use of these medications, their side effects, or the necessary monitoring required for each. Staff acknowledged that care plans should have been in place to guide monitoring and interventions for both the medications and the behaviors they were intended to treat. Additional deficiencies included the lack of care plans for residents with refusals of care (such as showering), use of dentures, and for those at risk of decline in activities of daily living (ADLs) due to conditions like stroke or dementia. In each case, staff interviews and record reviews confirmed that care plans were either missing or incomplete, failing to address the residents' specific needs, diagnoses, and required interventions. Facility policies required comprehensive care plans with measurable goals and timetables, but these were not consistently developed or implemented for the affected residents.
Failure to Ensure Resident Rights to Communication, Decision-Making, and Accurate Documentation
Penalty
Summary
The facility failed to complete and timely submit referrals for probate conservatorship for two residents who lacked decision-making capacity and had no responsible party or conservator. Both residents had severe cognitive impairments and were unable to make informed medical decisions, yet their records incorrectly listed them as self-responsible. The Social Services Director (SSD) did not initiate the conservatorship process because the Admission Records were not updated to reflect the residents' incapacity, resulting in a lack of oversight for their medical care and improper notification of changes, including during hospital transfers. Additionally, the facility did not ensure that the Minimum Data Set (MDS) accurately reflected residents' language preferences and need for interpreter services. For two residents, the MDS incorrectly indicated that they did not require an interpreter, despite their limited English proficiency and preference for communication in their native languages. Staff made assumptions about language preferences without verifying with the residents or their families, leading to communication barriers. Staff were also unaware of available interpreter services and had not received training on their use, further impeding effective communication. The facility also failed to provide a communication board for a non-verbal resident with aphasia, despite documentation in the care plan indicating the need for alternative communication tools. The resident was unable to express needs or participate in care planning due to the absence of a communication device. Staff acknowledged the lack of a communication board and recognized that the resident could not receive appropriate assistance without it. Facility policies required the provision of communication aids and staff training, but these were not implemented as needed.
Failure to Provide Dentures and Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident was provided with dentures, which impacted the resident's dignity and ability to chew food. The resident, who had a history of diabetes mellitus, epilepsy, major depressive disorder, and schizoaffective disorder, was documented as edentulous and required set-up assistance with eating and supervision for oral hygiene. Dental assessments indicated a need for full upper and lower dentures, and records showed that dentures were delivered to the facility and signed for by an unknown staff member. However, subsequent assessments and observations confirmed that the resident did not have dentures and remained edentulous. During interviews and observations, the resident expressed embarrassment about her appearance and difficulty chewing food, stating she did not know what happened to her teeth or dentures. The resident reported that staff ignored her inquiries about her missing teeth. Nursing staff, including an LVN, were unaware that the resident was eating a regular diet without dentures and acknowledged that the resident should have been on a mechanical soft diet. The Social Services Director was also unaware that the resident had received dentures and stated that staff should have notified him so the dentures could be added to the resident's inventory and replaced if lost. The facility's policies required staff to promote resident dignity, provide proper denture care, and ensure ongoing oral health assessments. Despite these policies, staff failed to ensure the resident had access to her dentures, did not communicate the loss or absence of dentures to appropriate personnel, and did not adjust the resident's diet to accommodate her edentulous status. This resulted in the resident experiencing embarrassment and difficulty eating, negatively affecting her quality of life.
Failure to Ensure Call Light Accessibility for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that the call light was kept within reach for two residents, both of whom were identified as being at risk for falls. For one resident, who had diagnoses including osteoarthritis and psychosis and required supervision or assistance for mobility, the call light was repeatedly observed to be out of reach—either hanging behind a bedside dresser or disconnected and coiled on the dresser. Staff interviews confirmed that the call light was not accessible, and the resident was observed getting out of bed without assistance to press the call button on the wall, while not wearing appropriate footwear, despite care plan interventions specifying that the call light should be within reach and proper footwear should be used. Another resident, with multiple diagnoses including diabetes, congestive heart failure, osteoarthritis, muscle wasting, and dysphagia, and who was non-ambulatory and used a wheelchair, was also found to have the call light out of reach. The call light was observed hanging behind the head of the bed, inaccessible to the resident, who confirmed she could not reach it and requested assistance. Staff acknowledged that the call light was not within reach and that this prevented the resident from being able to call for help when needed. Review of facility policies indicated that staff were required to ensure call lights were accessible to residents at all times, particularly for those at risk for falls, and that this was to be checked with each interaction in the resident's room. Despite these policies and individualized care plan interventions, staff failed to maintain call light accessibility for both residents, as confirmed by multiple observations and staff interviews.
Incomplete Advance Directive Acknowledgement for Resident with Impaired Cognition
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive Acknowledgement form was accurately completed. Upon review, the resident's admission record indicated a diagnosis of schizoaffective disorder, and the history and physical documented fluctuating capacity to understand and make decisions. The Minimum Data Set assessment showed the resident had moderately impaired cognition and required moderate assistance with activities of daily living. Despite these factors, the Advance Directive Acknowledgement form for the resident was left blank, with no indication of whether the resident had an advance directive or if they wished to formulate one. During an interview and record review, the Social Services Director confirmed that the form was incomplete and acknowledged that the resident had not been given the opportunity to discuss or formulate an advance directive. The facility's policy requires that, upon admission, staff determine if a resident has an advance directive and, if not, offer the opportunity to create one. The failure to complete the acknowledgement form resulted in an inaccurate and incomplete record regarding the resident's preferences for end-of-life care.
Failure to Notify Responsible Parties and Physicians of Resident Changes in Condition
Penalty
Summary
The facility failed to ensure proper notification of a resident's public guardian or responsible party, as well as the resident's physician, when two residents experienced significant changes in condition. In the first instance, a resident with severe cognitive impairment and multiple diagnoses, including dementia and stroke, was transferred to a general acute care hospital due to a change in condition. The resident's admission record incorrectly listed her as self-responsible, and emergency contact numbers were outdated. As a result, no responsible party or public guardian was notified of the transfer. The social services designee acknowledged that the admission record was not updated and that there was no system in place to ensure consistency between the admission record and the resident's medical documentation, leading to a failure to initiate the process for appointing a public guardian. In the second case, another resident with a history of bradycardia, syncope, hypertension, and major depressive disorder had physician orders for continuous heart rate monitoring and specific parameters for physician notification. The resident's heart rate was recorded outside the prescribed parameters on multiple occasions, and the resident was also non-compliant with wearing a cardiac monitor. Despite these significant changes, there was no documented evidence that the physician was notified as required by the care plan and physician orders. Nursing staff confirmed that they did not communicate these changes to the physician, and the director of nursing acknowledged that this failure could have resulted in delayed medical intervention. Facility policy and procedure required prompt notification of a resident's family, representative, or physician in the event of significant changes in condition, refusal of treatment, or transfer to another care setting. The investigation found that these policies were not followed in the cases reviewed, resulting in a lack of timely and appropriate notification to responsible parties and physicians when residents experienced changes in condition or required medical intervention.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
Staff failed to provide adequate care and services to maintain good grooming and personal hygiene for one resident by not keeping the resident's fingernails clean and neat. During observations on two separate occasions, the resident was found to have long fingernails with a black substance underneath. The resident expressed a desire to have his fingernails cut and cleaned. Review of the resident's records indicated he had multiple diagnoses, including schizoaffective disorder, diabetes mellitus, epilepsy, dysphagia, and muscle weakness. The Minimum Data Set showed the resident had intact cognitive skills and required moderate assistance with activities of daily living. Interviews with a CNA and the DON confirmed that it was the responsibility of CNAs to clean and trim residents' fingernails daily, as needed. Both staff members acknowledged the importance of maintaining clean and trimmed fingernails to prevent infection and maintain personal hygiene. Review of facility policies and the CNA job description further confirmed that nail care, including cleaning and trimming, was a required duty for CNAs. Despite these requirements, the resident's fingernails remained long and dirty during the survey period.
Failure to Provide Proper Shift Report Results in Resident Left Soiled and Exposed
Penalty
Summary
The facility failed to ensure proper hand-off or shift report between nursing staff, resulting in a resident being left undressed and covered in feces. During an observation, the resident was found lying in bed, exposed from the hallway, with feces on her body, sheets, and the floor. The resident was dependent on staff for all activities of daily living, including toileting, bathing, dressing, and personal hygiene, and had severe cognitive impairment, as documented in her medical records. The care plan required frequent assistance, keeping the resident clean and dry, and dressing her appropriately. A newly hired CNA assigned to the resident reported not receiving any hand-off or shift report from the charge nurse regarding the resident's behaviors, such as removing her diaper and undressing herself. The CNA stated he had not been trained on caring for residents with such needs and was told by the charge nurse to delay care until after his lunch break, despite the resident's agitation and refusal of care earlier. Facility leadership acknowledged that hand-off reporting was not included in CNA orientation and that communication between charge nurses and CNAs was lacking, especially for new and registry staff. The facility's policy required shift reporting to ensure continuity of care, but this was not followed in this instance.
Failure to Conduct Post-Dialysis Monitoring
Penalty
Summary
The facility failed to ensure that post-dialysis monitoring was conducted for a resident who required hemodialysis. The resident, who had end stage renal disease and was dependent on hemodialysis, was admitted and later readmitted to the facility. Documentation reviews for two separate dates showed that post-dialysis monitoring was not performed after the resident returned from hemodialysis treatments. This was confirmed during an interview with an LVN, who acknowledged that the records did not indicate any post-dialysis monitoring on those dates and emphasized the importance of such monitoring for resident safety. The resident's assessment indicated some cognitive impairment and a need for staff assistance with mobility. The facility's policy required ongoing assessment and oversight before, during, and after dialysis treatments, including monitoring for complications. However, the lack of post-dialysis monitoring and documentation on the specified dates demonstrated noncompliance with this policy.
Failure to Develop Dementia Care Plans for Two Residents
Penalty
Summary
The facility failed to develop individualized care plans addressing dementia for two residents who had been diagnosed with the condition. For one resident, records showed diagnoses of dementia, major depressive disorder, schizoaffective disorder, and mood disorder, with severe cognitive impairment and a need for maximal assistance with activities of daily living (ADLs). Despite these findings, there was no care plan in place to address the resident's dementia diagnosis. The MDS nurse confirmed that a care plan was necessary to create individualized goals and interventions, and its absence put the resident at risk of not receiving care tailored to their dementia-related needs. The Director of Nursing also acknowledged that a care plan should have been developed to guide staff in providing appropriate care for the resident's specific needs. Similarly, another resident with diagnoses including dementia, unspecified psychosis, and major depressive disorder, and who required moderate assistance with ADLs, did not have a care plan addressing dementia. The MDS nurse confirmed that no care plan was in place for this diagnosis, which was necessary to identify concerns and establish goals for behaviors associated with dementia. Facility policy required staff to monitor individuals with dementia for changes in condition and to develop individualized, comprehensive care plans to meet medical, nursing, mental, and psychosocial needs, but this was not done for these two residents.
Failure to Hold Glipizide for Low Blood Sugar Levels
Penalty
Summary
A deficiency was identified when a resident with type 2 diabetes mellitus and hypertension was administered Glucotrol (Glipizide) despite physician orders to hold the medication if blood sugar (BS) levels were less than 120 mg/dL. The resident's medical records indicated moderate cognitive impairment and a need for supervision with eating, as well as maximal assistance with other activities of daily living. The medication order specifically instructed staff to withhold Glipizide for BS readings below the prescribed threshold. Despite these orders, the resident received Glipizide on multiple occasions when their BS was below 120 mg/dL, with documented readings of 118, 119, 103, 115, and 97 mg/dL. During an interview and record review, an LVN confirmed that the medication was administered outside the prescribed parameters and acknowledged that this could further lower the resident's blood sugar. The facility's policy required staff to hold medications for vital signs outside physician-prescribed parameters, but this was not followed in these instances.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that one of five sampled residents was offered a pneumococcal vaccine as required by facility policy. Review of the resident's admission record showed that the resident had been admitted and readmitted to the facility, with diagnoses including chronic obstructive pulmonary disease (COPD) and atrial fibrillation. The resident's Minimum Data Set indicated moderately impaired cognition and a need for supervision or assistance with all activities of daily living except eating. During interviews, the Infection Preventionist confirmed there was no documentation that the resident was educated about or offered the pneumococcal vaccine, despite the facility's policy stating that all residents should be offered this vaccine. The Infection Preventionist acknowledged that the vaccine was intended to protect residents from pneumococcal infections and that the failure to offer it placed the resident at risk. Review of the facility's policy confirmed the requirement to offer the vaccine to all residents.
Failure to Provide Abuse Training to Registry Nurse Prior to Resident Care
Penalty
Summary
The facility failed to provide abuse prevention, identification, and reporting training to a Licensed Vocational Nurse (LVN) prior to the nurse providing direct care to residents. The LVN, who was employed through a nursing agency as registry staff, reported not receiving any abuse training from either the agency or the facility before starting her first shift. During interviews, the Director of Staff Development (DSD) confirmed that there were no records of abuse training for the LVN and acknowledged that the facility did not have a process in place to ensure registry staff received such training prior to working with residents. Further interviews revealed that the Administrator assumed registry staff received abuse training from their agency, but there was no verification or process to ensure this occurred. The facility's policy and procedure on abuse, neglect, and exploitation required new employees to be educated on these topics, but this was not extended to registry staff. As a result, the LVN was unaware of the facility's abuse reporting requirements, placing residents at risk of unreported or unidentified abuse.
Failure to Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident at risk of elopement. The resident, who was admitted with diagnoses including COPD, diabetes mellitus, hypertension, and dementia, was identified as having severely impaired cognitive skills and wandering behavior. Despite an order to monitor the resident's exit-seeking behavior and an Elopement Risk Evaluation indicating a history of attempted elopement, no care plan was created to address this risk. On review, the MDS-LVN confirmed the absence of a care plan for the resident's elopement risk, acknowledging that such a plan was necessary to prevent or minimize the risk of elopement. The Director of Nursing also confirmed that a care plan should have been in place, as indicated by the facility's policy, which requires comprehensive care plans to be developed within seven days of the MDS completion. The lack of a care plan was highlighted when the resident was reported missing from the facility, underscoring the deficiency in addressing the resident's elopement risk.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident at risk of elopement, resulting in the resident leaving the facility unsupervised. The resident, who had a history of elopement and was diagnosed with dementia, was identified as being at risk of elopement in their Elopement Risk Evaluation. Despite this, the staff, including a CNA and an LVN, were not aware of the resident's elopement risk, which contributed to the resident's unsupervised departure from the facility. The resident's Minimum Data Set indicated severe cognitive impairment and wandering behavior, necessitating supervision for safety. However, the CNA assigned to the resident was unaware of the elopement risk and did not provide the necessary supervision. The LVN also did not recognize the resident's risk, as there were no observed exit-seeking behaviors or expressions of wanting to leave the facility. This lack of awareness and communication among staff members led to the resident's elopement. The Director of Nursing acknowledged that the facility was not aware of the resident's elopement risk due to a lack of observed behaviors and information from the previous facility. The facility's policy required staff to assess and manage residents at risk of elopement, but this was not effectively communicated or implemented, resulting in inadequate supervision and the resident's elopement.
Unsafe Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain safe water temperatures in three resident restrooms and one shower room, with temperatures exceeding the maximum limit of 120 degrees Fahrenheit. During observations and interviews, it was found that the water temperature in the restroom of one room was 125 degrees Fahrenheit, while the shared restroom of two other rooms had a temperature of 126 degrees Fahrenheit. Additionally, the shower room in hall 8 had a water temperature of 122 degrees Fahrenheit. These temperatures were confirmed by the maintenance worker, who acknowledged that they were too warm and could potentially cause skin problems and burns to residents. The facility's policy and procedure for safe water temperatures indicated that water temperatures should not exceed 120 degrees Fahrenheit, and maintenance staff were responsible for checking water heater controls and tap water temperatures weekly. Despite this policy, the water temperature logs for December 2024 and January 2025 showed that the temperatures were within the acceptable range of 105 to 120 degrees Fahrenheit, suggesting a discrepancy between recorded and actual temperatures. The administrator confirmed that water temperatures above 120 degrees Fahrenheit were too hot and could harm residents.
Resident's Bathroom Sink Malfunction
Penalty
Summary
The facility failed to provide a safe, functional, and comfortable environment for a resident by not ensuring that the resident's bathroom sink was in working order. The sink lacked hot water and was leaking onto the floor, creating an uncomfortable and potentially hazardous situation. The resident, who was cognitively intact and required supervision for activities of daily living, reported the issue to maintenance staff, who acknowledged that the sink had a missing part and was corroded. Despite the maintenance log indicating that the sink was repaired on the same day it was reported, the specific issues and corrective actions were not documented. The resident expressed discomfort and had to resort to using showers or hand sanitizer instead of the sink. A Certified Nursing Assistant confirmed the lack of hot water and the presence of a leak, as well as an orange-colored stain on the bathroom floor, indicating a prolonged issue. Interviews with the Maintenance Supervisor and the Administrator revealed that the facility's policy required immediate repairs to ensure resident safety and comfort. The Maintenance Supervisor acknowledged the danger of water leaking onto the floor, which could cause slips. The Administrator emphasized the importance of completing repairs daily and ensuring that residents have what they need, highlighting a lapse in maintaining a safe and homelike environment as per the facility's policy.
Failure to Maintain Accurate Contact Information for Resident's Representative
Penalty
Summary
The facility failed to ensure that a resident's responsible party (RP) was able to exercise the resident's rights by not maintaining accurate contact information. The resident, who was diagnosed with Alzheimer's disease, epilepsy, and hypertension, was assessed to lack the capacity to make medical decisions. Despite this, the facility did not have the RP's telephone number on the resident's Face Sheet, which hindered communication regarding the resident's care. The deficiency was further compounded when the resident experienced falls on two separate occasions, and the RP was not notified. Interviews with staff revealed that there was no attempt to contact the RP following these incidents, and the RP was unaware of the resident's condition throughout the year. The facility's Social Services Director acknowledged the absence of the RP's contact information and admitted that no referral was made to the Public Guardian office, which could have appointed someone to make healthcare decisions for the resident. The facility's policy required that a surrogate or representative be informed of a resident's rights and responsibilities when the resident is deemed incompetent. However, the lack of communication and failure to update the resident's Face Sheet with the RP's contact information resulted in the RP being unable to participate in decision-making. This oversight was recognized by multiple staff members, including the Medical Records Director and the Director of Nursing, who noted the importance of having complete contact information readily available.
Failure to Notify Responsible Party of Resident Falls
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident after the resident experienced falls on two separate occasions. The resident, who was diagnosed with Alzheimer's disease, epilepsy, and hypertension, was assessed to have moderately impaired cognition and lacked the capacity to make medical decisions. Despite this, the RP was not informed of the falls that occurred on June 21, 2024, and August 7, 2024, as documented in the resident's Nurses Notes. Interviews with the Licensed Vocational Nurse (LVN) and Registered Nurse (RN) confirmed that no attempts were made to notify the RP, which was against the facility's policy. The Director of Nursing (DON) acknowledged that the RP should have been notified of the resident's falls and that there was a failure to document any attempts to contact the RP. The absence of the RP's telephone number on the resident's Face Sheet was identified as a contributing factor, and the facility staff did not take steps to rectify this issue. The facility's policy requires prompt notification of the resident's physician and representative in the event of a change in the resident's condition, which was not adhered to in this case.
Failure to Assess and Manage Resident's Severe Pain
Penalty
Summary
The facility failed to adhere to its policy and procedure for resident examination and assessment, resulting in a deficiency in the care provided to a resident. The resident, who had a history of urinary tract infection and neuropathy, complained of severe abdominal pain on two occasions. Despite the resident's complaints, the facility staff did not conduct a thorough assessment of the pain or the resident's suprapubic catheter, which was a potential source of the pain. The resident's care plan required staff to assess pain symptoms and provide interventions, but these actions were not documented or performed. The resident experienced severe pain for an extended period, from the night of the first complaint until the afternoon of the following day, when they were finally transferred to a general acute care hospital. The facility's records indicated that the resident was medicated for pain, but there was no documentation of a pain assessment before or after the administration of medication to evaluate its effectiveness. The resident's request to be taken to the hospital was not acted upon promptly, and the facility failed to notify the physician of the resident's condition in a timely manner. Upon arrival at the hospital, the resident was found to have a blocked suprapubic catheter, which was changed, leading to an improvement in their condition. The hospital also diagnosed the resident with sepsis, a serious complication that could have been prevented with timely intervention. Interviews with facility staff revealed that the necessary assessments and interventions were not carried out, and the facility's policies on pain management and resident assessment were not followed, resulting in the resident's prolonged suffering and eventual hospitalization.
Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered by the physician for three residents, leading to a deficiency in care. The facility's staff assignment sheets for September 2024 showed that no treatment nurse was assigned to perform wound care on several dates, leaving residents without necessary treatments. This lack of care was confirmed through interviews and record reviews, where it was found that treatment administration records (TAR) for the residents were blank on multiple days, indicating that wound care treatments were not performed. Resident 83, who was admitted with a Stage 4 pressure ulcer, did not receive the prescribed daily wound care treatments on several occasions. The resident's TAR for August and September 2024 had multiple blank entries, confirming the treatments were not administered. Similarly, Resident 16, who had a sacrum wound, also missed several wound care treatments as indicated by blank TAR entries. The resident's wound assessments showed an increase in wound size, suggesting a lack of proper care and monitoring. Resident 9, who had a sacral Stage 2 pressure ulcer, also did not receive the required daily treatments on several dates. The facility's Director of Nursing (DON) acknowledged that there had been no treatment nurse since April 2024, and that RNs and LVNs were responsible for wound care. However, the DON was unaware of the missed treatments, which could lead to worsening conditions for the residents. The facility's policies required wound treatments to be documented, but this was not adhered to, contributing to the deficiency.
Inadequate Staffing Leads to Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, resulting in inadequate care and medication administration. On multiple occasions, the Direct Care Service Hours Per Patient Day (DHPPD) for Certified Nurse Assistants (CNAs) fell below the required minimum of 2.4 hours, with actual hours ranging from 2.27 to 2.34. Interviews with staff revealed that CNAs were often assigned to care for 20 or more residents, making it difficult to provide timely and quality care. This staffing shortage led to delays in attending to residents' hygiene needs and increased the risk of pressure ulcers and other health issues. The report highlights specific instances where residents did not receive their prescribed medications due to insufficient nursing staff. Resident 65, who had multiple medical conditions including bipolar disorder and diabetes, missed several doses of critical medications such as ziprasidone, gabapentin, and insulin. The resident expressed frustration over the lack of assistance with repositioning and monitoring of colostomy and urostomy bags, which he had to manage himself. Similarly, Resident 8 missed doses of medications for schizophrenia and hyperlipidemia, and Resident 83 did not receive necessary wound care treatments for a Stage 4 pressure ulcer on multiple occasions. The facility's policies and procedures were not adhered to, as evidenced by the failure to administer medications and perform wound care as ordered by physicians. The Director of Nursing acknowledged the staffing issues and the impact on resident care, noting that the facility did not have enough CNAs to provide the required level of care. The report underscores the facility's non-compliance with state regulations mandating a minimum of 2.4 DHPPD by CNAs, which contributed to the deficiencies observed during the survey.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information, including the actual number of hours worked by nursing staff, was completed, current, and posted for two consecutive days. During observations on two separate days, the Direct Care Service Hours Per Patient Day (DHPPD) forms were found to be incomplete, with sections for Actual Total Direct Care Service Hours, Actual Total CNA Direct Care Service Hours, Actual DHPPD, and Actual CNA DHPPD left blank. This lack of information meant that residents, staff, and visitors were potentially unaware of the accurate number of clinical staff available to meet residents' needs. Interviews with the facility's Administrator and the Director of Staff Development (DSD) revealed that the responsibility for calculating and storing DHPPD hours lay with the DSD. However, the DSD admitted that actual hour calculations had not been performed since 2023, and the facility could not provide the DHPPD for 2024 with actual hours calculated. A review of the DHPPD form and instructions from 2019 indicated that the form must be legible, accurate, and complete, with the Director of Nursing or their designee required to review and sign the form at the end of each patient day to verify its accuracy.
Failure to Ensure Resident Privacy During ADL Care
Penalty
Summary
The facility failed to ensure the privacy of residents during Activities of Daily Living (ADL) care, as observed in four cases. Resident 5, who was totally dependent on staff for ADLs and lacked decision-making capacity, was exposed during care because the Certified Nurse Assistant (CNA) forgot to close the privacy curtain. Similarly, Resident 6, who also lacked decision-making capacity and was totally dependent on staff, was exposed during ADL care when the CNA left the privacy curtain open. Resident 7, who was dependent on staff for ADLs and lacked the mental capacity to make medical decisions, was exposed during care due to a broken privacy curtain and an open room door. The CNA acknowledged the need for privacy but cited the broken curtain as an issue. Resident 8, who required partial to moderate assistance with ADLs, was exposed because the CNA did not think to close the privacy curtain during care. The Director of Nursing (DON) confirmed that CNAs are required to close curtains for resident privacy and dignity. The facility's policy on Residents Rights emphasizes the importance of personal privacy, including during medical treatment and personal care. The failure to adhere to these privacy protocols was observed and acknowledged by the staff involved.
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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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