Vintage Faire Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Modesto, California.
- Location
- 3620-b Dale Rd, Modesto, California 95356
- CMS Provider Number
- 555355
- Inspections on file
- 27
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Vintage Faire Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with an anxiety disorder was observed in bed while an open packet of attends and personal hygiene wipes were left on top of a small bedside dresser in plain view. During a concurrent observation and interview, the IP confirmed these items were improperly stored on the dresser and acknowledged this as a dignity issue, noting the resident would not want others to know she was wearing attends. This practice conflicted with the facility’s Resident Rights policy requiring staff to treat residents with kindness, respect, and dignity and to support a dignified existence.
A resident with a gastrostomy tube had a care plan requiring tube feeding with the head of bed (HOB) elevated to 45 degrees during and for thirty minutes after feedings, and physician orders for enteral nutrition via pump at 50 ml/hr every shift. During surveyor observation with the IP, the resident was receiving enteral feeding at 50 ml/hr while the HOB was only 20–25 degrees. The IP confirmed the angle and stated it should be 35–45 degrees, and the DON reported residents should be positioned at least 30 degrees during enteral feedings, noting this resident was at high risk for aspiration pneumonia when not positioned at or above 30 degrees.
A resident with heart failure and sleep apnea was observed receiving oxygen at 3 LPM via nasal cannula without a corresponding physician order in the medical record. A nurse confirmed there was no oxygen order in place, and the DON later learned that a staff member had started the oxygen after the resident requested it, without obtaining a provider’s order. This failure had the potential to negatively affect the resident’s health and well-being, including possible lung and brain damage from unordered, unmonitored oxygen therapy.
A resident kept nine single-serve yogurts on an overbed table for three days after a friend brought them in, and staff did not intervene to ensure proper refrigeration. During observation and interviews, the IP confirmed the yogurts were unrefrigerated, stated they should have been stored in a refrigerator, and acknowledged that staff should have informed the resident that the yogurts required refrigeration. Review of the facility’s resident personal food storage policy showed that outside foods brought by visitors are to be monitored by staff for food safety and stored in a designated facility refrigerator, which did not occur in this situation.
Three residents did not have person-centered care plans developed or implemented for key diagnoses such as hypertension, depression, anticoagulant therapy, stroke, chest pain, and diabetes, despite physician orders and facility policy requiring such plans. Staff confirmed the absence of these care plans, citing factors such as ownership transition and oversight.
A resident with significant neurological and behavioral diagnoses was found with an unexplained bruise and bump on her forehead. Although the injury was assessed and communicated to the physician and responsible party, facility staff did not report the incident to the Department as required by policy and regulation. The DON and staff assumed the injury was self-inflicted without documentation or witness confirmation, and the cause remained unexplained.
Three residents had care plans that were not individualized or updated to reflect their current needs, including missing non-pharmacological pain interventions, lack of personalized ADL and hospice care details, and absent smoking safety measures. Staff confirmed that essential information was not included in the care plans or Kardex, making it difficult to provide appropriate care.
Three residents with contractures did not receive timely therapy evaluations or appropriate contracture management due to failures in communication and follow-up on physician orders. One resident's therapy order for hand braces was not relayed to therapy staff, another resident's order for contracture evaluation was not discussed or acted upon, and a third resident with a hand contracture and pressure ulcer did not receive assessment or intervention for contracture care. These lapses resulted in delays in treatment and missed opportunities for maintaining or improving ROM.
A clinical document related to dialysis care for a resident was incorrectly placed in another resident's electronic health record, despite the second resident not requiring dialysis. This misfiling was confirmed by the ADON, who noted the importance of proper record placement for resident privacy.
Two residents did not receive accurate nursing assessments, as staff failed to properly document reported pain levels and the presence of a pressure ulcer. One resident's weekly evaluation omitted documented pain, while another's assessment did not reflect an observed pressure ulcer on the left thumb. Additionally, a change of condition report was incomplete, lacking accurate wound details and interdisciplinary team input, contrary to facility policy.
A resident with a history of bipolar disorder and developmental delay was not accurately assessed through the PASRR process, as the Level I screening failed to document key diagnoses and did not trigger a required Level II assessment. Staff and the responsible party reported ongoing behavioral issues, medication refusal, and lack of mental health interventions. The MDS Coordinator did not verify or refer the resident for regional center services, and facility policy requirements for PASRR screening were not followed, resulting in missed opportunities for specialized services.
A resident began receiving mirtazapine for depression without a care plan being developed or implemented for 13 days. The DON confirmed that a care plan addressing depression should have been in place to guide care, in accordance with facility policy.
A resident who preferred in-room activities did not receive any one-to-one activity visits or individualized engagement for several months, despite a care plan specifying frequent room check-ins and support for independent leisure choices. The last documented activity was a word search packet, and the Activities Director confirmed the absence of further in-room activities.
A resident with diabetes and multiple wounds did not receive appropriate BG monitoring or treatment, as high BG readings were not reported to the MD and no insulin or diabetic medications were ordered. Nursing staff failed to notify the provider or document interventions for repeated elevated BG results, and physician orders lacked parameters for when to notify the MD. Facility policy required such notifications and documentation, but these actions were not taken.
A resident with hemiplegia and multiple contractures developed a pressure ulcer on the left hand after staff failed to implement preventive interventions, complete timely wound evaluations, and include necessary care plan measures such as splinting and range of motion exercises. The care plan lacked essential interventions for pressure relief and contracture management, and communication gaps prevented the interdisciplinary team and CNAs from being fully informed, resulting in delayed wound healing.
Two residents were found with unsecured smoking materials in their rooms, including one who was receiving O2 via nasal cannula and kept cigarettes and a lighter in her purse without a lock box, and another whose smoking paraphernalia was left unattended on the bed. Staff confirmed these items should have been secured according to facility policy, but proper procedures were not followed.
Two residents experienced significant unaddressed weight loss due to the facility's failure to follow RD recommendations, conduct weekly weights, and accurately document nutritional supplement intake. One resident with a gastrostomy tube did not have their feeding formula adjusted as recommended, while another was not weighed weekly and had incomplete intake documentation, contrary to facility policy.
A resident with a PICC line did not have the clear dressing changed within the required seven-day interval, and the dressing was observed to be ten days old. Nursing staff failed to properly document and initial the dressing change, and there was no care plan in place for the resident's PICC line, despite ongoing orders and infection risks. These actions were not consistent with facility policy or professional standards.
A resident with multiple serious diagnoses and moderate cognitive impairment was not given prescribed pain medication for moderate pain and had no pain regimen in place for severe pain, despite repeated high pain scores. Nursing staff did not communicate with the physician to review or adjust pain management, and facility policy for systematic pain assessment and intervention was not followed.
A resident with diabetes and wound care needs did not receive appropriate blood glucose management due to the absence of physician orders specifying monitoring parameters or instructions for when to notify the physician. Despite repeated high blood glucose readings, nursing staff did not document interventions or notify the physician, and the resident did not receive a diabetic diet or insulin coverage. The physician was unaware of the resident's prior insulin use, and facility policies requiring notification for abnormal blood glucose levels were not followed.
Two CNAs were unable to access or utilize the electronic Kardex to review essential resident care information, resulting in one CNA being unaware of a resident's pressure injury. Both staff members relied on verbal reports rather than the required documentation system, contrary to facility policy and orientation standards. The Director of Staff Development confirmed that daily review of the Kardex is expected to ensure proper care.
A resident with bipolar disorder and developmental delay did not receive appropriate behavioral health services after a psychiatric consult's recommendations were not communicated to the MD or nursing staff, and no follow-up neuropsychology referral or mental health interventions were arranged. The resident continued to display escalating behavioral issues, medication refusal, and social withdrawal, while staff were unclear about responsibilities for coordinating mental health care.
A resident was started on and had dosage increases of multiple psychotropic medications for psychosis and depression, but there was no documented follow-up or assessment by Social Services. Although the Social Services Director reported daily visits, these were not documented, and the DON confirmed that such documentation and assessment are required when psychotropic medications are initiated. This failure to document and follow up did not meet facility policy or regulatory expectations for medically-related social services.
Controlled medication disposal containers were found unsecured, unsealed, and with contents easily accessible in the shared DON and ADON office. The medications inside were not rendered unusable, contrary to facility policy, and both the DON and Pharmacist Consultant acknowledged the risk of unauthorized access and drug diversion due to these lapses.
A resident's amlodipine bubble pack label did not match the current MAR instructions, as the label was not updated with new hold parameters after a physician order change. Nursing staff and pharmacy confirmed that the required 'change in direction' sticker was not applied to the medication packaging while awaiting a new bubble pack, resulting in inconsistent medication directions and a breakdown in established procedures.
The facility did not coordinate hospice care for two residents with serious medical conditions by failing to include hospice staff in IDT meetings and not ensuring hospice documentation was available in the residents' medical records. Hospice care plans and interventions were not integrated into the facility's care plans or physician orders, and staff confirmed that hospice staff were not invited to participate in care planning or meetings.
A resident received influenza and pneumococcal vaccines without documented education on the risks and benefits prior to administration. The Infection Preventionist confirmed that no education was provided or documented, despite facility policy requiring informed consent through discussion before vaccination.
A resident with a history of dementia and other health issues experienced six days of low body temperature, which was not communicated to the MD by the facility staff. The resident was later found unresponsive and transferred to a hospital, where they were treated for sepsis and other critical conditions. Interviews revealed that the facility's process for handling abnormal vital signs was not followed, as staff failed to notify the MD and reassess the resident's condition.
A resident with multiple health issues, including dysphagia and acute kidney failure, was hospitalized for dehydration due to the facility's failure to monitor and document fluid intake. Despite being at risk, there was no physician order for intake and output monitoring, and the facility lacked a standard protocol. Staff interviews revealed inconsistencies in monitoring practices, and the facility's electronic health record system no longer supported I&O monitoring, contributing to the resident's decline.
The facility failed to ensure POLST forms were completed accurately for seven residents, leading to missing contact information, dates, and unverified healthcare agents. One resident's POLST was signed despite her lack of capacity, and another's Advance Directive section was left blank. These omissions risked not honoring residents' medical treatment preferences.
The facility failed to ensure a clean, comfortable, and homelike environment in four rooms. Issues included stained and broken tiles, deep scratches in drywall, a bathroom sink pulling away from the wall, a broken striker plate, and a leaking toilet. These deficiencies were confirmed by the Maintenance Director and the Director of Nurses.
The facility failed to provide necessary care and services for two residents, resulting in poor nail hygiene and missed showers. One resident had long, dirty fingernails and scratch marks, while another had long, untrimmed toenails and missed multiple scheduled showers due to conflicting schedules. Staff acknowledged the importance of maintaining personal hygiene, which was not upheld in these cases.
The facility failed to provide appropriate respiratory care for six residents, including administering oxygen without an order, not posting oxygen safety signage, not providing oxygen at prescribed flow rates, and not changing oxygen and nebulizer tubings as required. These failures were confirmed by staff and had the potential to negatively impact the residents' health and safety.
The facility failed to ensure safe medication disposition practices for 91 residents, with discontinued and discharged medications stored improperly and disposed of without documentation or cosignatory of licensed staff. Interviews revealed a lack of awareness and documentation regarding the destruction of prescription medications, contrary to the facility's policies.
The facility failed to ensure safe medication use and monitoring for three residents, leading to potential adverse consequences. A resident was administered a high-risk blood thinner without proper monitoring, another resident received heart medication against doctor's orders, and a third resident was given duplicate doses of Vitamin D without proper documentation or justification.
The facility failed to ensure safe use and monitoring of psychotropic medications for four residents. Antidepressant and anxiety medications were not monitored for specific symptoms and behaviors, and behavior monitoring was not included in the MAR for documentation by nursing staff. The DON confirmed that care plans were completed by social services, not nursing staff.
The facility failed to ensure safe medication storage practices in three medication rooms and two treatment carts. The Automated Dispensing Device (ADD) was stored in the same room as a hopper used for disposing of body fluids, and the room's temperature log was inconsistently monitored. Undated and unlabeled prescription medications were found in medication rooms and treatment carts, and the medication refrigerator was cluttered with excessive frosting, with insulin products and a vaccine stored in direct contact with the frosted area.
The facility failed to follow physician-prescribed therapeutic diets for three residents, including providing salt packets to a resident with a no-salt order, serving improperly sized food to a resident with dysphagia, and not updating a diet order for a resident trialing a puree liquidized diet.
The facility failed to ensure safe and sanitary food storage practices for 90 residents. Undated and unlabeled food containers, a dirty unit snack/nourishment refrigerator with moldy and expired food, and the absence of a temperature log were observed. The DSS, VPNS, and DON confirmed these deficiencies, which violated the facility's policies and procedures for food safety and storage.
The facility staff failed to maintain accurate medical records for three residents, including undocumented wound care, inaccurate nail care records, and conflicting shower schedules, leading to missed care and services.
The facility failed to promptly accommodate the needs of two residents when call lights were not answered in a timely manner. One resident waited over 20 minutes for assistance with hearing aids, while another resident with bilateral lower extremities missing waited approximately 19 minutes for help to get up and sit in his wheelchair. The Director of Nursing stated that call lights should be answered in less than 5 minutes, but the facility did not adhere to this policy.
The facility failed to develop and revise comprehensive care plans for three residents, including those requiring oxygen therapy and a specialized diet. This lack of documentation was confirmed by staff and could affect the residents' care.
The facility failed to follow professional standards for IV therapy for two residents. One resident's IV tubing lacked a cap, and another resident's PICC line dressing was not changed upon admission as required by physician orders, increasing the risk of infection.
The facility failed to honor food preferences for three residents, leading to potential adverse health effects. One resident who dislikes pasta was served pasta, another with hypertensive heart disease received salt packets, and a third who dislikes rice was served rice. The Dietary Services Supervisor, Registered Dietitian, and Director of Nurses all acknowledged these errors and emphasized the importance of following residents' tray cards.
The facility failed to follow infection control policies by not posting signage indicating the type of transmission-based precautions (TBP) and required personal protective equipment (PPE) needed prior to entering a resident's room. The resident was on contact precautions for a multi-drug resistant organism (MDRO), but no signage was present, increasing the risk of cross-contamination.
Personal Incontinence Supplies Left in Public View Compromising Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity by leaving personal incontinence and hygiene products in public view in a resident’s room. During an observation, a resident was seen in bed while a full open packet of attends and a packet of personal hygiene wipes were stored on top of a small three-drawer bedside dresser, rather than being kept out of sight. The resident’s admission record showed a diagnosis that included an anxiety disorder. In a concurrent observation and interview, the Infection Preventionist confirmed that the attends and personal hygiene wipes were stored on top of the dresser and stated that they should not have been stored there. The Infection Preventionist identified this as a dignity issue, explaining that the resident would not want everyone to know she was wearing attends. The facility’s “Resident Rights” policy, revised 2/21, stated that employees shall treat all residents with kindness, respect, and dignity, and that residents’ rights include a dignified existence.
Improper Head-of-Bed Elevation During Enteral Feeding
Penalty
Summary
The facility failed to ensure proper positioning during enteral feeding for one resident receiving tube feedings. The resident had a gastrostomy tube and a care plan dated 9/22/25 that specified the need for tube feeding with the head of bed (HOB) elevated to 45 degrees during and for thirty minutes after the feeding. Physician orders dated 2/9/2026 directed that enteral nutrition be administered via an enteral pump at a rate of 50 ml/hr every shift. On 3/5/26 at 10:08 AM, during a concurrent interview and observation with the Infection Preventionist, the resident was observed receiving enteral feeding at 50 ml/hr while positioned with the HOB at approximately 20–25 degrees. The Infection Preventionist confirmed the observed HOB angle and stated the resident’s position should be 35 or 45 degrees. In a subsequent interview at 10:21 AM, the DON stated that residents should be positioned at least 30 degrees when enteral feedings are administered and explained that the resident was placed at high risk for aspiration pneumonia if the bed was not at least at a 30-degree angle or greater.
Oxygen Therapy Provided Without Physician Order
Penalty
Summary
The facility failed to ensure a resident received appropriate respiratory care when the resident was provided oxygen therapy without a physician’s order. The resident, who had diagnoses including heart failure and sleep apnea, was observed lying in bed wearing a nasal cannula with oxygen flowing at 3 LPM. A review of the resident’s physician orders on that date did not show any order for oxygen via nasal cannula at 3 LPM. During an interview, a licensed nurse confirmed there was no oxygen order for the resident and acknowledged that an order was required. Further investigation by the DON revealed that the resident had requested oxygen therapy via nasal cannula from a staff member several days earlier, and the staff member provided the oxygen without first obtaining a physician’s order. At the time of the surveyor’s observation, the resident continued to receive oxygen at 3 LPM despite the absence of an order in the medical record. The report states that this failure had the potential to negatively affect the resident’s health and well-being, including possible lung and brain damage related to unordered, unmonitored oxygen therapy.
Failure to Safely Store Visitor-Provided Yogurt for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of food brought in by visitors when a resident had nine single-serve yogurts left on the overbed table for three days. During observation and interview in the resident’s room, the resident reported that a friend had brought the yogurts three days earlier, and the yogurts remained unrefrigerated on the overbed table. In a concurrent interview, the Infection Preventionist confirmed the presence of the nine single-serve yogurts, stated they should have been refrigerated, and explained that staff should have informed the resident that the yogurts required refrigeration. The Infection Preventionist further stated that the yogurts could cause foodborne illness when left at room temperature and could make the resident sick. Review of the facility’s “Resident Personal Food Storage” policy showed that food or beverages brought from outside sources are to be monitored by designated staff for food safety and that outside foods brought in by visitors are to be stored in a facility refrigerator designated for resident use, which did not occur in this case. This failure to follow the facility’s food storage policy and to ensure proper refrigeration of visitor-provided food resulted in a deficiency related to safe storage of resident food items.
Failure to Develop and Implement Person-Centered Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents with significant medical diagnoses. For one resident, there were no care plans addressing hypertension, depression, or anticoagulant therapy, despite physician orders for multiple medications to manage these conditions. This omission was confirmed by a licensed nurse, who acknowledged that care plans should have been in place to guide care and interventions for these health issues. Another resident was admitted with diagnoses including hypertension, chest pain, and a history of stroke, but did not have care plans related to these conditions. Physician orders included medications for stroke prevention, hypertension, and chest pain, yet the care plans did not reflect these needs. The Minimum Data Set Assistant and the Director of Nursing both confirmed the absence of appropriate care plans, attributing the lapse to a transition in facility ownership and acknowledging that care plans should have been updated to reflect the resident's current health status. A third resident, admitted with diabetes and prescribed medications to control blood sugar, also lacked a care plan for diabetes until a significant increase in blood sugar was noted. The Director of Nursing confirmed that a care plan should have been in place to address the resident's diabetes and that the care plan should have included specific interventions for the resident's health concerns. The facility's policy requires a written care plan for each resident at admission, based on a comprehensive assessment, and updated as needed, but this was not followed for the residents in question.
Failure to Report Injury of Unknown Source as Required
Penalty
Summary
The facility failed to report an injury of unknown source to the Department as required by its abuse policy and state and federal regulations. A resident with a history of hemiplegia, hemiparesis, dysphagia, and anxiety disorder was found with an unexplained bruise and bump on the left side of her forehead. The injury was discovered by a CNA and assessed by a licensed nurse, who documented the findings, notified the treatment nurse, physician, and the resident's responsible party, but did not report the incident to the Department. The licensed nurse and the Director of Nursing assumed the injury was self-inflicted due to the resident's history of scratching herself, although there was no documentation or witness to support that the resident had ever hit herself in the head or face. The responsible party confirmed that while the facility regularly communicated about the resident's scratching behavior, she had never been informed of any self-hitting behavior. The facility's own investigation could not determine the cause of the injury, and no staff or resident could explain or had witnessed the event. Despite the facility's policy requiring the reporting of injuries of unknown source, especially those involving the face or head, the incident was not reported to the Department. The Administrator acknowledged that the injury should have been reported and recognized the importance of such notifications for thorough investigation and resident safety. The failure to report denied the Department the opportunity to conduct a timely investigation into the unexplained injury.
Failure to Individualize and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to timely review and revise person-centered comprehensive care plans for three residents, resulting in care plans that were not individualized or updated to reflect the residents' current needs. For one resident with chronic pain, the care plan did not include personalized non-pharmacological interventions to be attempted before administering pain medication. Both a licensed nurse and a certified nursing assistant confirmed that these interventions were missing from the care plan and the Kardex, despite the importance of such measures in potentially reducing the need for medication and its associated side effects. Another resident, admitted under hospice care with multiple diagnoses including atrial fibrillation and a pressure ulcer, had care plans for activities of daily living (ADLs), pressure ulcer management, and hospice services that were not personalized. The care plans did not specify the level of assistance required for ADLs, did not address risk factors or interventions for skin breakdown, and lacked details about hospice agency contacts, visit schedules, and specific tasks. Staff confirmed that this information was not available in the resident's Kardex, making it difficult for them to provide appropriate care. A third resident, who was an active smoker, had a care plan that did not include required interventions such as supervision and the use of a smoking apron during smoking sessions, as indicated by the resident's smoking safety screen. The activity director, assistant activity director, and MDS nurse all confirmed that these interventions were missing from the care plan, which could result in staff being unaware of necessary safety measures. The facility's policy requires care plans to be individualized and accessible to all caregivers, but this was not followed in these cases.
Failure to Provide Timely Contracture Management and Therapy Evaluation
Penalty
Summary
The facility failed to provide timely and appropriate treatment and services to maintain or improve range of motion (ROM) and manage contractures for three residents. For one resident with contractures in both hands and fingers, a physician's order for therapy evaluation for possible brace use was not communicated to the therapy department, resulting in a delay in assessment and intervention. The resident did not receive restorative exercises and was dependent on assistance for daily activities, with no documentation of the therapy order being relayed to the appropriate staff. Another resident with hemiplegia and left-hand contracture had a physician's order for therapy evaluation for a possible brace, but the order was not communicated to the therapy department. As a result, the evaluation was not completed, and the resident did not receive timely assessment or potential treatment to address the contracture. The order was also not discussed during the morning clinical meeting, further contributing to the delay. A third resident developed a pressure ulcer on the left hand due to a contracture, but there was no follow-up with the physician or therapy department regarding contracture management. Staff, including the CNA, were not aware of the contracture, and appropriate devices such as a carrot for hand positioning were not used. The lack of communication and assessment led to missed opportunities for contracture care and prevention of further complications.
Misfiled Dialysis Record Compromises Resident Privacy
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of twenty-seven residents when a clinical document related to dialysis care for a resident who was dependent on dialysis was found in the electronic health record (EHR) of another resident who did not have a diagnosis requiring dialysis. Specifically, a document titled 'DIALYSIS CARE COMMUNICATION COORDINATION' for the resident dependent on dialysis was incorrectly filed in the EHR of a different resident. This error was confirmed by the Assistant Director of Nursing (ADON), who acknowledged that the clinical document was in the wrong resident's record and emphasized the importance of maintaining resident documents in the correct location to ensure privacy.
Inaccurate Resident Assessments for Pain and Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate completion of resident assessments for two sampled residents. For one resident with a history of hemiplegia and secondary bone cancer, nursing staff did not accurately document reported pain levels in the weekly evaluation. Although the resident consistently reported pain on several days, the weekly nurse's evaluation incorrectly indicated no pain during the review period. This discrepancy was confirmed by both the medication administration record and the licensed nurse involved, who acknowledged the inaccuracy. For another resident with hemiplegia and multiple contractures, the weekly nursing assessment failed to document the presence of an unstageable pressure ulcer on the left thumb, despite direct observation and previous progress notes indicating its existence. The licensed nurse confirmed that the assessment was inaccurate for not including the pressure ulcer. Additionally, the change of condition report for this resident was incomplete and inaccurate, as it did not correctly specify the site or description of the pressure ulcer, nor did it include an interdisciplinary team assessment as required. Facility policies reviewed indicated that all areas of assessment forms must be completed without blanks and that assessments must be accurate and conducted by qualified staff. The Director of Nursing confirmed that the expectation is for nursing staff to accurately assess and document all relevant resident conditions, including pain and skin integrity, in both weekly and change of condition evaluations.
Failure to Accurately Complete PASRR Screening for Resident with Mental Disorder and Developmental Delay
Penalty
Summary
A deficiency occurred when the facility failed to accurately complete the Pre-Admission Screening and Resident Review (PASRR) for a resident with a history of bipolar disorder and developmental delay. The resident's Level I PASRR did not reflect his diagnosis of bipolar disorder or his diagnosis of lack of expected normal psychological development in childhood. As a result, a Level II PASRR, which is required for further assessment and potential specialized services, was never completed. The resident's admission records and hospital discharge summary documented his developmental delay and bipolar disorder, but these were not fully captured in the PASRR process. Interviews with staff and the resident's responsible party revealed ongoing behavioral health concerns, including agitation, verbal aggression, medication refusal, paranoia, and social isolation. Staff noted that the resident had escalating behaviors, refused care, and had to be moved to a private room due to his interactions with others. The responsible party and staff expressed concerns about the resident's mental health and the lack of mental health interventions or therapies being provided. The PASRR Level I screening, completed by the MDS Coordinator, marked "no" for questions regarding regional center services and did not accurately reflect the resident's functional limitations or history of substantial disability prior to age 22. The MDS Coordinator acknowledged that the PASRR was not completed accurately and that she had not contacted the local regional center to verify information or refer the resident for services. The Social Services Director confirmed that the resident had a diagnosis of developmental delay at admission and that a referral to the regional center should have been made. Facility policies required PASRR screening for individuals with major mental illness or developmental disabilities, but these procedures were not followed, resulting in the resident not being assessed for or receiving potentially beneficial specialized services.
Failure to Timely Develop and Implement Depression Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan for a resident who was prescribed mirtazapine for depression. The resident was admitted without a diagnosis of depression, but a physician order for mirtazapine to treat depression was entered on 3/26/25. Despite this, a care plan addressing the resident's depression was not initiated until 13 days after the medication was started. During an interview and record review, the DON confirmed that there was no care plan in place for the resident's depression during this period and acknowledged that one should have been developed to ensure appropriate goals and interventions. Facility policy requires individualized care plans to be created based on resident needs and to be accessible to all caregivers, but this was not followed in this instance.
Failure to Provide Person-Centered In-Room Activities
Penalty
Summary
The facility failed to provide activities that met the interests and needs of one resident who preferred in-room activities and did not attend group activities. The resident reported that the last activity provided was a word search packet with crayons and pencils, which occurred several months prior. Review of the resident's care plan indicated a preference for spending time in her room and specified that she should be offered room visit check-ins four times weekly to empower her to make independent leisure choices. However, documentation and interviews confirmed that no one-to-one activity room visits had been provided since the last recorded instance, despite the care plan requirements. The Activities Director acknowledged the lack of person-centered activities and confirmed the gap in service.
Failure to Monitor and Report High Blood Glucose in Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of diabetes mellitus and multiple wounds did not receive appropriate blood glucose (BG) monitoring and management according to physician orders and facility policy. The resident had orders for BG checks four times daily but did not have any diabetic medications or insulin ordered, despite experiencing multiple high BG readings, some as high as 390 mg/dL. There were no parameters in the physician's orders specifying when to notify the provider about abnormal BG readings, and no documentation of nursing interventions or physician notifications for these elevated results. The resident expressed concern about not receiving insulin for high blood sugars, which she had previously managed independently at home and in the hospital. Nursing staff confirmed that high BG readings were recorded but not communicated to the medical doctor, and no interventions were documented. One nurse stated she consulted another nurse about whether to notify the physician but ultimately did not do so. The medical doctor was unaware of the resident's high BG levels and prior insulin use, and acknowledged that notification parameters and treatment orders should have been in place. Facility policy required nurses to notify physicians of BG levels outside the normal range and to document such communications. The Director of Nursing confirmed that high BG trends should have been reported to the physician and that monitoring parameters were necessary for resident safety. The lack of communication and absence of clear monitoring parameters led to the resident's high BG levels not being addressed, despite the known risk of delayed wound healing in diabetic patients.
Failure to Prevent and Properly Manage Pressure Ulcer in Resident with Contracture
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis, and multiple contractures was admitted to the facility and developed a pressure ulcer (PU) on the left hand, specifically between the thumb and index finger. The resident was identified as being at high to moderate risk for skin breakdown based on Braden Scale assessments. Despite this, there was no care plan developed to address the risk of pressure ulcer development for the left contracted hand, nor were interventions such as splinting or range of motion exercises included in the care plan to prevent further contracture or promote healing. When the pressure ulcer was first identified, a wound evaluation was not completed as required by facility policy. The lack of timely wound assessment meant that the interdisciplinary team (IDT) was not made aware of the new wound, as the evaluation is necessary for the wound to appear on the report reviewed during IDT meetings. Additionally, the facility was not conducting IDT meetings for residents with wounds unless there was also weight loss, resulting in no IDT review of this resident's wound. The care plan for the pressure ulcer was also missing key interventions for pressure relief and did not reflect the interventions listed in the Skin & Wound evaluation. Observations and interviews confirmed that the care plan did not include interventions to maintain clean skin or prevent further breakdown, and the contracture care plan lacked range of motion or splinting interventions. The information about wound care and contracture management was not communicated to CNAs via the Kardex, and there was no documentation of discussions with hospice staff regarding the contracture. The hospice nurse also did not include interventions for skin breakdown or contracture prevention in their documentation. These omissions resulted in the development of a pressure ulcer on the resident's left thumb and had the potential to prolong healing.
Unsecured Smoking Materials and Oxygen Use Create Accident Hazard
Penalty
Summary
The facility failed to ensure the safety of 89 residents from accidental hazards related to unsecured smoking materials. One resident, who was receiving oxygen via nasal cannula, kept cigarettes and a lighter unsecured in her purse within her room and did not have a lock box, despite a history of noncompliance with the facility's smoking policy and a signed agreement acknowledging the need to secure such items. The resident expressed a desire to smoke at will and kept her smoking materials accessible, even while on oxygen, which was confirmed during interviews and observations with facility staff and the administrator. Additionally, another resident's room was found to have unsecured smoking paraphernalia, including loose tobacco and an unfilled cigarette wrapper, left unattended on the bed while the resident was not present. Staff interviews confirmed that these items should have been secured, typically in a locked medication cart or at the nurse's station, and that the resident did not have a lock box in the room. The facility's smoking policy required assessment and individualized interventions for safe smoking, including secure storage of smoking materials, but these procedures were not followed for the residents involved.
Failure to Follow Nutrition and Hydration Protocols for Two Residents
Penalty
Summary
The facility failed to meet the nutrition and hydration requirements for two residents, resulting in deficiencies related to significant weight loss and lack of appropriate interventions. For one resident with a gastrostomy tube, the Registered Dietitian (RD) recommended an adjustment to the resident's enteral feeding formula from 1.2 calories per milliliter (ML) to 1.5 calories per ML due to significant weight loss. Despite this recommendation, the resident's orders were not updated, and the resident continued to receive the lower-calorie formula. Multiple staff, including the Licensed Nurse (LN), RD, and Director of Nursing (DON), confirmed that the RD's recommendations were not implemented, leaving the resident at risk for continued weight loss. Another resident experienced significant unplanned weight loss over several weeks, with documented losses exceeding 10% of body weight since admission. The resident was not weighed weekly as required for new admissions and those with significant weight changes. There were gaps in weight documentation, and progress notes did not indicate any attempts to weigh the resident or refusals. The Assistant Director of Nursing (ADON) acknowledged that weekly weights should have been performed and that the RD should have initiated a weekly weight schedule, but this did not occur. Additionally, the resident was prescribed a dietary supplement to be administered daily, with instructions to encourage intake greater than 75%. However, the Medication Administration Record (MAR) did not consistently document the amount consumed, only whether the supplement was given or refused. The RD stated that knowing the exact amount consumed was necessary to assess nutritional intake, and that a weight committee should have been triggered for the resident. Facility policies required comprehensive nutritional assessments and weekly weight monitoring for new admissions and those with significant weight loss, but these procedures were not followed.
Failure to Timely Change and Document PICC Line Dressing and Absence of Care Plan
Penalty
Summary
A resident with a history of diabetes, wound care needs, vascular access management, and chronic infections was admitted with a peripherally inserted central catheter (PICC) in place. The facility failed to change the resident's PICC line clear dressing within the required seven-day interval, as the dressing was observed to be ten days old. Nursing staff acknowledged that the dressing change was not performed as scheduled, and documentation of the dressing change was either missing or incorrectly recorded in the electronic health record. The dressing was also not properly initialed and dated by the nurse who performed the change, contrary to facility policy and professional standards. Further review revealed that there was no care plan in place for the resident's PICC line, despite active physician orders and the resident's ongoing need for parenteral therapy. Interviews with nursing staff, the infection preventionist, and the director of nursing confirmed that the absence of a care plan was not in line with facility expectations or policy. The care plan is intended to guide staff in the safe and appropriate care of the PICC line, including monitoring, interventions, and infection prevention measures. Facility policies and professional guidelines reviewed during the survey emphasized the importance of timely dressing changes, proper documentation, and individualized care planning for residents with central lines. The lack of adherence to these standards in this case resulted in a deficiency related to the safe administration and management of IV fluids and vascular access devices.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple serious diagnoses, including malignant neoplasm of the prostate, hemiplegia, and secondary malignant neoplasm of bone. The resident, who had moderate cognitive impairment, was observed exhibiting nonverbal signs of pain such as grimacing, wincing, and moaning while repositioning in bed. Despite a physician's order for Norco to be administered for moderate pain (pain level 4-6), the resident was not given the medication when his pain was recorded at a level 4. This was confirmed by a licensed nurse, who acknowledged that the medication was not administered as ordered for the documented pain level. Additionally, the resident's pain scores were frequently recorded at 7 or higher over several days, but there was no pain management regimen in place for severe pain (pain level 7-10). Nursing staff did not contact the resident's physician to review or adjust the pain medication orders despite repeated high pain scores. There was also no documentation of any communication with the physician regarding the need for a change in the pain management plan. Facility policy required systematic recognition, assessment, treatment, and monitoring of pain, including collaboration with the physician to develop and revise interventions as necessary. The policy also specified that staff should notify the practitioner if pain was not controlled by the current regimen. These procedures were not followed, resulting in the resident not receiving appropriate pain relief as required by both physician orders and facility policy.
Failure to Provide Blood Glucose Monitoring Parameters and Physician Oversight for Diabetic Resident
Penalty
Summary
A deficiency occurred when the attending physician failed to provide blood glucose monitoring parameters and adequate oversight for a resident with a diagnosis of diabetes. The resident was admitted with a history of diabetes and wound care needs, and her medical record indicated orders for blood glucose checks four times daily. However, there were no specific parameters for managing high or low blood sugar levels, nor were there instructions for when to notify the physician. The resident reported not receiving a diabetic meal or insulin coverage for elevated blood sugars, despite experiencing blood glucose readings significantly above the normal range. Nursing staff confirmed that the resident had multiple high blood glucose readings, including values over 300 mg/dL, but there was no documentation of nursing interventions or physician notification in response to these abnormal results. The medical record and progress notes lacked any assessment or plan of care addressing the resident's diabetes management, and the physician was unaware of the resident's prior insulin use at home or in the hospital. The facility's policies required physician notification for abnormal blood glucose levels, but this was not followed. Interviews with staff, including the DON and the physician, revealed that there was an expectation for nurses to communicate high blood sugar trends and for monitoring parameters to be in place for resident safety. The lack of physician oversight and absence of clear orders for blood glucose management contributed to the resident not receiving appropriate diabetic care, as evidenced by the lack of interventions for high blood sugar and the absence of a diabetic diet or medication orders.
CNAs Unable to Access Resident Kardex, Compromising Individualized Care
Penalty
Summary
Two certified nursing assistants (CNAs) at the facility were found to lack the competency to access and utilize the resident Kardex, a key tool for summarizing and guiding individualized resident care. During observations and interviews, both CNAs, each with approximately one month of experience at the facility, were unable to locate or access the Kardex for their assigned residents using the electronic system. One CNA was unaware that a resident under her care had a pressure injury, stating she relied solely on verbal reports from the charge nurse and had not received information about the resident's condition during shift handoff. Both CNAs confirmed they did not know how to access the Kardex, and one acknowledged that this lack of access would impact her ability to provide proper care. The Director of Staff Development confirmed that CNAs are expected to review the Kardex daily to be aware of resident care needs, and that failure to do so could result in incomplete care and worsening of conditions such as pressure injuries. Facility policy and orientation materials indicated that individualized care plans, including the Kardex, should be accessible to all caregivers and that CNAs are required to use the facility's documentation system as directed. The deficiency was identified through observation, interview, and review of facility records and policies.
Failure to Provide Behavioral Health Services and Follow-Up for Resident with Mental Health Needs
Penalty
Summary
The facility failed to provide appropriate behavioral health treatment and services to a resident with a history of bipolar disorder and developmental delay. The resident had a psychiatric consult via telehealth, which included recommendations for a neuropsychology referral and continued assessment of psychotropic medications. However, these recommendations were not communicated to the medical doctor or licensed nursing staff, and no evidence was found that the orders were transcribed or acted upon. The medical doctor was unaware of the psychiatric consult and its recommendations, and the social services department did not arrange for the recommended neuropsychology referral. The resident exhibited escalating behavioral issues, including anger, verbal aggression, medication refusal, and social withdrawal. Staff interviews confirmed that the resident was refusing care and medications, had become more aggressive, and was isolated in a private room due to his behaviors. Despite a physician's order for a psychiatric evaluation and adjustment of treatment, there was no documentation that the evaluation occurred as ordered, and staff were unclear about who was responsible for scheduling and following up on mental health consults. The telehealth psychiatric service was not effectively coordinated, and there was a lack of communication between nursing, social services, and the medical provider. Facility policies indicated that social services should arrange for needed mental and psychosocial counseling and that behavioral health services should be person-centered and coordinated. However, interviews with staff revealed confusion about roles and responsibilities, with both nursing and social services staff unaware of the resident's psychiatric consult orders or the need for follow-up. As a result, the resident's psychosocial needs were not met, and recommended mental health interventions were not provided.
Lack of Social Services Follow-Up After Psychotropic Medication Initiation
Penalty
Summary
The facility failed to ensure the psychosocial well-being of a resident when there was no documented evidence of Social Services following up after the initiation and dosage increases of three separate psychotropic medications. The resident, who was admitted with diagnoses including hypo-osmolality and hyponatremia but no psychiatric diagnoses, was prescribed brexpiprazole and aripiprazole for psychosis, as well as mirtazapine for depression. Despite these significant medication changes, there was no documentation of Social Services assessments or follow-up in the resident's clinical record. Interviews with the Social Services Director revealed that although she visited residents daily, she did not document these visits. The DON confirmed that Social Services should be informed and conduct assessments when psychotropic medications are initiated, and that documentation is necessary for team discussions and care planning. Facility policy also requires the social worker to obtain a comprehensive history and conduct assessments related to psychotropic use, including family interviews and identification of causal factors for behaviors. The lack of documentation and follow-up by Social Services constituted a failure to provide medically-related social services as required.
Failure to Secure and Render Unusable Controlled Medication Disposal Containers
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements for the safe disposition and destruction of controlled prescription medications. During an observation in the shared DON and ADON office, two controlled medication disposal containers were found on top of a file cabinet. These containers were not secured, not sealed, and the contents were easily accessible by hand. The medications inside the containers were not rendered unusable, and pills could be seen and identified. Both the Pharmacist Consultant and the DON acknowledged that the containers were not securely sealed and that the medications could be accessed or removed, which was not in accordance with facility policy. A review of the facility's policies indicated that drugs should be destroyed in a manner that renders them unfit for human consumption, and that sealed containers must be maintained in a secure area until transferred to a waste disposal service. The policies also required that a substance be added to render medications unusable. The DON confirmed that these procedures were not followed, and that the unsecured, unsealed containers with accessible medications posed a risk of unauthorized access and drug diversion.
Failure to Update Medication Labeling for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that medication labeling practices were accurately followed for a resident prescribed amlodipine, a blood pressure medication. During a medication administration observation, it was found that the label on the resident's bubble pack for amlodipine did not match the current Medication Administration Record (MAR). The bubble pack label instructed staff to hold the medication if the resident's systolic blood pressure (SBP) was greater than 110 mm Hg, while the MAR correctly indicated to hold the medication if the SBP was less than 110 mm Hg. This discrepancy was confirmed during interviews and record reviews with nursing staff, who acknowledged that the label should have been updated to reflect the new physician order and that the process for addressing such discrepancies was not followed. Further investigation revealed that the pharmacy had sent a fax to the facility to clarify the order and received the corrected hold parameter from the facility. However, due to insurance constraints, a new bubble pack with the correct label could not be sent immediately. The pharmacy's established process required the facility to place a 'change in direction' sticker on the existing bubble pack to alert staff to the updated order, but this step was not taken. Both the consultant pharmacist and pharmacy supervisor confirmed that the failure to apply the sticker represented a breakdown in the process and could have led to medication administration errors. A review of the facility's policies indicated that staff are required to reconcile medication labels with current orders, communicate any changes to the pharmacy, and use a 'change in direction' sticker when waiting for updated packaging. The failure to follow these procedures resulted in the medication label remaining inconsistent with the MAR and the physician's order, creating the potential for the resident to receive the medication incorrectly.
Failure to Coordinate Hospice Care and Documentation for Two Residents
Penalty
Summary
The facility failed to develop and implement a coordinated plan of care with hospice services for two residents who were admitted under hospice care, one with hypertensive heart disease and the other with vascular dementia. The facility did not invite or include hospice staff in the interdisciplinary team (IDT) meetings for either resident, and there was no documentation that hospice staff were informed of or attended these meetings. The IDT assessments and progress notes for both residents did not specify the hospice services being provided or the name of the hospice agency involved. Additionally, the facility did not ensure that hospice agency documentation, such as nurse progress notes, IDT notes, and plan of care updates, were available in the residents' facility medical records. For both residents, there were no hospice orders in the physician orders for the relevant months, and hospice care plan interventions were not transferred into the facility's care plans or physician orders. Staff interviews confirmed that hospice documentation was missing from the residents' records and that the process for sharing and integrating hospice information was not followed. Facility staff, including the MDS nurse, Social Service Director, and DON, acknowledged that hospice staff had not been invited to IDT meetings and that hospice documentation was not consistently incorporated into the residents' records. The hospice nurse also confirmed she had not been contacted or invited to participate in care conferences and was unaware of the facility's process for joint care planning. The facility's own policy emphasized the importance of joint care and communication between hospice and facility staff, which was not adhered to in these cases.
Failure to Provide Vaccine Education Prior to Administration
Penalty
Summary
The facility failed to ensure that one of five sampled residents received education regarding the risks and benefits of influenza and pneumococcal vaccines prior to their administration. According to interviews and record reviews, the resident received the influenza vaccine on 9/23/24 and the pneumococcal vaccine on 9/26/24, but there was no documented evidence that education about the vaccines was provided beforehand. The Infection Preventionist confirmed that education was not documented and acknowledged the importance of informing residents about the side effects and benefits of the vaccines. The facility's own policy required informed consent through discussion of risks and benefits prior to vaccination, but this was not followed in this instance.
Failure to Notify MD of Low Body Temperature
Penalty
Summary
The facility failed to provide quality care to a resident by not notifying the Medical Doctor (MD) when the resident experienced six days of low body temperature. The resident, who had a history of dementia, bariatric surgery, protein calorie malnutrition, and anemia, was found unresponsive and transferred to an acute care hospital for further evaluation and treatment. The resident's clinical records showed consistently low body temperatures over several days, which were not communicated to the MD, potentially contributing to the resident's critical condition. Interviews with facility staff revealed that the process for handling abnormal vital signs was not followed. Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) were responsible for assessing vital signs and notifying the MD of any abnormalities. However, the LNs did not recall notifying the MD about the resident's low body temperatures, and the CNAs did not ensure that the LNs were informed of the abnormal readings. The Director of Nursing (DON) acknowledged that the job descriptions and policies were not adhered to, as there was no documentation of reassessment or MD notification for the abnormal temperatures. The resident was admitted to the hospital with altered mental status, dehydration, hypernatremia, acute kidney injury, and bradycardia. The hospital records indicated that the resident was treated for sepsis and required intensive care, including intubation, norepinephrine administration, blood transfusions, and warming measures. The facility's failure to notify the MD of the resident's low body temperatures and reassess the condition in a timely manner contributed to the resident's severe health decline.
Failure to Monitor Fluid Intake Leads to Resident Hospitalization
Penalty
Summary
The facility failed to maintain the hydration status of Resident 1, leading to hospitalization for dehydration and electrolyte imbalance. Resident 1 was admitted with several diagnoses, including cerebral infarction, dysphagia, acute kidney failure, and hyperkalemia. Despite these conditions, the facility did not monitor or document Resident 1's fluid intake accurately. The care plan indicated a need for monitoring, but there was no physician order for intake and output (I&O) monitoring, and the facility lacked a standard protocol for such monitoring. Interviews with staff revealed a lack of clarity and consistency in monitoring fluid intake. Certified Nurse Assistant 1 and Licensed Nurse 1 indicated that fluid intake was only checked if there was an order in the resident's chart. Licensed Nurse 2 confirmed that Resident 1 did not have an order for I&O monitoring, despite being at risk for dehydration due to refusal to eat or drink. The Director of Nursing acknowledged that Resident 1's fluid intake was not monitored, and the Registered Dietician's recommendations were not followed. The facility's electronic health record system no longer supported I&O monitoring due to a corporate change, further complicating the situation. The Medical Doctor confirmed that Resident 1 was at risk for dehydration and emphasized the importance of routine I&O monitoring in nursing homes. The lack of monitoring and documentation of fluid intake contributed to Resident 1's decline in health, resulting in hospitalization for severe dehydration and related complications. The deficiency highlights the facility's failure to implement preventative measures and ensure adequate hydration for residents at risk.
Incomplete POLST Forms and Lack of Verification of Advance Directives
Penalty
Summary
The facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST) forms were completed accurately for seven residents. For Resident 22, the POLST did not contain the resident representative's contact information. Similarly, Resident 62's POLST was missing the resident's contact information and the date of signing. Resident 491's POLST lacked the conservator's contact information and the date signed. These omissions had the potential to delay emergency treatment or not honor personal preferences for life-sustaining treatment. Resident 3's POLST was signed by the resident herself, despite her severe intellectual disabilities and lack of capacity to make her own healthcare decisions. This increased the risk that her medical treatment preferences would not be honored. For Resident 63, the POLST was not dated when prepared, and the section for the healthcare agent was not verified from the resident's Advance Directive. This unverified information increased the risk that medical treatment preferences would not be honored. Resident 78's POLST had the section for the Advance Directive left blank, despite the resident stating she had a power of attorney for healthcare decisions. The facility's failure to collect and document this information increased the risk that the resident's medical treatment preferences would not be honored. The Director of Nursing acknowledged that the facility's policy on promoting the right of self-determination for healthcare decisions and advanced healthcare directives was not followed, and staff needed reeducation on the importance of completing all aspects of the POLST form.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for four out of 46 facility rooms. In Room A, the floor under the nightstand contained stained, broken tiles and various pieces of trash, which was confirmed by a housekeeper and the Maintenance Director (MDir). In Room B, two areas of deep scratches in the drywall behind the first bed were observed, with peeled drywall hanging off the wall. The MDir confirmed these issues and expressed disappointment in the room's condition. In Room C, the bathroom sink was pulling away from the wall, and the caulking material needed replacement. Additionally, the wall behind the bed had deep scratches, and the bathroom door had a broken, jagged-edged striker plate, exposing a cracked area in the door. The MDir confirmed these issues and acknowledged the safety risks they posed. The Director of Nurses (DON) also confirmed that these conditions did not meet the facility's expectations for a homelike environment. In Room D, the toilet had been leaking for an unknown period, as reported by a resident and confirmed by the MDir. The MDir found a large stain area around the toilet, indicating a prolonged leak. Housekeeping staff acknowledged the leak but had not informed the MDir. The DON confirmed that the leaking toilet did not provide a sanitary homelike environment and that the facility's policy and procedure were not followed.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services for two residents, Resident 3 and Resident 8, as observed during a survey. Resident 8, who was admitted in early 2023 with hemiplegia and hemiparesis following a stroke, was found to have long fingernails with dirt in them and scratch marks on her left forearm. Certified Nursing Assistant (CNA) 4 confirmed the poor condition of Resident 8's nails and acknowledged that they needed to be trimmed and cleaned to prevent potential skin issues and infections. Similarly, Resident 3, admitted in 2012 with severe intellectual disabilities, had long toenails, including a blackened small toenail on the right foot, which she had requested to be cut. CNA 4 confirmed that Resident 3's nails were long and dirty and stated that toenail care should be provided by a podiatrist, although the Director of Staff Development (DSD) indicated that CNAs were responsible for non-diabetic residents' toenail care, which Resident 3 was confirmed to be non-diabetic. The podiatrist's visit records did not include any care provided to Resident 3, indicating a lapse in toenail care provision. Additionally, Resident 3 did not receive showers as per her shower schedule. The electronic record indicated that Resident 3 was scheduled for showers on Mondays and Thursdays, but there was no record of showers being offered or given on several scheduled days. A paper shower schedule at the nurses' station conflicted with the electronic record, showing different shower days (Wednesdays and Saturdays). This discrepancy led to Resident 3 missing multiple scheduled showers, as confirmed by Licensed Nurse (LN) 8 and the DSD. The Director of Nursing (DON) emphasized the importance of regular showers for residents' hygiene, dignity, and infection control, which was not upheld in Resident 3's case. The facility's procedures for nail care and bathing were not followed, resulting in poor hygiene and potential health risks for the residents. The DON and other staff members acknowledged the importance of maintaining residents' personal hygiene and the need for consistent care, which was not provided to Resident 3 and Resident 8. The failure to adhere to care schedules and procedures highlights significant deficiencies in the facility's care practices.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure respiratory care was provided in accordance with professional standards of practice for six residents. Resident 6 received oxygen without an order, and there was no oxygen safety signage posted outside the rooms of Residents 6, 341, and 53. Additionally, the oxygen flow rates for Residents 53 and 32 were not provided at the prescribed levels. Resident 53 was observed receiving oxygen at three liters per minute (LPM) instead of the prescribed two LPM, and Resident 32's oxygen flow rate was set to three LPM instead of the prescribed two LPM. These discrepancies were confirmed by licensed nurses and the Director of Nursing (DON), who acknowledged the potential risks associated with incorrect oxygen flow rates, including hyperoxygenation and hypoxia. Furthermore, the facility failed to change oxygen and nebulizer tubings as required. Resident 16's nasal cannula was undated, and there was no documentation indicating when it had last been changed. Similarly, Resident 6's oxygen tubing was not dated, and there was no order to change it. Resident 491's nebulizer tubing was also not dated, and there was no physician's order specifying how often it needed to be changed. The DON confirmed that the facility's policy required oxygen tubing to be changed every 28 days and nebulizer tubing to be changed weekly, but these procedures were not followed. The lack of proper documentation and adherence to physician orders and facility policies had the potential to result in negative impacts on the health and safety of the residents, including risks for ineffective oxygen therapy, respiratory distress, infection, and fire safety. The observations and interviews conducted with the staff, including licensed nurses and the DON, highlighted the facility's failure to maintain professional standards of practice in providing respiratory care to the residents.
Failure to Ensure Safe Medication Disposition Practices
Penalty
Summary
The facility failed to ensure safe medication disposition practices for a census of 91 residents. Discontinued and discharged medications were stored improperly and disposed of without documentation or cosignatory of the licensed staff. During an observation and interview with the Director of Nursing (DON) in the facility's medication room, discontinued prescription medications were found piled up on a countertop next to the sink. The DON stated that these medications belonged to residents who were discharged or had their medications discontinued by the doctor, and that the nursing staff were responsible for destroying them when they had time. However, there was no documentation of the destruction process, and the DON admitted that the facility did not document the destruction as there was no perceived need to do so. Additionally, the DON was unsure how hazardous medications were disposed of, and acknowledged that staff were storing personal belongings in the medication room next to the discontinued medications, which were openly stored on the countertop. Interviews with Licensed Nurses (LNs) revealed a lack of awareness and documentation regarding the destruction of prescription medications. LN 1 stated that discontinued narcotic medications were given to the DON for disposal, but regular prescription drugs were not documented. LN 7 could not specify how often medications were destroyed or where it was documented. The facility's policies on medication storage and disposal indicated that discontinued or outdated medications should be destroyed in the presence of a registered nurse and witnessed by another staff member, with proper documentation. However, these policies were not being followed, leading to the unsafe practice of storing and disposing of medications without proper documentation and oversight.
Failure to Ensure Safe Medication Use and Monitoring
Penalty
Summary
The facility failed to ensure safe medication use and monitoring for three residents, leading to potential adverse consequences. Resident 342 was administered a high-risk blood thinner, Apixaban, without proper monitoring or care planning for its safe use. The medication administration record (MAR) did not include side effect monitoring parameters, and the care plan did not address the use of the blood thinner. The consultant pharmacist confirmed that the medication posed a risk of bleeding and bruising and should have been monitored. Licensed Nurse 4 acknowledged the lack of monitoring and care plan documentation for this high-risk medication during a review and interview session. Resident 33's heart medication, Metoprolol, was administered despite the heart rate being below the ordered parameter on multiple occasions. The MAR indicated that the medication was given even when the heart rate was below 60 beats per minute, contrary to the doctor's order. The progress notes did not provide any indication of why the medication was administered under these conditions. The Director of Nursing stated that the nursing staff should have followed the doctor's orders and notified the doctor if needed. Additionally, Resident 33's pain medication, Celebrex, was continued upon admission without reassessment of its safe use and potential side effects. The consultant pharmacist had not reviewed the resident's records, and the medical doctor acknowledged the risks associated with long-term use of Celebrex. Resident 343 was administered duplicate doses of Vitamin D without proper documentation or justification. The MAR showed two different orders for Vitamin D, but there was no indication of a diagnosis or monitoring for Vitamin D deficiency in the medical records. The consultant pharmacist and medical doctor both acknowledged the risks of Vitamin D accumulation and the need for proper monitoring and supplementation with calcium. The facility's policy on medication administration was not followed, leading to potential risks for the residents involved.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to ensure safe use and monitoring of psychotropic medications for four residents. Resident 33's antidepressant medication, citalopram, was not monitored for specific symptoms and behaviors affecting the resident's mental health. The Consultant Pharmacist acknowledged that behavior monitoring parameters were missed, and the Director of Nursing (DON) confirmed that the depression and anxiety care plan was completed by a social worker, not nursing staff, and behavior monitoring was not included in the Medication Administration Record (MAR) for documentation and monitoring by nursing staff. Resident 342's antidepressant medication, venlafaxine, was administered without explaining its use or indication, and there was no daily nursing monitoring for anxiety symptoms specific to the resident. The nursing Plan of Care did not address the use of mood-altering medication for Generalized Anxiety Disorder as ordered by the medical provider. The DON stated that nursing staff should document any unusual behavior in their nursing notes. Resident 343's antidepressant medication, escitalopram, was administered without explaining its use or indication, and there was no daily nursing monitoring for depression symptoms specific to the resident. The Plan of Care for behavior monitoring was not included in the MAR for documentation and monitoring by nursing staff. Similarly, Resident 390's anxiety and depression medications, duloxetine and buspirone, were not monitored for specific symptoms and behaviors associated with the mental health disorder. The DON confirmed that the depression and anxiety care plan was completed by social services, not nursing staff, and behavior monitoring was not included in the MAR for documentation and monitoring by nursing staff.
Unsafe Medication Storage Practices
Penalty
Summary
The facility failed to ensure safe medication storage practices in three out of three medication rooms and two out of four medication and treatment carts. The Automated Dispensing Device (ADD) was stored in the same room as a hopper used for disposing of body fluids, and the room was accessible to nursing assistants. The room's temperature log was inconsistently monitored and documented. The Director of Nursing (DON) acknowledged that the nursing staff should have been checking the room temperature daily, and the Consultant Pharmacist (CP) stated that the medications stored inside the ADD device were not exposed to infectious particles as a result of hopper use, assuming the hopper was not used for human waste disposal in the utility room. However, the facility's policy required daily temperature monitoring, which was not consistently followed. In the medication rooms at nursing stations 1 and 2, undated and unlabeled prescription medications were stored in the active storage areas. An unlabeled prescription medication called Sodium Polystyrene Sulfonate (SPS) was found on the same shelf as non-prescription medications. Additionally, an opened vial of Tuberculin Purified Protein (Aplisol) was stored without a marking indicating when it was first opened, and a plastic zip lock bag containing a controlled prescription medication called lorazepam had a faded and unreadable label. The DON and Licensed Nurse (LN) acknowledged these findings and stated that multi-use injectable medications should be dated when opened. The treatment cart in the Station 3&4 hallway contained several unlabeled and undated products, including Nystatin topical powder, Mupirocin ointment, Normal Saline sterile irrigation solution, and an open container of Iodoform packing strip with an expired date. Additionally, the medication refrigerator in the medication room at station 3&4 was cluttered with excessive frosting, and insulin products and a vaccine were stored in direct contact with the frosted area. An open vial of Aplisol was also found without a date indicating when it was first opened. LN 7 acknowledged these findings and stated that the multi-dose vials should have been dated when first opened. The facility's policy required that medication and biological storage areas be locked and not contain non-medication/biological items, and that opened medications should be dated and stored properly, which was not adhered to in these instances.
Failure to Follow Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets prescribed by the physician were followed for three residents. For Resident 5, who had a diagnosis of hypertensive chronic kidney disease, salt packets were added to her meal tray despite a physician's order for a no-salt diet. This was confirmed by the Dietary Services Supervisor (DSS) during a tray line observation. The DSS acknowledged the potential adverse effects of providing salt packets to residents who should not have them. Resident 344, who had hemiplegia and hemiparesis following a cerebral infarction, was served chicken cut into pieces larger than the prescribed size for his soft and bite-sized texture diet. This discrepancy was observed during a meal service, and the DSS admitted uncertainty about how the wrong tray was delivered. The Registered Dietitian (RD) and the Director of Nurses (DON) emphasized the importance of following diet textures to prevent choking and other health risks. Resident 8, who had dysphagia, was given a puree liquidized diet based on a family request and a trial suggested by the DSS. However, the DSS did not update the physician's order to reflect this change, resulting in a mismatch between the diet order and the food served. The DON stated that diet orders should match the tray cards to ensure the correct diet is followed, highlighting the risk of residents receiving inappropriate food textures or diet restrictions not being adhered to.
Failure to Ensure Safe and Sanitary Food Storage Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices for 90 residents. During an initial kitchen tour, three 5-gallon containers of flour, rice, and granulated sugar were found undated and unlabeled. The Dietary Service Supervisor (DSS) confirmed that the bins should have been labeled and dated to ensure staff knew the contents and their expiration dates. The Registered Dietitian (RD) also stated that all food items should be dated and labeled to maintain resident safety. Additionally, the unit snack/nourishment refrigerator was found with a thick brown substance on the bottom shelf, ice buildup in the freezer, and moldy and expired food items, including cheese, a packaged meal, and a container of milk. The Vice President of Nursing Services (VPNS) confirmed these observations and stated that the cleanliness of the refrigerator should be maintained and expired food should be discarded to prevent serving questionable or moldy food to residents. Furthermore, the unit snack/nourishment refrigerator did not have a temperature log, which was confirmed by the Director of Nurses (DON). The DON stated that the refrigerator temperature should be monitored to ensure resident safety and prevent foodborne illnesses. The facility's policies and procedures indicated that food should be stored to minimize contamination and bacterial growth, with expiration and use-by dates checked regularly. The policies also required that repackaged food be placed in sanitary containers, labeled, and dated, and that refrigerator temperatures be maintained at 41 degrees Fahrenheit or below. The lack of adherence to these policies and procedures led to the potential exposure of residents to expired and contaminated food, increasing the risk of foodborne illnesses.
Inaccurate Medical Records and Care Documentation
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records for three residents. For Resident 390, wound care was not documented in a timely manner on a specific date. The Treatment Administration Record (TAR) for Resident 390 showed blank administration dates for four treatments, which was confirmed by the Licensed Nurse (LN) and the Director of Nurses (DON). LN 7 admitted to forgetting to document the wound care, acknowledging that this could lead to forgetting the details of the care provided and questioning whether the order was carried out if it was not documented. For Resident 8, the records indicated that nail care was provided daily, but observations showed that the resident had long, dirty fingernails with scratch marks on her forearm. This was confirmed by a Certified Nursing Assistant (CNA) who stated that the nails needed to be trimmed and cleaned. Similarly, Resident 3's records also indicated daily nail care, but observations revealed long, dirty toenails, including a blackened small toenail. The CNA confirmed that nail care was not provided as documented, and the Director of Staff Development (DSD) and DON verified that the nail care documentation was inaccurate. Additionally, Resident 3's shower schedule in the electronic and physical records did not match, leading to missed showers. The electronic record showed scheduled showers on Mondays and Thursdays, while the paper record indicated Wednesdays and Saturdays. This discrepancy was confirmed by LN 8 and the DSD, who acknowledged that the conflicting schedules resulted in missed showers for Resident 3. The DON emphasized the importance of matching shower schedules in both records to ensure accurate documentation and consistent care.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure residents' needs were accommodated promptly for two residents when call lights were not answered in a timely manner. Resident 190, who was resting in bed, pressed her call light to request assistance with her hearing aids. Despite staff being present in the hallway, it took over 20 minutes for a CNA to respond and provide the hearing aids. Resident 190 expressed frustration and stated that it always took a long time for staff to answer her call light throughout the day. Her care plan indicated she was at risk for falls and injuries and encouraged the use of the call light, but the delayed response did not meet her needs promptly. Similarly, Resident 63, who had bilateral lower extremities missing, pressed his call light for assistance to get up and sit in his wheelchair. Despite his repeated attempts to get up on his own and his verbal requests for help, it took approximately 19 minutes for a CNA to respond. The CNA initially offered coffee before assisting Resident 63 with his request. Resident 63 also indicated that staff often took a long time to respond to his call light. His care plan also indicated he was at risk for falls and injuries and encouraged the use of the call light, but the delayed response did not meet his needs promptly. The Director of Nursing (DON) stated that call lights should be answered in less than 5 minutes and that delays longer than this were not acceptable as they could cause delays in care and put residents' safety at risk. The facility's policy on call lights emphasized the importance of timely responses and indicated that all staff members who see or hear an activated call light are responsible for responding. However, the observations and interviews indicated that the facility did not adhere to this policy, resulting in unmet needs and potential harm to the residents involved.
Failure to Develop and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and revised for three residents. Resident 16, who was readmitted with Chronic Obstructive Pulmonary Disease (COPD), did not have a care plan for her oxygen therapy use. This was confirmed by both a Licensed Nurse and the Director of Nurses (DON), who acknowledged that the care plan should have included this intervention to guide the resident's care and inform the nurses of specific interventions and complications to monitor for. Similarly, Resident 6, who was readmitted with multiple diagnoses including asthma and acute respiratory failure with hypoxia, also did not have a care plan for his oxygen therapy use. Observations confirmed that Resident 6 was using oxygen daily, yet this was not reflected in his care plan. The DON verified the absence of this critical information in the care plan, acknowledging that it could affect the resident's care. Additionally, Resident 8, who was admitted with dysphagia, had a nutrition care plan that was not updated to reflect a new diet intervention. Despite being on a pureed liquidized diet as per family request, this change was not documented in the care plan. The Dietary Services Supervisor and the DON both confirmed that the care plan should have been updated to reflect this dietary change to ensure proper care and intervention. The facility's policy on comprehensive care plans emphasizes the importance of updating care plans to reflect current interventions and resident needs.
Failure to Follow IV Therapy Protocols
Penalty
Summary
The facility failed to administer parenteral fluids within professional standards of practice for two residents on IV therapy. For Resident 22, the IV tubing did not have a cap at the end when not in use, which was against facility practice and increased the risk of infection. This was confirmed by Licensed Nurse 6 and further supported by the Director of Nursing, who acknowledged that the policy and procedure for intermittent infusion administration was not followed. Resident 22 was receiving ceftriaxone intravenously for a urinary tract infection, and the lack of a sterile end cap on the IV tubing was a significant oversight in care. For Resident 191, the PICC line dressing was not changed upon admission as required by physician orders. The dressing was last changed on 4/13/24, and Resident 191 was admitted to the facility a couple of days before the observation on 4/22/24. Licensed Nurse 4 confirmed that the dressing should have been changed upon admission to prevent infection and to check for any signs of redness or swelling at the insertion site. The Director of Nursing also stated that PICC line dressings should be changed every seven days and upon admission if ordered by the physician. The physician order for Resident 191 indicated that the PICC line dressing should be changed on admission, weekly, and as needed for complications. However, the IV Medication Administration Record for April 2024 did not show that the dressing was changed. The facility's policy on Central Vascular Access Device dressing changes also emphasized the importance of sterile dressing changes to prevent catheter-related infections. The failure to follow these protocols put Resident 191 at risk for infection.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for three residents, leading to potential adverse health effects. Resident 23, who dislikes pasta, was served a meal containing pasta. This was confirmed by the Dietary Services Supervisor (DSS) during a tray line observation. Resident 23's care plan indicated a risk for impaired nutritional status and required that food preferences be honored to encourage meal intake. Similarly, Resident 41, who has hypertensive heart disease, was given salt packets despite her care plan specifying no salt packets. The DSS acknowledged this error and noted the potential for adverse health effects. Resident 41's care plan also emphasized the importance of following meal interventions per the tray card to manage her altered nutrition status. Resident 344, who dislikes rice, was served a meal containing rice. This was observed during a dining room visit, and a visitor confirmed that Resident 344 could not eat the food on his tray. The DSS admitted uncertainty about how the wrong tray was sent and stressed the importance of following residents' preferences for palatability. The Registered Dietitian (RD) and the Director of Nurses (DON) both emphasized that tray cards should be followed to meet residents' personal preferences and minimize potential adverse effects. The facility's policy on resident food preferences, dated November 2016, also mandates that all food and dining services staff be aware of and attempt to meet residents' food preferences.
Failure to Post Signage for Transmission-Based Precautions
Penalty
Summary
The facility failed to follow their infection control policies and procedures by not posting signage indicating the type of transmission-based precautions (TBP) and required personal protective equipment (PPE) needed prior to entering Resident 64's room. Resident 64, who was admitted with a nephrostomy tube and had an infection in the urine, was on contact precautions for a multi-drug resistant organism (MDRO). However, there was no signage on the door or wall outside the room to alert staff and visitors of the necessary precautions, which could have led to the spread of infection. During interviews, both a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN) confirmed that Resident 64 was on contact precautions, but no signage was present. The Director of Nursing (DON) and the Infection Preventionist (IP) also acknowledged that signage should have been posted to indicate the need for PPE. The facility's policy and CDC guidelines both require clear signage to prevent the spread of MDROs, but this was not followed, increasing the risk of cross-contamination within the facility.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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