West Hills Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Canoga Park, California.
- Location
- 7940 Topanga Canyon Blvd., Canoga Park, California 91304
- CMS Provider Number
- 056133
- Inspections on file
- 75
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 44 (1 serious)
Citation history
Health deficiencies cited at West Hills Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cirrhosis, DM, and chronic respiratory failure was assessed by an RN as capable of self-administering XyliMelts and Biotene oral gel and of securely storing these medications, but the RN did not obtain a physician’s order authorizing self-administration or bedside storage. Surveyors later observed the medications left openly on the bedside table, and the resident reported taking them whenever needed and was seen self-administering a dose while an LVN was out of the room. The LVN was unaware the resident was self-administering or storing the medications at bedside and confirmed there were no corresponding physician orders, despite facility policies requiring safe, secure storage and administration as prescribed.
A resident with severely impaired cognition, mobility limitations, and multiple medical conditions fell onto a floor mat while returning from the bathroom, as reported by a cognitively impaired but decision-capable roommate who activated the call light. An RN Supervisor assessed the resident, who reported mild left wrist pain, and notified the physician, who issued a stat order for a left wrist x-ray and Tylenol for pain. The facility’s policy required stat orders to be completed within four to six hours, but surveyors found that the stat x-ray was not completed within this timeframe, resulting in a cited deficiency for failure to timely complete the ordered diagnostic test.
A resident with cognitive impairment reported non-consensual physical contact by another resident, which was relayed through staff to the administrator. Despite staff concerns and facility policy requiring investigation and reporting of all abuse allegations, the administrator did not initiate a thorough investigation or complete the required documentation, resulting in a deficiency.
A resident with cognitive impairment reported that another resident entered her room and tickled her foot without consent, leading her to believe the act was sexual in nature. The incident was reported by staff up the chain of command, but the Administrator did not report the allegation to authorities as required, resulting in a delay in investigation.
The facility did not ensure that all nursing staff attended required behavioral health in-service training, as only a portion of the staff participated despite the training being mandatory. This failure was identified through a review of training records and confirmed by facility leadership, in violation of facility policy and regulatory expectations for staff competency in behavioral health care.
The facility did not post the actual hours worked by licensed and unlicensed nursing staff responsible for resident care, instead displaying only projected hours based on the staffing schedule. Staff interviews confirmed that actual hours were not calculated or posted daily, resulting in incomplete staffing information being accessible to residents and visitors, contrary to facility policy.
A resident with severe cognitive impairment and multiple health conditions was assessed and ordered to participate in a scheduled toileting program to manage incontinence. Despite clear documentation and physician's orders, staff were unaware of the plan, and there was no evidence that the program was implemented or documented. The DON confirmed the failure to carry out the scheduled toileting intervention as required by facility policy.
A resident with severe cognitive impairment and a principal diagnosis of cerebral palsy was admitted and readmitted, but the Level 1 PASARR did not reflect the correct diagnosis. The DON acknowledged the error and that a corrected PASARR was not submitted as required by facility policy, resulting in a deficiency related to accurate assessment and potential service needs.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
A CNA assisted a dependent, cognitively impaired resident with feeding while standing and hovering over them, rather than sitting at eye level as required by facility policy. The CNA reported being unable to find a chair, and the DSD confirmed that sitting at eye level is necessary to maintain resident dignity during mealtime assistance.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
A resident with significant cognitive and physical impairments, along with their responsible party, was not informed of the right to choose or change the attending physician. Facility staff confirmed there was no documentation or evidence that this right was discussed at admission, despite facility policy requiring such notification.
A resident with significant cognitive and physical impairments was admitted without any personal belongings, and staff did not document or recall any attempts to retrieve the resident's possessions from a previous facility, despite facility policy requiring such efforts.
A resident who lacked decision-making capacity and required total assistance was moved to a different room after testing positive for COVID-19. The facility failed to verify and notify the correct responsible party of the room change, as required by policy, resulting in a breakdown of communication regarding the resident's care.
A resident with multiple serious diagnoses had STAT laboratory tests ordered, but the facility did not collect the samples until eight hours after the order, exceeding the expected four-hour window for STAT labs. Both the MDS nurse and DON confirmed the delay, which did not align with facility policy or the laboratory contract.
A resident with multiple complex medical conditions was not weighed as ordered by the physician due to a typographical error in the order summary and a missed scheduled weight. The DON confirmed the resident was not weighed on the required date, despite facility policy and physician orders specifying regular weight monitoring.
A resident with multiple complex medical conditions and severe cognitive impairment did not receive ordered monthly laboratory tests, including CBC, CMP, Pre-albumin, Serum Iron, and Serum Ferritin. The DON confirmed that the responsible nurse failed to carry out the physician's order and complete the necessary lab requisitions, resulting in the omission of required testing.
A resident with severe cognitive impairment and multiple medical conditions was observed sitting in a wheelchair with the call light out of reach, contrary to facility policy. Both an RN and the DON confirmed that the call light should have been accessible to allow the resident to request assistance as needed.
A resident with swallowing difficulties and intact cognition was discharged without their upper and lower dentures, which were documented as present at admission but not returned at discharge. Facility staff did not follow up on the status or replacement of the dentures, despite the resident later reporting the loss and filing grievances. This failure resulted in the resident not receiving medically-related social services as required.
Two residents with significant cognitive and physical impairments engaged in a physical altercation in a hallway, intentionally grabbing and pushing each other's arms, resulting in abrasions that required first aid and daily wound care. The incident was witnessed by a CNA, and both residents sustained injuries. Despite facility policy requiring protection from abuse by anyone, staff did not prevent the altercation, and leadership did not recognize the event as abuse.
Two residents with significant cognitive and medical conditions developed new skin abrasions, but staff failed to document wound measurements during the initial assessment as required by facility policy. Although daily wound care orders were in place, the lack of baseline measurements prevented proper monitoring of wound progression.
A resident with a history of falls, cognitive impairment, and recent fracture was identified as high risk for falls and had care plans specifying the use of floor mats to prevent injury. Despite these documented interventions and facility policy, staff did not implement the floor mats due to not obtaining a physician's order, leaving the resident without this protective measure.
A facility failed to document a resident's food allergies on a dietary communication slip upon re-admission, despite the resident having known allergies to dairy, certain vegetables, and mint. The nursing staff entered the allergy information into the EHR, but did not include it on the slip used by dietary staff, who do not have EHR access. This oversight led to the dietary staff preparing meals without knowledge of the resident's allergies, contrary to facility policy.
A resident's bed controller was not cleaned and disinfected, leading to a deficiency in infection control practices. The resident, admitted with a right foot fracture, wrapped the controller in a plastic bag due to its dirtiness and reported it to staff, but it remained uncleaned. Housekeeping staff did not clean it, assuming the bag was intentional. The Infection Control Preventionist and Director of Nursing confirmed the need for daily cleaning to prevent germ spread, as per facility policy.
A resident with cognitive impairment mistakenly gargled soap left in an unlabeled cup in their room, thinking it was mouthwash. Additionally, an unlabeled cup containing hair and body shampoo was found in a utility room, posing a risk of confusion with mouthwash. These incidents highlight the facility's failure to ensure a safe environment by not properly labeling temporary containers.
The facility failed to provide timely discharge notifications to two residents, resulting in a lack of opportunity to appeal the discharge decisions. One resident with severe cognitive impairment and another with intact cognition were both notified of their discharge on the day of discharge, contrary to the facility's policy requiring at least 30 days' notice or as soon as practicable. The Director of Nursing acknowledged the oversight.
A facility failed to document catheter care and urinary monitoring for a resident with bladder cancer and urinary retention. Despite requiring assistance with hygiene, there was no evidence of daily catheter care or monitoring of urine characteristics, as confirmed by the DON. The facility's policy requires detailed documentation of catheter care, which was not adhered to, potentially impacting the resident's health.
The facility failed to ensure that attending physicians documented History and Physicals (H&Ps) within 72 hours of admission for two residents. One resident had severe cognitive impairment and required assistance with hygiene, while the other had intact cognition but also required assistance. Both lacked documented H&Ps, contrary to facility policy, potentially leading to inconsistent care coordination.
A resident with multiple diagnoses, including cerebral palsy and quadriplegia, experienced inaccurate nursing assessments and documentation in an LTC facility. The MAR showed the resident receiving meropenem beyond the prescribed period, and ADL logs inaccurately recorded activities while the resident was absent. The DON confirmed these discrepancies, highlighting a failure to adhere to the facility's documentation policy.
A facility failed to clarify a physician's order for potassium chloride for a resident with cerebral palsy and altered mental status, who was unable to self-administer medications. The resident required total dependence on staff for daily activities, and the order was not verified with the physician as per facility policy, risking incorrect dosage administration.
A facility failed to clarify a G-tube feeding order for a resident, leaving the daily volume and caloric intake unspecified. The resident, with cerebral palsy and impaired cognition, was dependent on staff for daily activities. The facility's policy requires complete nutritional orders, but the nurse did not confirm the order's completeness, risking the resident's nutritional status.
A resident with cerebral palsy did not receive specialized rehabilitative services as ordered by their physician. The resident required total dependence on staff for daily activities and had cognitive impairments. Despite orders for therapy evaluations and treatments, the facility did not ensure these services were provided, and there was a lack of communication with the previous facility or responsible party to continue prior care. This failure was against the facility's policy and could impact the resident's functional mobility and quality of life.
A facility failed to implement its Falling Star Program for a resident at high risk for falls, as no identifying star was placed on the resident's room name plate. The resident, with a history of repeated falls and severe cognitive impairment, experienced multiple falls, including one resulting in a laceration and hospital transfer. Staff interviews confirmed the absence of the star sign could lead to unawareness of the fall risk, contrary to the facility's policy.
A resident in an LTC facility used an electric portable space heater in their room, which was against facility policy due to safety concerns. The resident, who had conditions like rheumatoid arthritis and asthma, was cognitively intact and required supervision. A CNA noticed the heater but did not report it, assuming the facility was aware. The Maintenance Supervisor was unaware of the heater's presence, highlighting a lapse in communication and adherence to safety protocols.
A resident's call light was found on the floor and not within reach, despite the care plan's intervention to ensure accessibility. The resident, with multiple diagnoses including Parkinsonism and cognitive impairment, required assistance with daily activities. Observations and interviews with an LVN and the DON confirmed the deficiency, which contradicted the facility's policy that mandates call lights be accessible to residents for safety.
A facility failed to check the functionality of a bed pad alarm daily for a resident at high risk for falls, as required by their policy. The resident, with Alzheimer's and multiple fractures, was observed with the alarm in place, but there was no documentation of its functionality being monitored. This oversight had the potential to place the resident at risk for injuries and falls.
The facility failed to develop and implement person-centered care plans for four residents, leading to deficiencies in addressing their specific needs. A resident with severe cognitive impairment used a non-self-release seatbelt restraint without a documented care plan. Another resident prescribed buprenorphine for pain management lacked a care plan addressing medication use and potential side effects. A resident with dementia exhibited wandering behavior without a care plan, and a diabetic resident had no care plan for insulin use. These omissions violated the facility's policy requiring comprehensive care plans.
The kitchen staff failed to follow food service safety standards, affecting 139 residents. Five open bags of bread and bagels lacked documented open dates, and the ice machine lid was left open, risking contamination. The Dietary Supervisor was unaware of the need for open dates, and the Registered Dietitian confirmed the requirement. Facility policies mandate labeling open food items and keeping the ice machine lid closed to prevent contamination.
The facility failed to adhere to infection control protocols in two instances. An LVN did not wear gloves while administering medication to a resident on Enhanced Barrier Precautions, despite the facility's policy requiring such precautions to prevent the spread of multi-drug resistant organisms. Additionally, an Activities Assistant was observed eating personal food in the resident dining area, contrary to facility policy, raising concerns about potential cross-contamination and infection control.
A facility failed to ensure an LVN knocked on a resident's door before entering, violating the resident's rights to dignity and self-determination. The resident, with severe cognitive impairment and dependent on staff for daily activities, was observed being entered upon multiple times without prior notice. The DON highlighted the importance of knocking to respect residents' rights, as per the facility's dignity policy.
The facility failed to discuss and document Advance Directives for two residents. One resident, with conditions like hypertension and heart failure, did not have an Advance Directive Acknowledgement form filled out, violating their right to be informed. Another resident, with severe cognitive impairment, did not have their Advance Directive placed in the medical chart, as required by facility policy.
A resident with severe cognitive impairment did not receive privacy during medication administration via a gastrostomy tube, as the LVN failed to close the privacy curtain. This action was against the facility's policy on dignity, which mandates maintaining resident privacy during care.
A resident with severe cognitive impairment and frequent seizures was found restrained with a non-self-release seatbelt (NSRB) in a high-back wheelchair without proper documentation or a physician's order. The facility's policy required a pre-restraining assessment and a physician's written order, which were not present in the resident's records.
An LVN in a facility signed the MAR for a resident's eye drop medications before administering them, contrary to professional standards. The resident, with severe cognitive impairment, was dependent on staff for daily living activities. The DON confirmed that MARs should be signed post-administration to prevent dosing errors.
A resident with dementia and severe cognitive impairment had a hematoma on their hand that was not documented by an LVN as ordered by the physician. The LVN admitted to incorrectly documenting the absence of discoloration, despite the facility's policy on skin care.
A resident identified as incontinent of bladder and bowel did not receive a scheduled toileting plan, despite being assessed as a candidate for such care. The resident, with intact cognitive skills but dependent on staff for toileting, was not provided with the necessary interventions as per the facility's policy, potentially compromising skin integrity and increasing the risk of infections.
A facility failed to follow a Consultant Pharmacist's recommendation to monitor a resident's respiratory rate while on Oxycodone, risking respiratory depression. The resident, with intact cognitive skills and dependent on staff for daily activities, was not monitored as advised, despite facility policy requiring such actions.
A facility failed to ensure a medication cart was locked before being left unattended by an LVN during a med pass. The LVN admitted to forgetting to lock the cart, which was not within their line of sight. The DON highlighted the importance of securing medication carts to prevent unauthorized access. Facility policy requires carts to be locked when out of sight.
A resident's MDS assessment failed to include critical diagnoses such as CHF, AFIB, PMH, and CKD, despite these being documented in other medical records. The Director of Nursing confirmed the inaccuracy, which contradicted the facility's policy requiring an accurate diagnosis list. This omission had the potential to affect the resident's care plan and service delivery.
The facility was found to have two rooms exceeding the resident occupancy limit during a survey. One room housed three beds, and another housed two beds, with a combined space of 563 square feet. Despite the excess occupancy, observations indicated sufficient space for resident movement and care. A waiver was submitted, arguing that the space met the minimum requirements and did not impact resident well-being.
Failure to Obtain Orders and Ensure Safe Storage for Self-Administered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who was assessed as clinically appropriate to self-administer medications had a physician’s order to self-administer or store medications at bedside before doing so, and to ensure the medications were stored safely and securely. The resident was admitted with cirrhosis of the liver, diabetes mellitus, and chronic respiratory failure with hypoxia. An MDS assessment showed the resident could make herself understood and understand others, required supervision or touching assistance with eating, moderate assistance with oral hygiene, and maximal assistance with bed mobility and transfers. A Self-Administration of Medication (SAOM) assessment completed by an RN on 2/2/2026 indicated the resident was fully capable of storing medications in a secure location and safely self-administering them. On observation in the resident’s room, surveyors saw bottles of XyliMelts and Biotene oral gel on top of the bedside table, accessible in the open. The resident stated she needed to take medications, pointed to these products, and reported that she took them whenever she needed to and kept them on top of her bedside table. When asked if she had been instructed to call a nurse before taking the medications, she stated that the nurses knew she was taking them. During a subsequent observation with an LVN, the same medications were again seen on top of the bedside table, and the resident was observed taking a XyliMelts tablet while the LVN was out of the room. The LVN reported he was not aware the resident was self-administering or storing these medications at bedside and, upon checking, found no physician’s orders authorizing self-administration or bedside storage at that time. The RN who completed the SAOM assessment acknowledged that she had assessed the resident as alert and oriented and able to correctly demonstrate how and when to take the XyliMelts and Biotene oral gel, and had documented that the resident was capable of safe self-administration and secure storage, but she did not notify the physician or obtain the required orders on the day of the assessment. The ADON confirmed that the SAOM was completed without obtaining physician orders for self-administration or bedside storage and stated that medications should be stored in a secure location, noting that leaving medications on the bedside table could allow cognitively impaired residents access to them. Facility policies on self-administration and administering medications required that self-administered medications be stored in a safe and secure place not accessible by other residents and that medications be administered as prescribed.
Failure to Timely Complete Stat X-Ray Order After Resident Fall
Penalty
Summary
The facility failed to ensure that a physician’s stat order for an x-ray was completed within the facility’s required timeframe for one resident following a fall. The facility’s policy titled “Stat Orders,” last reviewed on 1/8/2025, required that stat orders be completed promptly within a four to six-hour timeframe. After a fall event, a Change of Condition/Interact assessment form dated 1/1/2026 at 7:40 p.m. documented that a resident’s roommate activated the call light to report that the resident was on the floor mat, having fallen on his back while returning from the bathroom. The RN Supervisor assessed the resident, who reported left wrist pain rated 3/10, and notified the physician and responsible party. The physician returned the call on 1/1/2026 at 7:45 p.m. and ordered a left wrist x-ray and Tylenol 325 mg for pain, which the RN Supervisor documented as noted and carried out. However, the survey findings concluded that the stat x-ray order was not completed timely in accordance with the facility’s policy. The resident involved had been originally admitted with diagnoses including diverticulosis of the large intestine without perforation or abscess, asthma, and unspecified abnormalities of gait and mobility, and had severely impaired cognition with a need for moderate to maximal assistance for toileting, bathing, dressing, personal hygiene, and mobility. The deficiency was cited for failure to complete the stat x-ray order within the required four to six-hour timeframe following the fall.
Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to implement its policy and procedure regarding abuse when an allegation of sexual abuse was made by a resident. The incident involved a resident with moderate cognitive impairment and multiple medical diagnoses, who reported that another resident entered her room, tickled her foot under her blanket without consent, and left when told to stop. The resident expressed that she did not consent to the contact and believed the other resident wanted to have sex with her. The incident was reported to a CNA the following morning, who then informed an LVN, and subsequently, the matter was escalated to an RN and the facility administrator. Despite the report being relayed through appropriate staff channels, the administrator, who also served as the abuse coordinator, did not consider the incident to be sexual in nature and therefore did not initiate a thorough investigation or complete the required five-day follow-up investigation report. The administrator's decision was based on her personal assessment of the situation, rather than following the facility's written policy, which mandates that all allegations of abuse be thoroughly investigated and documented, with findings reported to the appropriate authorities. Interviews with staff indicated that both the LVN and RN considered the incident to be a possible case of sexual abuse, as the contact was non-consensual and made the resident feel uncomfortable and distressed. The facility's policy, reviewed during the investigation, clearly states that all allegations of abuse must be reported, investigated, and documented, regardless of the administrator's personal judgment. The failure to follow these procedures resulted in the deficiency cited by surveyors.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to implement its policies and procedures to ensure timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of sexual abuse. A resident with moderate cognitive impairment and multiple medical diagnoses reported that another resident, who also had cognitive impairment, entered her room and tickled her foot without consent. The incident made the resident feel uncomfortable and she believed the other resident wanted to have sex with her. The resident did not report the incident immediately but informed a Certified Nursing Assistant (CNA) the following morning, who then reported it up the chain of command to a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and finally to the facility Administrator (ADM), who is the abuse coordinator. Despite the report being escalated through appropriate staff, the ADM did not consider the incident to be sexual in nature and therefore did not report the allegation to the State Survey Agency (SSA) as required by Section 1150B of the Act and the facility's own policy. The facility's policy mandates immediate reporting of suspected abuse, neglect, or exploitation to local, state, and federal agencies, including the SSA, but this was not followed in this case. The staff members involved, including the CNA, LVN, and RN, recognized the incident as potentially sexual abuse and reported it accordingly, but the final decision by the ADM resulted in a failure to report. The deficiency was identified through interviews and record reviews, which confirmed that the facility did not report the allegation of sexual abuse within the required timeframe. This lapse was due to the ADM's judgment that the incident was not sexual in nature, despite the resident's statements and the opinions of other staff members. The facility's failure to report the incident as required delayed the investigation of the suspicion of sexual abuse.
Failure to Provide Mandatory Behavioral Health Training to All Nursing Staff
Penalty
Summary
The facility failed to provide mandatory in-service behavioral health training to all nursing staff as required by its own policies and as scheduled on the in-service calendar. A review of the training sign-in sheets for the scheduled behavioral health in-service revealed that only 36 out of 142 nursing staff attended, despite the training being mandatory for all licensed nurses and certified nursing assistants. The Director of Staff Development confirmed that not all staff attended the training, and the Director of Nursing reiterated that attendance was required for all nursing staff. The facility's policies specify that all staff must participate in regular in-service education, including behavioral health topics such as recognizing psychosocial distress, implementing care plan interventions, and following protocols for mental health conditions. The facility assessment indicated that the resident population includes individuals with psychiatric and mood disorders, and that staff are expected to be trained to care for residents with dementia and other mental health issues. The failure to ensure full staff participation in behavioral health training resulted in noncompliance with facility policy and regulatory requirements.
Failure to Post Actual Daily Nursing Staff Hours
Penalty
Summary
The facility failed to ensure that the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care were posted daily, as required by both facility policy and federal regulations. Observations on multiple dates revealed that the posted staffing information consisted of projected hours based on the monthly schedule, rather than the actual hours worked. Interviews with the Director of Staff Development (DSD), Assistant Director of Staff Development (ADSD), Payroll Manager (PM), and Director of Nursing (DON) confirmed that the posted information did not reflect real-time staffing, but rather estimates or projections. The PM stated that actual hours are calculated after the fact and not available for posting on the day worked. The facility's policy requires that within two hours of the beginning of each shift, the number of licensed and unlicensed nursing staff and their actual hours worked be posted in a prominent location accessible to residents and visitors. However, the staff responsible for posting the information, including the ADSD and PM, acknowledged that only projected hours were posted and that no updates were made to reflect actual hours worked during the shift. This resulted in the total number of staff and actual hours worked not being readily accessible as required.
Failure to Implement Scheduled Toileting Program for Identified Resident
Penalty
Summary
A deficiency occurred when a resident, who was identified as a candidate for scheduled toileting based on assessments and physician's orders, did not receive the required toileting retraining plan. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, need for assistance with personal care, and severe cognitive impairment. Facility records, including the Minimum Data Set and Bowel and Bladder Program Screener, indicated the resident should have been placed on a scheduled toileting program for 90 days, with specific interventions such as offering toileting at set times and documenting each occurrence. Despite these documented assessments and orders, interviews with facility staff revealed that the scheduled toileting program was not implemented. The assigned CNA was unaware of the toileting plan, and the charge nurse did not know the resident was on such a program, instead deferring responsibility to the MDS nurse. The MDS nurse confirmed that, although the resident was identified as a candidate, there was no evidence in the medical record that the scheduled toileting program had been initiated or documented for the resident during the specified period. The Director of Nursing acknowledged that the facility failed to implement the scheduled toileting plan, despite the resident's assessment and physician's order. Facility policy required staff to provide appropriate services and treatment to help restore or improve bladder function, including scheduled toileting for those identified as candidates. However, the lack of communication and documentation among staff resulted in the resident not receiving the scheduled toileting intervention as required.
Failure to Submit Corrected PASARR for Resident with Cerebral Palsy
Penalty
Summary
The facility failed to submit a new, corrected, and accurate Level 1 Preadmission Screening and Resident Review (PASARR) for a resident who was admitted and later readmitted with diagnoses including cerebral palsy, Chiari Syndrome, and dysphagia. The resident's admission record indicated a principal diagnosis of cerebral palsy, but the Level 1 PASARR completed prior to admission did not reflect this diagnosis. The discrepancy was identified during a review of the resident's records, which also showed severe cognitive impairment and total dependence on staff for activities of daily living. During an interview and record review, the DON acknowledged responsibility for overseeing PASARR and confirmed that the Level 1 PASARR contained an error by not listing cerebral palsy as a primary diagnosis. The facility's policy required submission of a new Level 1 PASARR if any error or discrepancy was found in the previous screening, but this was not done. The failure to correct the PASARR could have affected the determination of appropriate placement and the identification of specialized services for the resident.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Staff Stood Over Resident During Feeding, Violating Dignity Policy
Penalty
Summary
Staff failed to maintain resident dignity during mealtime assistance for one resident. Observation revealed that a Certified Nursing Assistant (CNA) stood and hovered over a resident while assisting with feeding, rather than sitting at eye level as required by facility policy. The CNA stated she was unable to find a chair to sit on, despite knowing the expectation to sit while feeding residents. The Director of Staff Development confirmed that staff are expected to sit at eye level to promote dignity and prevent residents from feeling intimidated. The affected resident had been readmitted with diagnoses including anoxic brain damage, epileptic seizure, and dysphagia, and was assessed as severely cognitively impaired and dependent on staff for eating and other activities of daily living. Facility policies reviewed indicated that residents should be assisted with meals in a manner that ensures safety, comfort, and dignity, specifically noting that staff should not stand over residents during feeding. The incident was identified through observation, interviews, and record review.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Inform Resident and Responsible Party of Right to Choose Attending Physician
Penalty
Summary
The facility failed to ensure that a resident and their responsible party were informed of the right to choose or change the attending physician. Upon admission, the resident, who had diagnoses including cerebral palsy, altered mental status, and quadriplegia, was not provided with documentation or evidence that the right to select an attending physician was discussed with either the resident or their responsible party. The resident's medical records indicated a lack of cognitive capacity to make decisions, and the Minimum Data Set confirmed total dependence on staff for activities of daily living. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed that while the facility has a process for informing residents of their rights, including the right to change physicians, there was no documentation that this process was followed for this particular resident. The Social Services Director was not employed at the time of the resident's admission, and the Director of Nursing confirmed that there was no record of any discussion or documentation regarding the choice of attending physician for the resident or their responsible party. A review of the facility's policy on the choice of attending physician confirmed that residents have the right to choose their own physician and that the facility should not interfere with this process. However, the lack of documentation and failure to inform the resident or responsible party of this right resulted in the resident and their responsible party not being made aware of the option to select or change the attending physician, as required by federal regulations.
Plan Of Correction
F 555 RIGHT TO CHOOSE/BE INFORMED ATTENDING PHYSICIAN CFR(s): 483.10(d)(1)-(5) IMMEDIATE CORRECTIVE ACTION: Resident 1 was discharged on 1/3/21. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All residents had the potential to be affected by this deficient practice. The Social Services Director and Designee interviewed 10 newly admitted residents in the last two (2) weeks to determine if they were aware of their rights to choose an attending physician and if they needed assistance with changing their attending physician. No other residents were found to be affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The Director of Nursing Services (DON) conducted an in-service education with the licensed staff on 6/30/25, regarding facility policy and procedure on Change of Physician, ensuring that residents are aware of their rights and assistance is available when they request a change of physician. The Administrator conducted an in-service with Social Services department staff on 7/7/25, regarding facility policy on Choice of Attending Physician focusing on the right of the resident to choose his or her own attending physician. Effective 7/7/25, the Activity Director will review residents' rights to include the right to choose an attending physician during the monthly Resident Council meeting for the next three months and quarterly thereafter. If the resident subsequently chooses another attending physician who meets the requirements and responsibilities of an attending physician, the facility will honor that choice. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All residents had the potential to be affected by this deficient practice. The Social Services Director and Designee interviewed 10 newly admitted residents in the last two (2) weeks to determine if they were aware of their rights to choose an attending physician and if they needed assistance with changing their attending physician. No other residents were found to be affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The Director of Nursing Services (DON) conducted an in-service education with the licensed staff on 6/30/25, regarding facility policy and procedure on Change of Physician, ensuring that residents are aware of their rights and assistance is available when they request a change of physician. The Administrator conducted an in-service with Social Services department staff on 7/7/25, regarding facility policy on Choice of Attending Physician focusing on the right of the resident to choose his or her own attending physician. Effective 7/7/25, the Activity Director will review residents' rights to include the right to choose an attending physician during the monthly Resident Council meeting for the next three months and quarterly thereafter. If the resident subsequently chooses another attending physician who meets the requirements and responsibilities of an attending physician, the facility will honor that choice. Effective 7/7/25, the Social Service Director or the Social Services Designee will notify the resident and/or resident's RP during the Interdisciplinary Team (IDT) meeting of their right to choose a physician and assist them as needed. If the resident subsequently chooses another attending physician who meets the requirements and responsibilities of an attending physician, the facility will honor that choice. The DON and/or her designee will conduct a random review of five (5) residents or residents' RP weekly for the next 30 days to ensure that they are aware of their rights to choose an attending physician and that assistance is provided if they need to change physicians. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON and/or her designee will report findings of the weekly random reviews to the Quality Assessment and Assurance Committee (QAA) at the next monthly meeting. The DSS will also report her daily findings at the next monthly QAA meeting. The Administrator will monitor compliance through review of the DON's report. CORRECTIVE ACTION COMPLETION: July 7, 2025
Failure to Assist Resident in Obtaining Personal Belongings
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not assisting with obtaining personal belongings from the resident's previous facility. The resident, who was admitted with diagnoses including cerebral palsy, altered mental status, and quadriplegia, was documented as having no personal belongings upon admission. The resident's medical records indicated a lack of cognitive capacity and total dependence on staff for activities of daily living. Despite facility policy requiring efforts to retrieve personal property for new admissions, there was no documentation or evidence that staff attempted to contact the previous facility or retrieve the resident's belongings. Interviews with the Social Services Director and the Director of Nursing confirmed that the standard practice is to contact the previous facility or arrange for staff to collect a resident's belongings. However, both were unable to provide any documentation or recall any attempts made in this case. The facility's own policies emphasized the importance of residents retaining personal possessions to maintain a homelike environment, but these procedures were not followed for this resident.
Plan Of Correction
RESPECT, DIGNITY / RIGHT TO HAVE PERSONAL PROPERTY CFR(s): 483.10(e)(2) IMMEDIATE CORRECTIVE ACTION: Resident 1 was discharged on 1/3/2021. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: Residents admitted from other facilities had the potential to be affected by this deficient practice. The Social Services Director and Social Services Designee interviewed 10 residents admitted in the last two weeks if assistance is needed in retrieving any belongings from prior facility. No other residents were affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The DON conducted an in-service education with licensed staff and social services staff on 6/30/25, regarding facility policy on Residents' Rights and Personal Property to ensure that assistance will be provided in securing belongings if the resident came from another facility. The Administrator conducted an in-service education with social services staff on 7/7/25, regarding facility policy on Residents' Rights and Personal Property to ensure that assistance will be provided in securing belongings if the resident came from another facility. Effective 7/7/25, the Social Services Director and the Social Services Designee will check newly admitted residents' inventory lists to ensure residents have personal belongings brought to the facility and provide assistance in obtaining personal belongings from the previous facility if needed. The DON and/or her designee will conduct random reviews of five (5) newly admitted residents weekly for the next four (4) weeks, then monthly for two (2) months of all new admissions to ensure the belongings checklist is completed and assistance is provided in securing and locating belongings from other facilities if needed. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON will report findings at the Quality Assessment and Assurance Committee (QAA) regarding weekly random checks at the next monthly meeting. The Administrator will monitor compliance through review of DON reports. CORRECTIVE ACTION COMPLETION: July 7, 2025
Failure to Notify Correct Responsible Party of Room Change
Penalty
Summary
The facility failed to ensure that the correct responsible party (RP) for a resident was accurately documented in the medical record and failed to notify the correct RP of a room change. The resident in question was admitted with diagnoses including cerebral palsy, altered mental status, and quadriplegia, and was determined to lack the capacity to make decisions. The resident required total assistance with activities of daily living and was dependent on staff for care. When the resident tested positive for COVID-19, a room change to the COVID-19 unit was required. Documentation showed that the facility notified an RP listed on the admission record, but did not verify that this was the correct RP. Interviews with facility staff confirmed that the standard procedure is to notify the resident or their RP of any room change, complete the necessary documentation, and inform the ombudsman. However, in this instance, the DON acknowledged that although a listed RP was contacted, staff did not confirm that this was the correct RP as documented in the admission record. The facility's policy requires advance written notice to all involved parties prior to a room or roommate change, but this was not properly followed in this case.
Plan Of Correction
F 559 CHOOSE/BE NOTIFIED OF ROOM/ROOMMATE CHANGE CFR(s): 483.10(e)(4)-(6) IMMEDIATE CORRECTIVE ACTION: Resident 1 was discharged on 1/3/25. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All residents had the potential to be affected by this deficient practice. The Medical Records Director (MRD) reviewed five (5) residents with room change requests in the last 30 days, to check if written notice of room change was provided to the resident and/or resident's RP. No other residents were affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The Director of Nursing Services (DON) conducted an in-service education with the licensed staff on 6/30/25, regarding facility policy on Room Change, ensuring that advance notice is provided to the resident and/or RP prior to room change. The Administrator conducted an in-service with Social Services department staff on 7/7/25, regarding facility policy on Room Change, ensuring that advance notice is provided to the resident and/or resident's RP prior to room change. Effective 7/7/25, the MRD or her designee will review weekly room change requests to ensure completion of the advance notice and notification of resident and/or resident's RP. The Social Services Director or the Social Services Designee will immediately correct any deficient practice identified in the audit. The DON and/or her designee and the MRD will randomly review five (5) resident charts weekly for the next 30 days to ensure residents' RPs were notified and documentation completed regarding room changes. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON will report findings to the Quality Assessment and Assurance Committee (QAA) regarding weekly random reviews for the next 30 days. The MRD will also report findings to the QAA regarding weekly random reviews for the next 30 days. The Administrator will monitor compliance through review of DON and MRD reports. CORRECTIVE ACTION COMPLETION: July 7, 2025 This page intentionally left blank
Delay in STAT Laboratory Collection for Resident
Penalty
Summary
The facility failed to provide timely laboratory services for one of three sampled residents. A resident was admitted with multiple diagnoses, including nontraumatic subarachnoid hemorrhage, cirrhosis of the liver, type 2 diabetes mellitus, and bacteremia. On the day following admission, a physician ordered several STAT laboratory tests at 10:00 a.m., including CBC, BMP, HgbA1C, urinalysis, culture and sensitivity, and two sets of blood cultures. According to facility staff, STAT laboratory tests are expected to be collected within four hours of the order to ensure prompt diagnostic evaluation and care. However, the laboratory tests for this resident were not collected until 6:15 p.m., which was eight hours after the order was placed. The laboratory results were subsequently received and reported later that evening. Both the MDS nurse and the DON confirmed that the collection of the STAT labs did not meet the facility's expected timeframe, as outlined in their policy and contract with the laboratory provider, which require immediate dispatch and prompt return of results for STAT orders.
Plan Of Correction
F 770 LABORATORY SERVICES CFR(s): 483.50(a)(1)(i) IMMEDIATE CORRECTIVE ACTION: The DON and/or her designee conducted a one-on-one in-service education with the licensed nurse on 5/30/25, regarding facility policy STAT orders. The laboratory company provided a clarification of the laboratory policy on 5/26/25, regarding the definition of STAT order which is 4-6 hours and will be presented and reviewed at the next Quality Assessment/Utilization Review Committee Meeting. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All residents with physician's orders for STAT Laboratory Tests had the potential to be affected by this deficient practice. The MRD randomly reviewed STAT Laboratory Tests in the last five (5) months. Five out of five STAT lab tests/radiology were collected/examined within 4-6 hours. No other residents were affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The DON conducted an in-service education with licensed nurses on 5/8/25 and 5/23/25, regarding laboratory company's policy on STAT laboratory tests. The MRD will conduct daily audits of STAT laboratory tests for the next three months to ensure that tests were completed timely. A report of the audit will be submitted to the DON for follow-up. The RN Supervisor during each shift will review STAT laboratory tests and follow-up with laboratory personnel to ensure laboratory tests were done timely. The DON and/or her designee will conduct weekly random reviews of five (5) residents with order for STAT laboratory tests to ensure compliance with policy for the next three months. Licensed staff identified with deficient practice will be given a one-on-one in-service education. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON and MRD will report findings to the Quality Assessment and Assurance Committee (QAA) for the next three months regarding random checks by DON and audits by the MRD. The Administrator will monitor compliance through review of DON and MRD reports. CORRECTIVE ACTION COMPLETION: May 30, 2025 This page intentionally left blank
Failure to Obtain Resident Weight as Ordered
Penalty
Summary
The facility failed to obtain a resident's weight as ordered by the physician. The resident, who had multiple diagnoses including cerebral palsy, altered mental status, urinary tract infection, heart failure, quadriplegia, and anxiety disorder, was dependent on staff for all activities of daily living. The physician's order required the resident to be weighed every Sunday for four weeks and then monthly, but there was also a conflicting order to weigh every Wednesday. The weight records showed that weights were documented on several dates, but no weight was recorded for the required date of 1/2/2021. During a review with the DON, it was acknowledged that there was a typographical error in the order summary, and the resident should have only been weighed on Sundays. The DON confirmed that the resident was not weighed as ordered on the specified date. The facility's policy required weights to be obtained upon admission and at intervals established by the interdisciplinary team, but this was not followed in this instance.
Plan Of Correction
F 692 NUTRITION/HYDRATION STATUS MAINTENANCE CFR(s): 483.25(g)(1)-(3) IMMEDIATE CORRECTIVE ACTION: Resident 1 was discharged on 1/3/21. The Director of Nursing Services (DON) conducted an in-service training with the Restorative Nurse Assistants (RNA) on 5/20/25, to conduct scheduled weekly weights for four weeks from the date of admission. Weekly weights will be taken on a specific day of the week, if indicated on the physician's order. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All newly admitted residents had the potential to be affected by this deficient practice. The Medical Records Director (MRD) reviewed the weekly weights in the last two weeks to ensure weekly weights were taken and documented. No other residents were identified. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The DON conducted in-service education with the RNAs on 5/23/25, regarding facility policy on "Weight Assessment and Intervention," focusing on taking weights upon admission and weekly thereafter for four weeks. The MRD will audit the weight record of newly admitted residents weekly for four weeks from admission to ensure that weights are recorded as ordered. The DON and/or her designee will conduct weekly random record reviews of five (5) newly admitted residents for 30 days to ensure that the timely and accurate documentation of the weekly weight is done. Any licensed nurse or RN staff identified with deficient practice will be given one-on-one education. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON and MRD will report findings to the Quality Assessment and Assurance Committee (QAA) for the next three months regarding results of the random checks. The Administrator will monitor compliance through review of DON & MRD reports. CORRECTIVE ACTION COMPLETION: May 23, 2025 PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The DON conducted an in-service education with licensed nurses on 5/23/25, regarding facility policy on "Request for Diagnostic Services," to ensure diagnostic services will be promptly carried out as instructed by the physician's order. The MRD will conduct daily audits of the diagnostic orders for the next three months to ensure that it was done and results were on file. A report of the audit will be submitted to the DON for follow-up. The RN Supervisor during the 7-3 shift will review the diagnostic orders daily from the previous day and follow-up with diagnostic personnel on the results to avoid delay in notifying the physician. The DON and/or her designee will conduct weekly random reviews of 10 residents with orders for diagnostic tests to ensure compliance with policy for the next three months. Licensed staff identified with deficient practice will be given one-on-one in-service education. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON and MRD will report findings to the Quality Assessment and Assurance Committee (QAA) for the next three months regarding weekly random checks. The Administrator will monitor compliance through review of SSD logs. CORRECTIVE ACTION COMPLETION: May 23, 2025 This page intentionally left blank. This page intentionally left blank.
Failure to Provide Ordered Laboratory Services
Penalty
Summary
The facility failed to provide laboratory services as ordered for one resident. Specifically, the resident was admitted with multiple diagnoses, including cerebral palsy, altered mental status, urinary tract infection, heart failure, quadriplegia, and anxiety disorder. The resident's Minimum Data Set indicated severely impaired cognitive skills and total dependence on staff for daily activities. Physician orders dated 10/29/2020 required a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Pre-albumin, Serum Iron, and Serum Ferritin to be obtained on 10/30/2020 and then monthly thereafter. A review of records and an interview with the DON confirmed that the required laboratory tests were not completed as ordered for the resident on 11/30/2020. The DON acknowledged that the licensed nurse responsible for receiving the physician's order did not carry out the order or complete the necessary laboratory requisition forms for subsequent months. The facility's policy required prompt execution of diagnostic service orders, but this was not followed in this instance.
Call Light Not Within Reach for Resident with Severe Cognitive Impairment
Penalty
Summary
Facility staff failed to ensure that a call light was within reach for a resident with severe cognitive impairment and multiple medical diagnoses, including atherosclerosis of the aorta, paroxysmal atrial fibrillation, and hypertension. The resident required moderate to maximum assistance with activities of daily living such as toileting, dressing, personal hygiene, and mobility. During an observation, the resident was found sitting in a wheelchair with the call light hanging on the wall by the overhead light, out of the resident's reach. Both a registered nurse and the Director of Nursing confirmed during interviews that the call light should have been accessible to the resident to allow them to request assistance when needed. The facility's policy requires that each resident be provided with a means to call staff for assistance from their bed, toileting or bathing facilities, and from the floor. The failure to provide the call light within reach constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Ensure Timely Replacement and Return of Missing Dentures
Penalty
Summary
The facility failed to provide medically-related social services to meet the needs of a resident by not following up on the status of the resident's missing dentures and not ensuring timely replacement. The resident was admitted with upper and lower dentures, as documented in the admission inventory, and had diagnoses including spinal stenosis and oropharyngeal dysphagia. The resident required staff assistance with eating and had intact cognition. Upon discharge, the inventory list did not indicate that the dentures were returned to the resident, and the resident was discharged without them. Subsequently, the resident returned to the facility to report that the dentures were not provided at discharge. Facility records, including concern and grievance reports, confirmed the resident's claim that the dentures were missing during the stay and not received at discharge. The Social Service Assistant acknowledged that there was no follow-up on the status or replacement of the dentures, which was required by facility policy to ensure medically-related social services were provided.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse when both, while in their wheelchairs in a hallway, engaged in a physical altercation. One resident grabbed the other's arm, and both pushed against each other's hands and arms, resulting in abrasions that required first aid and daily wound care. The incident was witnessed by a CNA, who observed both residents intentionally grabbing and applying pressure to each other's arms, but could not determine who initiated the contact. One of the residents involved had a history of encephalopathy, heart disease, and vascular dementia, and was assessed as able to make himself understood and requiring moderate assistance with most activities of daily living. The other resident had diagnoses including type two diabetes mellitus, schizoaffective disorder, and reduced mobility, with severely impaired cognition and complete dependence on staff for most activities of daily living. Both residents sustained skin abrasions as a result of the altercation, with one resident requiring wound care for two separate injuries and the other for one. Despite the facility's policy stating that residents must be protected from abuse by anyone, including other residents, the staff did not prevent the altercation. Interviews with the Administrator and DON revealed that they did not consider the incident to be abuse, instead characterizing it as an accident or self-protective behavior. However, the documented evidence and staff observations indicated that both residents were subjected to physical abuse while under the care of the facility.
Failure to Document Wound Measurements During Initial Assessment
Penalty
Summary
The facility failed to ensure that two residents received wound care in accordance with professional standards of practice by not measuring their wounds during the initial assessment of new abrasions. For both residents, the Non-Pressure Sore Skin Problem Reports documented the presence of new right arm abrasions but did not include any measurements of the wounds. Physician orders were in place for daily wound care, but the initial wound size was not recorded. Treatment nurses confirmed during interviews that they did not document wound measurements at the time of the initial assessment, and the Director of Nursing acknowledged that wounds should have been measured on the day they were first assessed to establish a baseline for monitoring progress. Both residents had significant medical histories and cognitive impairments. One resident had diagnoses including encephalopathy, heart disease, and vascular dementia, with severely impaired cognition and moderate assistance required for most ADLs. The other resident had type two diabetes mellitus, schizoaffective disorder, and reduced mobility, with severely impaired cognition and complete dependence on staff for most ADLs. The facility's policy required documentation of all wound assessment data, including size, but this was not followed for the new wounds identified in these residents.
Failure to Provide Fall Prevention Floor Mats for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide a high fall-risk resident with floor mats as indicated in the resident's care plan. The resident had a history of Guillain-Barre syndrome, osteoporosis with a pathological fracture, cognitive impairment, and a recent fall resulting in hospitalization for a fracture. The resident was assessed as being at high risk for falls, with care plans specifically stating that floor mats should be in place to help prevent injury from falls. Despite these documented interventions, observations revealed that no floor mats were present at the bedside, and staff interviews confirmed that the mats had not been implemented due to the absence of a physician's order. The care plan interventions, including the use of floor mats, were developed based on the resident's assessment, fall history, and medication profile. Staff acknowledged that the care plan required floor mats and that an order should have been obtained, but this step was missed, resulting in the intervention not being carried out. Facility policies also required the use of floor mats for residents at severely high risk for falls, but these were not followed for this resident, placing the individual at increased risk for injury from another fall.
Failure to Document Food Allergies on Dietary Communication Slip
Penalty
Summary
The facility failed to accurately complete a dietary communication slip for a resident upon re-admission, which omitted critical food allergy information. The resident, who was readmitted with diagnoses including malnutrition, atrial fibrillation, and Parkinson's disease, had documented allergies to dairy foods, certain vegetables, and mint. Despite this, the handwritten diet communication slip prepared on the day following re-admission did not include these allergies, posing a risk of exposure to allergens. The deficiency occurred because the nursing staff did not complete the diet communication slip with the necessary allergy information, relying instead on the electronic health record (EHR) where the allergies were documented. However, the dietary staff, who did not have access to the EHR, prepared and served meals based on the incomplete diet communication slip. The Director of Nursing and the Director of Support Services acknowledged that the dietary staff should have been informed of the allergies through the diet communication slip, as per the facility's policy, to prevent potential allergic reactions.
Failure to Clean and Disinfect Bed Controller
Penalty
Summary
The facility failed to implement proper infection control practices by not ensuring that a resident's bed controller was cleaned and disinfected. This deficiency was identified during an observation and interview with a resident who had wrapped the bed controller in a plastic bag due to its dirtiness. The resident, who was admitted with a right foot fracture and required assistance with daily activities, reported that they had informed staff about the unclean bed controller, but it was not addressed. The Infection Control Preventionist confirmed the bed controller was visibly dirty and required immediate cleaning. Housekeeping staff admitted to not cleaning the bed controller because it was wrapped in a plastic bag, which they assumed was intentional and did not want to disturb. The Housekeeping Supervisor stated that the bed controller should be cleaned and disinfected daily. The Director of Nursing also confirmed that bed controllers should be cleaned daily to prevent the spread of germs, as per the facility's infection control policy. The facility's policy on cleaning and disinfecting residents' rooms emphasized regular cleaning and disinfection of environmental surfaces, especially when visibly soiled.
Unlabeled Soap and Shampoo Cups Pose Safety Risks
Penalty
Summary
The facility failed to provide a safe and comfortable environment by leaving an unlabeled drinking cup containing soap in a resident's room. The resident, who had a pelvis fracture and moderately impaired cognitive skills, mistakenly gargled the soap, thinking it was mouthwash due to its similar color. A Certified Nursing Assistant (CNA) witnessed the incident and instructed the resident to rinse their mouth, then reported the event to the charge nurse. In another instance, a drinking cup containing an unlabeled blue liquid was found in a utility room near a nurse station. The liquid was initially thought to be mouthwash due to its color, but upon further inspection by the Housekeeping Supervisor, it was identified as hair and body shampoo (H&BS). The Director of Nursing (DON) confirmed that the liquid in the cup was similar to the H&BS found in the utility room, highlighting the risk of confusion with mouthwash. The facility's policies and procedures emphasize the importance of providing a safe and homelike environment, ensuring all temporary containers are properly labeled, and not leaving work areas unattended with supplies. However, these guidelines were not followed, leading to the potential for residents, staff, and visitors to be exposed to unsafe conditions.
Failure to Provide Timely Discharge Notification
Penalty
Summary
The facility failed to provide timely notification of proposed transfer and discharge to two residents, Resident 2 and Resident 3, as required by regulations. Resident 2 was admitted with severe cognitive impairment and other medical conditions, including encephalopathy and legal blindness. The facility issued a Notice of Medicare Non-Coverage (NOMNC) on February 26, 2025, indicating that Medicare coverage would end on March 1, 2025. However, the Notice of Proposed Transfer and Discharge was not given until March 4, 2025, the day of discharge, which was four days after the discharge order was received from the physician. This delay in notification did not allow Resident 2 or their representative adequate time to appeal the discharge decision. Resident 3, who had intact cognition and required moderate assistance with daily activities, was also not provided timely notification. The NOMNC was issued on February 28, 2025, with Medicare coverage ending on March 2, 2025, and discharge planned for March 3, 2025. The Notice of Proposed Transfer and Discharge was given on the day of discharge, March 3, 2025, three days after the discharge order was received. This late notification similarly did not provide Resident 3 the opportunity to appeal the discharge decision. The facility's policy requires that residents and their representatives be notified in writing at least 30 days prior to transfer or discharge, or as soon as practicable in certain circumstances. However, in both cases, the facility did not adhere to this policy, resulting in a failure to provide the residents with their right to appeal the discharge. The Director of Nursing acknowledged the oversight and confirmed that the notifications should have been provided earlier to allow for the appeal process.
Failure to Document Catheter Care and Urinary Monitoring
Penalty
Summary
The facility failed to adhere to its policy on urinary catheter care for a resident diagnosed with malignant neoplasm of the bladder, retention of urine, and post-surgical aftercare for the genitourinary system. The resident, who required partial/moderate assistance with oral and toileting hygiene, did not have documented evidence of receiving daily catheter care or monitoring of urinary output, including the color, odor, and consistency of the urine. This lack of documentation was confirmed during an interview and record review with the Director of Nursing (DON), who acknowledged the absence of records indicating that catheter care was provided or that urinary output was monitored. The facility's policy on catheter care, reviewed earlier in the year, mandates that specific information be recorded in the resident's medical record, such as the date and time of catheter care, the name and title of the caregiver, and details about the urine's characteristics and any issues at the catheter-urethral junction. However, the facility did not provide evidence of compliance with these documentation requirements for the resident in question. The DON emphasized the importance of monitoring urinary output, especially given the resident's cancer diagnosis, to prevent complications such as urinary tract infections.
Failure to Document Admission History and Physicals
Penalty
Summary
The facility failed to ensure that the attending physician documented a History and Physical (H&P) within 72 hours following admission for two residents. Resident 2 was admitted with diagnoses including encephalopathy, memory deficit following a nontraumatic intracerebral hemorrhage, and legal blindness. The Minimum Data Set (MDS) indicated that Resident 2 had severely impaired cognition and required assistance with hygiene tasks. During interviews and record reviews, it was confirmed that there was no documented evidence of Resident 2's admission H&P, which should have been completed and documented by the attending physician within the specified timeframe. Similarly, Resident 3 was admitted with diagnoses including a transient cerebral ischemic attack, cellulitis of the left lower limb, and sepsis. The MDS indicated that Resident 3's cognition was intact, and they required assistance with hygiene tasks. However, there was also no documented evidence of Resident 3's admission H&P. The facility's policy requires that a current H&P be provided by the attending physician within 72 hours following admission, and it is not appropriate to rely solely on hospital records without updating them to reflect the resident's current condition and diagnosis. The lack of documented H&Ps for both residents indicates a failure to adhere to this policy, potentially leading to inconsistent care coordination due to incomplete medical records.
Inaccurate Nursing Assessments and Documentation
Penalty
Summary
The facility staff failed to ensure accurate nursing assessments and documentation for a resident, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including cerebral palsy, altered mental status, and quadriplegia, required total dependence on staff for assistance with activities of daily living (ADLs). However, the facility's records showed discrepancies in the administration of medication and documentation of the resident's ADLs. Specifically, the Medication Administration Record (MAR) indicated that the resident was receiving meropenem for a urinary tract infection beyond the prescribed end date, and the ADL logs inaccurately documented the resident's activities while they were not present in the facility. During an interview and record review, the Director of Nursing (DON) acknowledged that the licensed nursing staff and Certified Nursing Assistants (CNAs) had documented incorrect information regarding the resident's medication and ADLs. The facility's policy on charting and documentation emphasized the need for accurate and complete records to facilitate communication among the interdisciplinary team. Despite this policy, the documentation errors persisted, potentially affecting the resident's quality of life and care.
Failure to Clarify Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that physician orders were accurately written and clarified for a resident who was unable to self-administer medications. Specifically, the facility did not clarify the order for potassium chloride for a resident with cerebral palsy and altered mental status, who required total dependence on staff for assistance with activities of daily living. The resident's admission record and assessments indicated that they did not have the capacity to understand and make decisions, highlighting the necessity for staff to manage medication administration accurately. The deficiency was identified during an interview with the Director of Nursing, who confirmed that the resident could not self-administer medication and that the nursing staff should have clarified the order with the physician. The facility's policy on verbal orders required that orders be read back to the practitioner to ensure clarity and correct transcription, which was not adhered to in this case. This oversight placed the resident at risk of receiving an incorrect dosage of potassium chloride, potentially leading to health complications.
Failure to Clarify G-tube Feeding Order
Penalty
Summary
The facility failed to clarify a gastrostomy tube (G-tube) feeding order for a resident, which did not specify the daily volume in cubic centimeters (CC) and caloric intake. This oversight was identified during a review of the resident's physician order dated 12/17/2020, which indicated an enteral order for Jevity 1.5 at 65 cc per hour via pump, but left the total daily CC and caloric intake blank. The Director of Nursing (DON) confirmed that nursing staff should verify with the physician the total volume and caloric intake for G-tube feedings. The resident involved was admitted on 10/28/2020 with diagnoses including cerebral palsy and altered mental status, and was assessed as having impaired cognition and total dependence on staff for daily activities. The facility's policy on enteral nutrition, revised in 11/2018, requires that nutritional support be provided as ordered, with the dietician, provider, and nurse collaborating to ensure the resident's nutritional needs are met. However, the nurse did not confirm the completeness of the enteral nutrition orders, leading to a potential risk of unplanned weight changes and altered nutritional status for the resident.
Failure to Provide Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services to a resident diagnosed with cerebral palsy, as required by their physician's order. The resident, who was admitted with cerebral palsy, altered mental status, and a urinary tract infection, was noted to have cognitive impairments and required total dependence on staff for activities of daily living. Despite a physician's order for evaluations and treatments in physical, occupational, and speech therapy, there was no evidence that these services were provided. The Director of Rehabilitation was unaware if the necessary communication with the previous facility or responsible party had occurred to continue the resident's prior care. The Director of Nursing confirmed that the standard procedure involves discussing the resident's previous functional level and therapy with the responsible party or previous facility, but it was unclear if this was done for the resident in question. The facility's policy on providing specialized rehabilitative services, as indicated by the Minimum Data Set, was not followed, leading to a potential decrease in the resident's functional mobility and quality of life.
Failure to Implement Falling Star Program for High-Risk Resident
Penalty
Summary
The facility failed to implement its Falling Star Program for a resident identified as high risk for falls. This program requires placing an identifying colorful star on the resident's name plate at the entrance to their room to alert staff of the fall risk. The deficiency was identified when it was observed that no star sign was posted for the resident, despite their documented history of repeated falls and severe cognitive impairment, which necessitated maximal assistance with daily activities. The resident had experienced multiple falls, including one incident where they sustained a laceration and required hospital transfer. Interviews with staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that the absence of the star sign could lead to staff being unaware of the resident's fall risk, potentially increasing the likelihood of further falls. The facility's policy, last reviewed in January 2024, clearly states the requirement for the star sign as part of the Falling Star Program, which was not adhered to in this case.
Resident's Use of Prohibited Space Heater
Penalty
Summary
The facility failed to provide a safe and comfortable environment for a resident who used an electric portable space heater in their room. The resident, who had been admitted with conditions including rheumatoid arthritis, asthma, and atrial fibrillation, was cognitively intact and required supervision for personal hygiene and transferring. On a specific date, the resident was observed using the space heater, which was placed upside down on a trash can in their room. The resident stated they had been using the heater whenever they felt cold since a few days prior. The Maintenance Supervisor was unaware of the heater's presence, as no reports had been made by staff. A Certified Nursing Assistant (CNA) had noticed the heater earlier and informed the resident of the facility's policy against its use due to fire risks but did not report it to licensed nurses or maintenance, assuming the facility was already aware. The facility's policy, last reviewed earlier in the year, explicitly prohibited portable space heaters to prevent risks such as burns and fire.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident while in bed, which is a device used by residents to signal their need for assistance from staff. This deficiency was observed during a review of a resident's admission record and care plan, which indicated that the resident had several diagnoses, including Parkinsonism, acquired absence of the left upper limb below the elbow, anxiety disorder, morbid obesity, and heart failure. The resident's Minimum Data Set (MDS) indicated moderately impaired cognitive skills and required assistance with daily activities. Despite the care plan's intervention to place the call light within easy reach, the call light was found on the floor and not accessible to the resident during an observation. During interviews and observations, both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the call light was not within reach and emphasized that it should always be accessible to residents for their safety. The facility's policy on the call light system, reviewed earlier in the year, stated that residents should have a means to call staff directly from their bed, and calls for assistance should be answered promptly. However, the failure to adhere to this policy was evident in the observations made, highlighting a lapse in ensuring the resident's needs and preferences were reasonably accommodated.
Failure to Monitor Bed Pad Alarm Functionality
Penalty
Summary
The facility failed to implement its policy on personal alarms by not checking the functionality of a resident's bed pad alarm daily. This deficiency was identified for a resident who was admitted with diagnoses including Alzheimer's disease, unspecified osteoarthritis, and multiple fractures. The resident was assessed as high risk for falls and had a history of fall-related injuries. An order for a bed pad alarm was placed to ensure safety and prevent unassisted transfers. However, there was no documented evidence that the functionality of the bed pad alarm was monitored as required by the facility's policy. During an observation, the resident was found sleeping with the bed pad alarm in place, but the Director of Nursing confirmed that there was no documentation of the alarm's functionality being checked. The facility's policy and the manufacturer's guidelines both emphasize the importance of daily checks to ensure the alarm is working properly. The lack of monitoring had the potential to place the resident at risk for injuries and falls, as the alarm's purpose is to alert staff to assist the resident and prevent accidents.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents, leading to deficiencies in addressing their specific needs. Resident 440, who was admitted with severe cognitive impairment and physical limitations, used a non-self-release seatbelt restraint due to frequent seizures. However, there was no care plan documenting the use of this restraint, which is necessary for staff awareness and proper monitoring. The facility's policy requires care plans for restraints to address medical symptoms and underlying problems, but this was not followed. Resident 123, admitted with low back pain and a stage four pressure ulcer, was prescribed buprenorphine for pain management. Despite the importance of having a care plan to address the use of narcotic pain medication, including potential side effects and black box warnings, no such plan was found. The Director of Nursing acknowledged the risk of inadequate pain management and adverse reactions without a comprehensive care plan. Resident 489, diagnosed with dementia and Alzheimer's Disease, exhibited wandering behavior since admission. However, there was no care plan to manage this behavior, posing a safety risk to the resident and others. Similarly, Resident 2, with type two diabetes mellitus, had no care plan for insulin use, which is essential for setting treatment goals and evaluating outcomes. The facility's policy mandates comprehensive care plans with measurable objectives, but these were not implemented for the residents in question.
Deficiencies in Food Storage and Ice Machine Maintenance
Penalty
Summary
The kitchen staff failed to adhere to professional standards for food service safety, affecting 139 out of 140 residents who receive food from the facility's kitchen. During an observation, it was noted that five open bags of bread and bagels in the walk-in refrigerator did not have a documented open date. The Dietary Supervisor (DS) admitted to not knowing that opened bags required an open date. The Registered Dietitian (RD) later confirmed that all opened food items must be labeled with an open date to prevent the storage of potentially spoiled food. The facility's policy on Canned and Dry Goods Storage, last reviewed in July 2024, mandates that all open food items should have an open date and use-by-date per manufacturer's guidelines. Additionally, the ice machine lid was observed to be left open, exposing the ice to potential contamination. The DS acknowledged that the lid was likely left open by a certified nursing assistant and emphasized the importance of keeping the lid closed to prevent debris and germs from contaminating the ice. The RD reiterated the necessity of keeping the ice machine lid closed to avoid contamination. The facility's Infection Control policy, also reviewed in July 2024, aims to prevent and control infections and maintain a safe and sanitary environment.
Infection Control Lapses in Medication Administration and Dining Area
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in two instances. First, a Licensed Vocational Nurse (LVN 3) did not wear gloves while administering medication to a resident who was on Enhanced Barrier Precautions (EBP). This resident, admitted with diagnoses including hypertension and bipolar disorder, required maximum assistance for personal care and had a colostomy, necessitating EBP to prevent the spread of multi-drug resistant organisms. Despite the facility's policy requiring glove use during high-contact activities, LVN 3 acknowledged the oversight, recognizing the importance of gloves in reducing infection risk. In a separate incident, an Activities Assistant (AA) was observed eating personal food in the resident dining area while residents were having lunch. The AA admitted that this was against facility policy due to potential infection control and cross-contamination issues. The facility's policy explicitly prohibits employees from consuming meals at their assigned workstations, highlighting the importance of maintaining a sterile environment in resident areas to prevent the spread of harmful bacteria.
Failure to Knock Before Entering Resident's Room
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) knocked on a resident's door before entering the room, which is a violation of the resident's rights to dignity and self-determination. This incident involved Resident 118, who was originally admitted to the facility on July 5, 2023, and readmitted on July 25, 2023, with diagnoses including hemiplegia and hemiparesis. The resident had severely impaired cognitive skills and was dependent on staff for assistance with activities of daily living, as indicated in the Minimum Data Set dated July 11, 2024. On August 6, 2024, at 8:06 a.m., LVN 1 was observed entering Resident 118's room multiple times without knocking. During an interview, LVN 1 admitted to not knocking before entering the room. The Director of Nursing (DON) emphasized the importance of knocking on residents' doors to respect their rights and maintain their sense of home. The facility's policy on dignity, last reviewed on July 10, 2024, requires staff to knock and request permission before entering residents' rooms.
Failure to Ensure Advance Directives Discussed and Documented
Penalty
Summary
The facility failed to ensure that Advance Directives (AD) were discussed and written information was provided to residents or their responsible parties, as evidenced by the cases of two residents. Resident 34 was admitted with conditions including hypertension, muscle weakness, and heart failure. Despite having the ability to sometimes understand and communicate, the facility did not provide or document an Advance Directive Acknowledgement (ADA) form for Resident 34. The Licensed Vocational Nurse (LVN) confirmed that the ADA form, which informs residents of their rights to formulate an AD, was not filled out, violating the resident's right to be informed. In the case of Resident 81, who was admitted with severe cognitive impairment and required maximal assistance for daily activities, the facility failed to obtain and place a copy of the resident's AD in the medical chart. The Medical Records Director (MDR) acknowledged the absence of the AD in the chart, which is necessary for licensed nurses to access during emergencies. The MDR stated that the AD was with the resident's family and had not been provided to the facility, contrary to the facility's policy that requires ADs to be maintained in the resident's medical record for easy retrieval.
Failure to Ensure Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure privacy for a resident during medication administration via a gastrostomy tube. The incident involved a Licensed Vocational Nurse (LVN 1) who did not close the privacy curtain while administering medication to the resident. This action was observed during a survey, and it was confirmed through an interview with LVN 1, who admitted to not providing the necessary privacy. The resident involved had been admitted and readmitted to the facility with diagnoses including hemiplegia and hemiparesis, and was noted to have severely impaired cognitive skills, requiring assistance with activities of daily living. The facility's policy on dignity, which emphasizes the importance of maintaining resident privacy during care, was not followed in this instance, as confirmed by the Director of Nursing during an interview.
Failure to Document and Justify Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically a non-self-release seatbelt (NSRB), which the resident could not unbuckle themselves. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was observed in a high-back wheelchair with the NSRB fastened around their waist. The resident expressed that they were unable to unbuckle the seatbelt themselves. Treatment Nurse 1 confirmed that the resident used the NSRB for safety due to frequent seizures but was unsure if there was a physician's order for its use. Further investigation revealed that there was no documentation in the resident's medical records, including physician orders, care plans, assessments, or progress notes, regarding the use of the NSRB. Registered Nurse 1 acknowledged the absence of necessary documentation and emphasized the importance of documenting the need and use of restraints to ensure staff awareness and proper monitoring. The facility's policy required a pre-restraining assessment and a physician's written order before using restraints, which was not followed in this case.
Improper MAR Signing Before Medication Administration
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) adhered to professional standards of practice by signing the Medication Administration Record (MAR) before administering medications to a resident. Specifically, LVN 1 signed the MAR for the administration of Dorzolamide Hydrochloride-Timolol maleate and Prednisolone Acetate eye drops to a resident before actually administering the Prednisolone Acetate. This action was observed during a concurrent observation and interview, where LVN 1 was seen administering the Dorzolamide Hydrochloride-Timolol maleate and then signing the MAR for both medications before waiting five minutes to administer the Prednisolone Acetate. The resident involved, identified as Resident 118, had a history of hemiplegia and hemiparesis and was noted to have severely impaired cognitive skills, being dependent on staff for assistance with activities of daily living. The Director of Nursing (DON) confirmed that the MAR should only be signed after the medication has been administered, as signing it beforehand poses a risk of missed doses or overdosing. The facility's policy on administering medications, last reviewed in July 2024, also indicated that the MAR should be signed after each medication is given and before administering the next one.
Failure to Document Hematoma on Resident's Hand
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 2) documented the presence of a hematoma on the left dorsal hand of a resident, as ordered by the physician. The resident, who was admitted with dementia and was severely impaired in cognition, was dependent on staff for daily activities. On a specific date, a Change in Condition Form indicated that skin discoloration was discovered on the resident's left dorsal hand. However, the Medication Administration Record for that day showed no documentation of bruising by LVN 2 during her shift. During an interview and record review, LVN 2 acknowledged that she incorrectly documented the absence of discoloration on the resident's hand. She admitted that the resident did have discoloration on the following day. The facility's policy on skin care, which aims to guide the prevention and treatment of skin issues, was not adhered to in this instance, leading to the potential for the resident not receiving the necessary care and services for the discoloration.
Failure to Implement Scheduled Toileting Plan
Penalty
Summary
The facility failed to provide a scheduled toileting plan for a resident who was identified as incontinent of bladder and bowel. The resident, admitted with diagnoses including gastro-esophageal reflux disease, major depressive disorder, and the presence of an artificial knee joint, was assessed using the Minimum Data Set (MDS) and found to have intact cognitive skills but was dependent on staff for various activities, including toileting hygiene. The Bladder and Bowel Screener indicated that the resident was a candidate for scheduled toileting, yet there was no documented evidence of such a plan being implemented from the time of assessment. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the resident should have been receiving scheduled toileting. The absence of this care was acknowledged as potentially uncomfortable and embarrassing for the resident, with implications for skin integrity and the risk of developing skin impairments and urinary tract infections. The facility's policy on urinary incontinence, which mandates scheduled toileting based on assessment, was not followed in this case.
Failure to Monitor Respiratory Rate for Resident on Oxycodone
Penalty
Summary
The facility failed to implement the recommendation of the Consultant Pharmacist to monitor the respiratory rate of a resident who was prescribed Oxycodone Hydrochloride for severe pain. The recommendation included adding a parameter to withhold the medication if the resident's respiratory rate fell below 12 breaths per minute. This oversight was identified during a review of the Medication Regimen Review for May 2024 and the Medication Administration Records for June and July 2024, which showed no evidence of respiratory rate monitoring. The resident involved had been admitted with diagnoses including gastro-esophageal reflux disease, major depressive disorder, and the presence of an artificial knee joint. The resident's cognitive skills were intact, and they were dependent on staff for various activities of daily living. Despite the pharmacy consultant's recommendation, the facility did not monitor the resident's respiratory rate, which was crucial given the potential for respiratory depression from the combination of Gabapentin and Oxycodone. The facility's policy required that recommendations from the Consultant Pharmacist be acted upon and documented, which was not done in this case.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) locked a medication cart before leaving it unattended during a medication pass observation. This incident involved LVN 1, who was observed entering a resident's room while leaving Medication Cart 1 unlocked and unattended. The cart was not within LVN 1's line of sight, which is necessary to maintain security and prevent unauthorized access. During an interview, LVN 1 admitted to forgetting to lock the medication cart before leaving it unattended. The Director of Nursing (DON) emphasized the importance of securing medication carts to prevent unauthorized access by personnel or residents, which could lead to adverse side effects. The facility's policy, last reviewed on 7/10/2024, mandates that medication carts must be kept closed and locked when out of the sight of the medication nurse or aide.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment reflective of their medical status, as evidenced by the omission of several critical diagnoses in the resident's Minimum Data Set (MDS). The resident, identified as Resident 108, had been admitted and readmitted with various diagnoses, including dementia, GERD, gastrointestinal hemorrhage, anemia, severe protein-calorie malnutrition, and nonthrombocytopenic purpura. However, the MDS did not include significant diagnoses such as Congestive Heart Failure (CHF), Atrial Fibrillation (AFIB), Pulmonary Hypertension (PMH), and Chronic Kidney Disease (CKD), which were documented in other medical records, including a progress note by a Nurse Practitioner and a cardiology consultation report. During an interview and record review, the Director of Nursing acknowledged that the MDS for Resident 108 was inaccurate and should have reflected the resident's complete medical status. The facility's policy and procedure on cumulative diagnoses required maintaining an accurate list of diagnoses, which should be updated in the resident's chart and MDS. The failure to include these diagnoses in the MDS had the potential to negatively impact the resident's plan of care and the delivery of necessary services.
Room Occupancy Exceeds Limit
Penalty
Summary
The facility failed to comply with the requirement that resident rooms hold no more than four residents, as observed during a recertification survey. Specifically, two rooms were identified where the number of residents exceeded this limit. One room housed three beds, and another housed two beds, with the rooms being connected and partitioned by a curtain. Despite the partition, the combined space of 563 square feet was deemed sufficient for resident movement and the operation of mobility aids such as wheelchairs, walkers, or canes. The facility's Client Accommodation Analysis form confirmed the room configurations, and a waiver request was submitted by the Administrator to address the room occupancy issue. During the Resident Council Meeting, no concerns were raised by the residents regarding their room space, and observations during the survey indicated that the room variance did not negatively impact the care and services provided by the nursing staff. The waiver letter submitted by the facility argued that the combined square footage exceeded the minimum requirement of 80 square feet per resident and did not restrict residents' freedom of movement. The facility maintained that the room configuration did not adversely affect the health, safety, or welfare of the residents, and there was adequate space to ensure residents' care, dignity, and privacy.
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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