West Hollywood Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 855 North Fairfax Avenue, Los Angeles, California 90046
- CMS Provider Number
- 055710
- Inspections on file
- 44
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at West Hollywood Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage, labelling, and sanitation, including expired and unlabelled food items, improper cooling of hazardous foods, and unclean kitchen equipment such as the ice machine and water dispenser. Staff interviews revealed inconsistent adherence to facility policies for food safety and cleaning, and record reviews showed missing documentation for required food cooling procedures.
Staff failed to cap and secure a gastric tube after disconnecting it from a resident, leaving the tube and feeding solution on the floor, and did not promptly remove a peripheral IV catheter after therapy was completed for another resident. These actions did not follow infection control policies and were confirmed by interviews with nursing staff and the DON.
Surveyors found that a laundry room was not maintained in good repair, with cracked and dirty floors, a large hole, an open pipe, a damaged wooden platform for chemical buckets, peeling ceiling paint, and a broken door to the trash area. These deficiencies were confirmed by the Maintenance Supervisor and Administrator, and were not in compliance with facility policy.
Thirteen rooms were found to house three residents each, but the room sizes did not meet the required 80 square feet per resident, with each resident receiving between 69.7 and 73.3 square feet. Staff and residents reported adequate space for movement and care, but the facility's documentation confirmed the rooms were below the regulatory minimum.
Closet doors in nine rooms were found unhooked and nonfunctional, as nurses had removed the bottom attachments to store residents' wheelchairs due to limited space. A family member reported the issue, but no repair requests were logged, and the DON confirmed that this practice was not permitted and could lead to resident injury.
A resident with chronic medical conditions had an abnormal potassium lab result that was not promptly reported to the physician, despite facility policy requiring immediate notification. The delay in communication was confirmed through record review and staff interviews.
A resident with a stage 4 sacral pressure ulcer and complex medical history was found without a required dressing on the wound, despite physician orders and facility policy mandating daily wound care with Silvadene, Santyl, and a foam dressing. Staff interviews confirmed the dressing was missing during care, and the DON acknowledged that the wound should always be covered to prevent infection and further injury.
A resident with multiple chronic conditions received IV hydration as ordered, but the IV catheter was not removed after therapy was completed, despite facility policy and lack of a physician order to maintain access. Nursing staff and the DON confirmed the catheter should have been discontinued promptly, but it remained in place for several days.
A resident with multiple medical conditions, including CHF and acute respiratory failure, did not have their oxygen tubing changed weekly as required by facility policy, and their physician's order for oxygen therapy was incomplete, lacking clear parameters for administration. Staff confirmed these deficiencies during interviews, and facility policies supported the requirements for both timely tubing changes and complete orders.
A resident with end-stage renal disease and a history of kidney transplant failure did not have current vital signs assessed and documented within the required timeframe before being transported for dialysis. Nursing staff took vital signs several hours before departure instead of within two hours as required by facility policy and physician orders, and this information was not properly communicated to the dialysis center.
The facility failed to ensure timely follow-up and documentation of Advance Directives for four residents, despite indications that these directives were executed or intended. This deficiency involved residents with various medical conditions, including cognitive impairments, and was acknowledged by the Social Services Director.
A resident with multiple health issues refused medications for several consecutive days, but the facility failed to notify the physician or document any educational efforts. The resident expressed a preference for taking medications with food and was not informed of the risks of refusal. The facility's policies require physician notification after a certain number of refusals, which was not followed.
A facility failed to obtain necessary physician orders and informed consent for the use of bilateral bed side rails for nine residents, despite their cognitive and mobility impairments. Observations confirmed the use of side rails without proper documentation, and staff interviews revealed a misunderstanding of policy requirements, leading to potential misuse of restraints.
The facility failed to develop and implement comprehensive care plans for 12 residents, leading to deficiencies in areas such as mobility aids, medical treatments, and infection precautions. Observations showed residents using side rails without care plans, missing precautions for infection control, and improper management of medications and oxygen therapy, placing residents at risk for missed care and potential harm.
The facility failed to manage pain effectively for two residents by not following physician orders and facility policies for lidocaine patch application and removal. One resident did not receive the patch at the scheduled time, and removal times were not documented, while another resident's patches were applied inconsistently and without proper labeling. The DON acknowledged the lack of documentation and adherence to policies, placing residents at risk for untreated pain.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights for several residents. Residents reported waiting 30 minutes to an hour for assistance, as CNAs were on lunch breaks and no other staff responded. The facility's policy required call lights to be answered within two minutes, which was not followed.
A facility failed to ensure its nursing staff had verified competencies necessary for resident care. A review revealed that a RN, an IPN, and two CNAs lacked documented skills competencies, as confirmed by the DSD. Facility policy requires competency assessments upon hire, annually, and as needed, but these were missing from the employee files, potentially compromising resident safety.
The facility failed to properly secure and reorder medications from emergency kits, leading to potential harm. An IV E-kit was improperly resealed, and a narcotic E-kit was not reordered promptly after use. The Emergency Kit Pharmacy Logs were incomplete, and procedures for reordering were not followed, as confirmed by the DON and an RN.
The facility failed to properly manage pharmaceutical supplies and medications, including the disposal of expired items and labeling of opened medications. Expired sterile supplies were found in storage, and opened medications lacked proper dating. Additionally, medication carts and pill cutters were not maintained in a clean and organized manner, posing risks of cross-contamination and infection.
The facility failed to provide appropriate meals for residents on renal and vegetarian diets, leading to dissatisfaction and potential nutritional inadequacies. A resident on a renal diet received chicken jambalaya instead of the prescribed meal, while residents on vegetarian diets reported limited meal variety and inappropriate options like fish sticks. The facility's dietary supervisor acknowledged the lack of a specialized vegetarian menu and the need for reassessment of dietary needs.
The facility failed to honor dietary preferences and physician-ordered diets, serving a vegan resident fish sticks and providing inadequate protein substitutes for vegetarian residents. This resulted in a deficiency in meal service, as the facility did not adhere to its policies on dietary profiles and resident preferences.
The facility failed to ensure safe food storage and preparation, as food brought in from outside was not dated, and there was no monitoring system for refrigerator temperatures. Expired food was not discarded, and the resident refrigerator lacked a thermometer and temperature log. The facility's policy on labeling and discarding perishable food was not followed.
The facility's Administrator failed to maintain professionalism during a recertification process, hindering an investigation into infection control practices. A resident with chronic conditions and on Enhanced Standard Precaution was observed with visitors not wearing PPE. The Administrator's confrontational behavior towards the surveyor and lack of communication about precautions led to visitor dissatisfaction and an incomplete investigation.
The facility failed to maintain an effective infection prevention and control program, with staff not donning appropriate PPE during resident care, lack of education and PPE for visitors, and unclean medication carts. Residents with indwelling catheters were not placed on Enhanced Standard Precautions (ESP), and staff lacked understanding of ESP requirements, increasing the risk of infection spread.
The facility failed to implement its Antibiotic Stewardship protocol for three residents, resulting in incomplete infection analysis for prescribed antibiotics. A resident with osteomyelitis, another with a spinal abscess, and a third with a UTI were all prescribed antibiotics without proper evaluation against usage criteria. This deficiency was identified during reviews with the Infection Preventionist Nurse.
A resident was not informed about the Enhanced Standard Precaution (ESP) measures in place, leading to confusion about her health status. Despite having ESP signage, staff failed to communicate the reasons for wearing gowns and gloves, violating the resident's rights. An LVN incorrectly stated that precautions were unnecessary, and the Infection Preventionist Nurse admitted the facility was still finalizing ESP protocols.
A resident with dementia and other health issues was not provided with necessary personal hygiene assistance after meals, leaving them with food on their clothes and bed. This failure to adhere to the care plan and facility policies compromised the resident's dignity and respect.
The facility failed to maintain comfortable noise levels, impacting two residents' ability to sleep due to staff shouting at night. Despite awareness of the issue, no corrective actions, such as staff training, were implemented, violating the facility's policy on maintaining a homelike environment.
A resident with a history of stroke, diabetes, and renal dialysis was not using a humidifier with their oxygen concentrator, leading to a failure in notifying the MD about this significant change in condition. The resident turned off the oxygen due to discomfort and lack of education on the humidifier's importance. The Infection Preventionist Nurse noted the issue and completed a Change of Condition report, but acknowledged that the nursing staff should have reported the change sooner.
A resident with cognitive impairments and multiple health conditions was found with medications improperly stored at their bedside, contrary to facility policy. The DON confirmed the resident was not approved for self-administration, highlighting a failure to ensure a hazard-free environment.
The facility failed to provide proper IV access care for two residents. One resident lacked a care plan for IV therapy, while another had a PICC line dressing improperly labeled. Additionally, a nurse did not wear required PPE during PICC line care. These actions were inconsistent with professional standards and facility policies.
Two residents in the facility did not receive prescribed oxygen therapy as per physician's orders. One resident, with multiple health conditions, was not provided with any oxygen therapy despite a physician's order. Another resident, with acute respiratory failure, received less oxygen than prescribed. The facility's policy required adherence to physician's orders for oxygen therapy, which was not followed.
A facility failed to document a post-hemodialysis assessment for a resident with end-stage renal failure, as required by professional standards. The resident, who needed maximal assistance for daily activities, did not have a post-dialysis evaluation form completed, indicating a lapse in care. An LVN confirmed that assessments should occur before, during, and after dialysis, but the facility did not maintain the necessary documentation.
The facility did not post the required daily nurse staffing hours on one occasion due to the absence of the Director of Staff and Development (DSD), who was on vacation. The posted information was outdated by two days, failing to provide residents, family, or visitors with access to current staffing hours, as mandated by federal regulations.
The facility failed to communicate pharmacist recommendations to the attending physician for two residents. One resident had a recommendation to re-evaluate duplicate antihistamine therapy, which was not documented or communicated, and the other had a recommendation to add a 'do not crush' instruction to a medication order, which was also not documented. The facility's policy required these recommendations to be acted upon and documented, which was not followed.
A resident on a kosher and fortified diet did not receive the fortified diet as ordered by the physician. During lunch service, the resident's prepackaged kosher meal was not opened to add butter, which was part of the fortified diet plan to increase caloric intake. The dietary staff failed to communicate and implement the fortified diet order, resulting in the resident not receiving the necessary additional calories.
A resident's room was found to have an uncovered overhead light with an exposed bulb, posing a potential safety risk. The Maintenance Supervisor confirmed the absence of a protective cover, which is required to prevent electrical accidents. The resident had multiple diagnoses, including hemiplegia and Alzheimer's, and required total dependence on staff for ADLs.
The facility did not meet the required 80 square feet per resident in 13 out of 34 rooms, with each room providing less than the minimum required space for three residents. Despite this, observations showed that residents and staff had enough space to move freely, and nursing staff could provide care safely. A room waiver request was submitted to address the issue.
Deficient Food Storage, Labelling, and Sanitation Practices in Dietary Services
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as evidenced by multiple observations and interviews. Surveyors found expired food items, such as pudding and strawberries, in the kitchen refrigerator, as well as unlabelled containers of cooked foods like fish sticks, cream soup, and meatloaf. The ice machine and water dispenser trays were observed to be dirty, and the residents' outside food storage refrigerator and freezer were found to be unclean, with old and dried food present. The refrigerator temperature was above 40 degrees, and some food items, including yogurt and sausages, were not properly labelled with expiration dates or use-by instructions. Interviews with dietary staff and supervisors revealed that the required cooling down method for hazardous foods was not consistently followed. One dietary cook admitted to not using the cool down method for recently prepared meatloaf and tuna, despite having received training on the procedure. Record reviews confirmed the absence of documentation for the cooling process of several cooked items, including meatloaf, soups, and fish sticks. The Registered Dietician confirmed that dietary staff are expected to follow the cool down method and that failure to do so could result in residents consuming unsafe food. Further interviews indicated a lack of clarity and consistency regarding staff responsibilities for food labelling, discarding expired foods, and cleaning equipment. The Maintenance Supervisor stated that he cleans the ice machine and water dispenser daily and the residents' refrigerator every three days, but there were no cleaning logs or policies for the water dispenser. Facility policies required labelling, dating, and timely discarding of food, as well as routine cleaning of the ice machine, but these procedures were not consistently implemented or documented.
Failure to Maintain Infection Control for Enteral Feeding Tubes and IV Catheters
Penalty
Summary
The facility failed to implement and maintain infection control measures for two residents, resulting in deficiencies related to the handling of a gastric tube (GT) and the removal of an intravenous (IV) catheter. For one resident with a history of urinary tract infection and gastrostomy, observations revealed that the GT feeding machine was disconnected, and the GT bottle containing Jevity was left uncapped and lying on the floor, with a moderate amount of the nutritional supplement leaking onto the floor. Interviews with nursing staff and the Director of Nursing confirmed that the GT tubing should have been capped when disconnected to prevent contamination, and that failure to do so constitutes an infection control issue. Additionally, the facility did not remove a peripheral IV catheter from another resident after the completion of IV therapy. The resident, who had diagnoses including hypertension, chronic kidney disease, and diabetes, was observed with a peripheral IV line still in place two days after the physician's order for hydration had ended. Nursing staff and the Director of Nursing confirmed that IV access should be discontinued promptly after therapy is completed unless there is a physician's order to maintain it, which was not present in this case. Record reviews of facility policies indicated that staff are trained on infection control procedures, including the proper handling of enteral feeding tubes and the removal of peripheral IV catheters. However, the observed practices did not align with these policies, as the GT tubing was not capped and was left on the floor, and the IV catheter was not removed in a timely manner after therapy completion.
Failure to Maintain Laundry Room in Safe and Operable Condition
Penalty
Summary
Surveyors observed that the facility failed to maintain one of two laundry service rooms in good repair, as required by policy. The laundry room was found to have multiple areas in disrepair, including cracked and dirty floors, a large hole in the floor, an open pipe in the wall, and a wooden platform supporting chemical buckets that was rotted or water-damaged with holes and cracks. The ceiling had dark spots of unknown origin, peeling and flaking paint, and the door leading to the trash area was broken at the bottom. The floor was also noted to be several different colors, indicating possible staining or further disrepair. These findings were confirmed during interviews with the Maintenance Supervisor, who acknowledged the need for immediate repairs, and the Administrator, who agreed that repairs were necessary once estimates were obtained. The facility's own policy and procedures require the Maintenance Department to keep all areas of the building, grounds, and equipment in a safe and operable manner at all times, and to maintain the building in good repair and free from hazards. The observed conditions in the laundry room, including structural damage, unclean surfaces, and compromised containment of chemicals, represent a failure to adhere to these requirements. No information about residents' medical history or condition was provided in relation to this deficiency.
Resident Rooms Below Minimum Space Requirements
Penalty
Summary
The facility failed to ensure that 13 out of 34 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms, as specified by regulations. Specifically, rooms identified as 3, 4, 8, 9, 11, 14, 15, 16, 17, 18, 20, 22, and 33 were found to house three residents each, with room sizes ranging from 209 to 220 square feet, resulting in less than the required space per resident. Documentation from the facility, including a room waiver request and Client Accommodation analysis, confirmed these measurements. Observations during the survey period noted that both residents and staff had enough space to move about freely, and staff interviews indicated that care could be provided adequately in the affected rooms. The facility's policy stated an intent to provide a safe, comfortable, and person-centered environment, but the physical room sizes did not meet the regulatory standard for space per resident.
Nonfunctional Closet Doors Used for Wheelchair Storage
Penalty
Summary
The facility failed to ensure that closet doors were functional in nine resident rooms, as observed during a survey. Family members reported that closet doors were broken and that the issue had been communicated to nursing staff, but the problem remained unresolved. During an observation with the Maintenance Supervisor, it was noted that the closet doors in the affected rooms were not attached at the bottom and would swing open. The Maintenance Supervisor explained that nurses had unhooked the closet sliding doors at the bottom to store residents' wheelchairs in the closets due to insufficient space in the rooms. A review of the facility's repair request log showed no recorded requests for the repair of the closet doors in the affected rooms. The Director of Nursing confirmed that nurses were not authorized to unhook closet doors and acknowledged the potential for resident injury due to the swinging doors. The facility's policy and job description for the Maintenance Supervisor require maintaining a safe, comfortable, and sanitary environment for residents, staff, and visitors.
Failure to Promptly Notify Physician of Abnormal Potassium Level
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify a physician of an abnormal laboratory result for a resident. The resident, who had a history of hypertension, chronic kidney disease, and diabetes, had a blood potassium level of 5.6 mEq/L, which was flagged as high. The laboratory result was available at 11:26 PM, but the physician was not notified until the following day at 5:50 PM. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that abnormal lab results should be reported to the physician as soon as they are received, in accordance with facility policy. The resident was cognitively intact and required substantial to maximal assistance with activities of daily living. The facility's policy required licensed nurses to promptly notify the attending physician of abnormal laboratory findings by telephone or fax, with the date and time noted. Despite this, there was a significant delay in notifying the physician about the resident's hyperkalemia, as documented in the records and confirmed during staff interviews.
Failure to Maintain Physician-Ordered Dressing on Sacral Pressure Ulcer
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for a resident with a stage 4 sacral pressure ulcer. The resident, who had a history of sepsis, osteomyelitis of the sacrum and coccyx, and a recent skin graft to the sacrococcyx area, was admitted and readmitted with significant medical needs. Physician orders and the resident's care plan required the application of Silvadene and Santyl ointments, cleansing with normal saline, and the use of a foam dressing to the sacral wound. However, during wound care observation, the resident's sacral pressure injury was found without a dressing in place. Staff interviews confirmed that the dressing was not present during morning care and that CNAs were instructed not to remove dressings, with responsibility for replacement falling to the charge nurse or RN supervisor if a dressing became soiled or detached. Record reviews further indicated that the facility's policies and the treatment nurse's job description required adherence to prescribed wound care treatments to prevent infection and promote healing. Despite these protocols, the resident's wound was left uncovered, contrary to both physician orders and facility policy. The DON and treatment nurses acknowledged that the wound should always be covered to prevent infection and further injury, and that the absence of a dressing was not in accordance with established procedures.
Failure to Timely Remove IV Catheter After Completion of Therapy
Penalty
Summary
The facility failed to remove a resident's intravenous (IV) catheter after the completion of ordered IV hydration therapy. The resident, who had a history of hypertension, chronic kidney disease, and diabetes, was cognitively intact and required substantial assistance with activities of daily living. Physician orders specified that IV hydration was to be administered until a specific date and time, after which there was no order to maintain the IV access. Despite this, observation revealed that the peripheral IV line remained in place on the resident's forearm two days after the hydration therapy was completed. Interviews with nursing staff and the Director of Nursing confirmed that facility policy required IV catheters to be discontinued promptly after therapy unless there was a physician's order to keep the access. There was no documentation of such an order for this resident. The facility's policy and procedures also indicated that peripheral IV catheters should be removed safely and aseptically by a competent nurse when therapy is completed. The failure to remove the IV catheter as required constituted a deficiency in following professional standards for IV administration.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not changing the resident's oxygen tubing weekly as required by facility policy and by maintaining an incomplete physician's order for oxygen therapy. During observation, the resident was found using a nasal cannula with a date label indicating it had not been changed within the required seven-day period. Staff interviews confirmed that the tubing should have been changed weekly to maintain infection control, and failure to do so could lead to infection. Additionally, a review of the resident's physician order for oxygen therapy revealed that the order lacked specific parameters, such as whether the oxygen was to be administered routinely or as needed, and did not provide clear instructions for when to start or stop oxygen. Both the RN Supervisor and the DON acknowledged that the order was incomplete and that oxygen, considered a medication, requires a complete and clear order to ensure safe administration. The facility's policies confirmed the need for weekly tubing changes and complete physician orders for oxygen therapy.
Failure to Assess and Document Pre-Dialysis Vital Signs Prior to Transport
Penalty
Summary
Facility staff failed to ensure that a resident requiring dialysis received care consistent with professional standards by not assessing and documenting the resident's current vital signs immediately prior to transport to the dialysis center. Record reviews showed that the resident's pre-dialysis vital signs were taken more than four hours before the resident left for dialysis on multiple occasions, despite facility policy and physician orders requiring that vital signs be taken within two hours of departure. Interviews with nursing staff and the Director of Nursing confirmed that vital signs are necessary to determine the resident's appropriateness for dialysis and to identify any potential complications before transport. The resident involved had a history of end-stage renal disease, dependence on renal dialysis, and kidney transplant failure, and required substantial assistance with activities of daily living. The care plan for this resident included monitoring vital signs and reporting abnormalities prior to dialysis. Facility policy and the care coordination agreement with the dialysis provider both required that current vital signs be communicated to the dialysis staff and that residents be assessed for medical stability before transport. Despite these requirements, the facility did not consistently follow these protocols, resulting in a failure to properly assess the resident's condition prior to dialysis treatments.
Failure to Follow Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents were informed, offered, or followed up regarding Advance Directives (ACHD) in a timely manner for four of the 18 sampled residents. This deficiency was identified through interviews and record reviews, revealing that the facility did not have copies of the ACHDs for Residents 43, 3, 48, and 58, despite indications that these residents had executed or intended to execute such directives. The absence of these documents in the residents' medical records could potentially lead to conflicts with the residents' healthcare wishes. For Resident 43, the admission records indicated a diagnosis of urinary tract infection, sepsis, and paroxysmal atrial fibrillation. The Minimum Data Set (MDS) showed that Resident 43 had mildly impaired cognitive skills and required assistance with activities of daily living. Despite choosing the option that an ACHD had been executed, there was no follow-up or documentation by the Social Services Department to obtain a copy of the ACHD. The Social Services Director (SSD) acknowledged the lack of follow-up and documentation. Similarly, Resident 3, who had diagnoses including hemiplegia, Parkinson's disease, and Alzheimer's disease, was noted to have moderately impaired cognitive skills and total dependence on staff for daily activities. Although the ACHD assessment indicated that an ACHD had been executed, there was no documentation or follow-up to obtain a copy. The SSD admitted to not following up or documenting the ACHD. For Residents 48 and 58, similar issues were noted, with the SSD failing to follow up on the residents' ACHD status or document any actions taken, despite the residents' intentions to execute or provide ACHDs.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician when a resident continued to refuse her medications, which was identified as a deficiency during a survey. The resident, who was admitted with diagnoses including metabolic encephalopathy, hypertension, a history of falling, and muscle weakness, had moderately impaired cognitive skills and required assistance with activities of daily living. Despite multiple consecutive days of medication refusals documented in the Medication Administration Record (MAR), there was no evidence in the Progress Notes that the physician was notified or that any education was provided to the resident regarding the risks of not taking her medications. During an interview, the resident expressed her dislike for taking medications without food and mentioned that nurses did not inform her of the risks associated with refusal. The Director of Nursing confirmed that the physician should be notified of medication refusals and that documentation should include the reason for refusal and any education provided. The facility's policy and procedure on medication administration and refusal of treatment require that the prescriber be notified after a certain number of doses are refused, but this was not adhered to in this case.
Improper Use of Bed Side Rails Without Physician Orders or Consent
Penalty
Summary
The facility failed to ensure that nine sampled residents were free from the use of physical restraints, specifically bilateral bed side rails, without obtaining the necessary physician's orders and informed consent as per the facility's policy and procedures. The residents involved had various medical conditions, including cognitive impairments, mobility issues, and other health diagnoses that required assistance with activities of daily living. Despite these needs, the facility did not have documented physician orders or informed consent for the use of side rails, which were observed to be in use for all nine residents. For Resident 43, the facility did not have a physician's order or informed consent for the use of bilateral bed side rails, and the resident's bed rail assessment indicated that side rails were not necessary. Similarly, Resident 48's care plan included the use of side rails for turning and repositioning, but there was no physician's order or informed consent documented. Observations confirmed that these residents were unable to lower the side rails independently, indicating a potential misuse of the rails as restraints. The Director of Nursing (DON) and other staff members, including an LVN, were interviewed and confirmed the use of side rails without the required orders or consent. The DON stated that side rails did not need a physician's order as they were not considered restraints, despite the facility's policy indicating otherwise. This misunderstanding and lack of adherence to policy resulted in the improper use of side rails, potentially compromising the residents' safety and dignity.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for 12 residents, leading to several deficiencies. For instance, residents requiring bilateral upper bed side rails as mobility enablers did not have corresponding care plans, despite observations showing the side rails in use. This oversight was noted for multiple residents, including those with cognitive impairments and physical limitations, who required assistance with daily activities such as toileting, bathing, and bed mobility. Additionally, the facility did not implement care plans for specific medical treatments and precautions. One resident receiving Venofer IV therapy for iron deficiency lacked a care plan for this treatment, and another resident requiring transmission-based precautions due to a risk of infection was not placed under the necessary precautions. Observations revealed that staff were not using personal protective equipment as required, increasing the risk of infection. The facility also failed to manage medications and oxygen therapy appropriately. A resident was found with medications at their bedside despite not being approved for self-administration, and another resident's oxygen therapy was not set up according to the physician's orders. These lapses in care planning and implementation placed residents at risk for missed care, worsening medical conditions, and potential harm.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, Resident 9 and Resident 58, by not adhering to physician orders and facility policies regarding the application and removal of lidocaine patches. Resident 9, who was admitted with diagnoses including aftercare following joint replacement surgery and major depressive disorder, had a care plan indicating the need for pain management. However, the facility did not administer the lidocaine patch at the scheduled time of 9:00 a.m. and failed to document the removal time of the patch, which was observed to be left on beyond the prescribed 12-hour period. Similarly, Resident 58, who had diagnoses including metabolic encephalopathy and a history of falling, also experienced deficiencies in pain management. The resident's care plan required the application of a lidocaine patch for 12 hours on and 12 hours off, but the facility did not document the removal times, and the patches were applied at inconsistent times, deviating from the scheduled 9:00 a.m. application. Observations revealed that the patches were not labeled with the date and time of application, as required by the facility's policy. The Director of Nursing acknowledged the lack of specific documentation regarding the application and removal of the patches. The facility's policies on pain management and transdermal drug delivery were not followed, as evidenced by the absence of documentation on the Medication Administration Record (MAR) and the failure to label the patches correctly. These deficiencies placed both residents at risk for experiencing untreated pain and discomfort.
Delayed Response to Call Lights Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by the delayed response to call lights for four out of five sampled residents. Residents 8, 18, 50, and 53 reported waiting between 30 minutes to an hour for assistance after activating their call lights. This delay occurred because the certified nursing assistants (CNAs) assigned to these residents were on lunch breaks, and no other CNAs responded to the call lights. The residents also reported hearing staff conversing outside their rooms without addressing the call lights. Resident 8 was admitted with diagnoses including obesity, osteoarthritis, and generalized muscle weakness, requiring moderate assistance for activities of daily living (ADLs). Resident 18 had monoplegia of the lower leg, spinal stenosis, and generalized muscle weakness, also requiring moderate assistance for ADLs. Resident 50 was diagnosed with bronchitis, obesity, and congestive heart failure, needing moderate assistance for ADLs. Resident 53 had diabetes mellitus, acute respiratory failure, and generalized muscle weakness, requiring minimal assistance for ADLs. The facility's policy required call lights to be answered promptly, within two minutes, which was not adhered to, as confirmed by the Director of Staff and Development.
Lack of Verified Competencies in Nursing Staff
Penalty
Summary
The facility failed to ensure that its nursing staff possessed the necessary competencies to provide safe and effective care to residents. During an interview and record review, it was found that four out of nine sampled nursing staff members, including a Registered Nurse, an Infection Prevention Nurse, and two Certified Nursing Assistants, lacked verified skills competencies. The Director of Staff and Development confirmed that these competencies were missing from the employee files. According to the facility's policy and procedures, competency assessments should be conducted upon hire, annually, and as needed, and should be documented in the employee files. The absence of these assessments indicates a failure to adhere to the facility's policy, potentially compromising resident safety.
Failure to Secure and Reorder Emergency Kits
Penalty
Summary
The facility failed to ensure proper pharmaceutical services by not securely sealing the emergency kits (E-kits) and not reordering medications used from these kits. In one instance, an Intravenous (IV) E-kit located in a medication storage closet was improperly resealed with a red zip-tie, which allowed it to be opened without cutting the tie. The Director of Nursing (DON) confirmed that the E-kit was not properly secured and should have been replaced by the pharmacy within 48 hours of opening. Additionally, the Emergency Kit Pharmacy Log inside the E-kit was incomplete, missing entries for the pharmacist taking the order and the serial number, which the DON acknowledged should have been filled out by the nurse when removing medication. In another instance, a narcotic E-kit in a medication cart was found with a red zip-tie, indicating it had been opened. The E-kit pharmacy log showed that a medication was removed, but the required reordering of a new E-kit was not completed promptly. The Registered Nurse (RN) stated that the procedure required the nurse to reorder a new E-kit as soon as possible, with a refill needed within 72 hours of opening. The facility's policy and procedures outlined the steps for documenting medication use and reordering E-kits, but these were not followed, leading to potential harm due to the unavailability of medications in emergencies.
Deficiencies in Pharmaceutical Management and Cleanliness
Penalty
Summary
The facility failed to ensure proper disposal and management of pharmaceutical supplies and medications, as observed during a survey. An open sterile central line dressing kit, along with expired sterile needles, alcohol pads, and a saliva collection kit, were found in the IV medication storage closet. A registered nurse confirmed the expiration of these supplies and acknowledged that they should not have been present. The facility's policy requires that equipment and supplies for medication administration be clean and orderly, and that expired items be removed and disposed of appropriately. Additionally, the facility did not adhere to proper labeling and usage protocols for medications. Opened bottles of acidophilus and bismuth subsalicylate were found without dates indicating when they were opened, contrary to the facility's policy that requires dating upon opening. Furthermore, a foil pack of ipratropium Bromide and albuterol sulfate solution was found open beyond the manufacturer's recommended two-week usage period. The facility's policy mandates that nurses check expiration dates before administering medications and remove expired medications from active supply. The survey also revealed issues with cleanliness and organization of medication carts and equipment. Pill cutters in two medication carts were observed with residue from previous uses, and the carts themselves were cluttered with various items. Both a registered nurse and a licensed vocational nurse acknowledged that pill cutters should be cleaned after each use to prevent cross-contamination. The infection preventionist nurse confirmed that maintaining cleanliness of medication carts and equipment is essential to prevent infection transmission, as outlined in the facility's general guidelines for medication administration.
Inadequate Dietary Accommodations for Renal and Vegetarian Diets
Penalty
Summary
The facility failed to adhere to the dietary requirements and preferences of its residents, leading to dissatisfaction and potential nutritional inadequacies. One resident on a renal diet, which requires careful management of fluid, electrolyte, and mineral intake, was served chicken jambalaya instead of the prescribed baked chicken and rice. This substitution was inappropriate for a renal diet due to the presence of tomatoes and sausage, which are not suitable for individuals with kidney disease. The resident expressed dissatisfaction with the meal, and their family noted that the food was not appropriate for a renal diet. Additionally, residents on vegetarian and vegan diets reported a lack of variety in their meal options. One vegan resident was mistakenly served fish sticks, while another vegetarian resident frequently received fish sticks as a meal option, despite their dietary preferences. The facility's dietary supervisor acknowledged the limited vegetarian options and the absence of a specialized menu for vegetarian diets. Attempts to introduce plant-based alternatives were unsuccessful, as residents did not find them palatable. The facility's policies and procedures for menu planning and dietary accommodations were not effectively implemented, resulting in meals that did not meet the nutritional needs and preferences of the residents. The dietary supervisor and facility administrator recognized the need to reassess and evaluate the residents' dietary needs in collaboration with a registered dietitian to ensure compliance with dietary requirements and resident satisfaction.
Failure to Honor Dietary Preferences and Provide Adequate Nutrition
Penalty
Summary
The facility failed to provide meals that adhered to the dietary preferences and physician-ordered diets of its residents, leading to a deficiency in meal service. Resident 69, who was on a vegan diet, was served fish sticks during lunch, which contradicts the vegan dietary restrictions that exclude all animal products, including fish. Despite the resident's dietary profile indicating a preference for plant-based foods and a dislike for meats and dairy, the dietary staff continued to serve fish sticks, believing the resident liked them. This inconsistency in meal service was further compounded by the resident's significant weight loss over two weeks, as noted in the nutrition progress notes. Additionally, two residents, identified as vegetarians, were served fish sticks as an alternative protein source, which provided significantly less protein than the regular menu options of beef paprika and roasted pork chop. The facility's dietary supervisor acknowledged the lack of a set menu for vegetarian diets and admitted that the protein content of the fish sticks was not equivalent to the meat options provided to other residents. This inadequate substitution resulted in a lower protein intake for the vegetarian residents, which could potentially affect their nutritional status. The facility's policies on dietary profiles and resident preferences were not effectively implemented, as evidenced by the repeated serving of inappropriate meal options. The dietary manager's failure to update and adhere to the residents' dietary preferences and physician orders contributed to the deficiency. The lack of suitable vegetarian and vegan meal options, as well as the improper substitution of protein sources, highlighted the facility's inability to meet the nutritional needs and preferences of its residents.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Food brought in from outside the facility, including leftovers stored in the resident refrigerator, was not dated, and there was no monitoring system for refrigerator temperatures. Expired food was not discarded, which could potentially lead to harmful bacteria growth and cross-contamination. During an observation, it was noted that the resident refrigerator lacked a thermometer and a temperature documentation log. Various food items, including plastic bags, a lunch box, and to-go containers, were found without labels or dates, and some exceeded the storage period for outside food. During an interview with the Dietary Supervisor and Administrator, it was revealed that the nursing staff were responsible for checking food labels and dates, but there was no clear explanation for the absence of a thermometer in the freezer. The facility's policy indicated that food brought in by visitors should be labeled with the resident's name and date received, and perishable food should be discarded after two hours at bedside or after 48 hours if refrigerated. However, these procedures were not followed, leading to the deficiency.
Administrator's Unprofessional Conduct Impedes Infection Control Investigation
Penalty
Summary
The facility failed to ensure that the Administrator maintained professionalism and appropriate behavior during the recertification process, which impeded the completion of an investigation. This deficiency placed residents at risk for the spread of infections and delays in care. The report highlights an incident involving Resident 278, who was admitted with chronic kidney disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. The resident was on Enhanced Standard Precaution (ESP) due to a history of multidrug-resistant organisms, but there was no physician's order for ESP, and visitors were observed entering the resident's room without wearing the required personal protective equipment (PPE). During an observation and interview, the Administrator approached the surveyor in a confrontational manner, interrupting the surveyor and displaying unprofessional behavior in front of staff, residents, and visitors. The Administrator's actions included speaking loudly, pointing a paper close to the surveyor's face, and angrily questioning the surveyor about the facility's policies. This behavior led to a visitor confronting the surveyor, expressing dissatisfaction with the facility's lack of communication regarding the precautions and the absence of PPE near the resident's room. The report also describes a telephone interview with the district office supervision, where the Administrator continued to interrupt and speak loudly, claiming to be passionate. During the formal exit conference, the Administrator wore an inappropriate outfit and interrupted the surveyor multiple times, further demonstrating a lack of professionalism. The facility's policy on Enhanced Standard Precautions was reviewed, indicating the need for clear communication and signage for infection control, which was not adequately followed in this case.
Infection Control Deficiencies in PPE Use and Education
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not donning appropriate personal protective equipment (PPE) when required. For instance, a Licensed Vocational Nurse (LVN) was observed wearing gloves but not a gown while disconnecting a resident from a gastrostomy tube, despite the resident being on Enhanced Standard Precautions (ESP). Additionally, a Certified Nursing Assistant (CNA) did not wear any PPE while assisting another resident, who was supposed to be on ESP, due to a lack of updated signage and readily available PPE. The facility also failed to provide necessary education and PPE to visitors of residents on ESP. In one case, visitors entered a resident's room without being informed about the precautions or offered PPE, as the facility relied on phone notifications prior to visits. Furthermore, residents with indwelling catheters, such as those undergoing hemodialysis, were not placed on ESP, contrary to the facility's policy and CDC guidelines. This oversight was partly due to a lack of understanding among staff about the requirements for ESP. Additional deficiencies included unclean medication carts and pill cutters, which were observed with residue and clutter, posing a risk of cross-contamination. A Registered Nurse (RN) also failed to don a gown while providing care for a resident with a peripherally inserted central catheter (PICC), despite the presence of signage indicating the need for gown and glove use during such procedures. These practices collectively increased the potential for cross-contamination and the spread of infection within the facility.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship for three residents, leading to a deficiency in monitoring antibiotic use. Resident 178, who was admitted with conditions including diabetes mellitus, end-stage renal failure, and hemodialysis dependence, was prescribed ceftriaxone sodium and daptomycin for osteomyelitis. However, the Infection Screening Evaluation (ISE) for these antibiotics lacked the necessary infection analysis results to determine if the antibiotic usage criteria were met. This oversight was confirmed during a review with the Infection Preventionist Nurse (IPN) and acknowledged by the Director of Nursing (DON). Resident 278, admitted with diagnoses such as diabetes mellitus, muscle weakness, and a spinal abscess, was prescribed daptomycin via a peripherally inserted central catheter (PICC). Similar to Resident 178, the ISE for Resident 278's antibiotic treatment was incomplete, missing the infection analysis result needed to confirm if the antibiotic usage criteria were met. This deficiency was also identified during a review with the IPN. Resident 13, with a history of diabetes mellitus, major depressive disorder, and essential hypertension, was prescribed ciprofloxacin for a urinary tract infection. The ISE for this antibiotic was also found to be lacking the infection analysis result necessary to verify if the antibiotic usage criteria were met. The facility's policy on Antibiotic Stewardship, which mandates tracking antibiotic use against McGeer's Criteria, was not followed, leading to the potential for antibiotic resistance and adverse events.
Failure to Inform Resident About Health Status and Precautions
Penalty
Summary
The facility failed to ensure that a resident's right to be informed about their health status and care was honored, leading to a deficiency in the delivery of necessary care and services. Resident 43, who was admitted with diagnoses including urinary tract infection, sepsis, and paroxysmal atrial fibrillation, was observed to have an Enhanced Standard Precaution (ESP) signage posted outside her door. Despite this, Resident 43 was not informed about the reason for the precautionary measures, such as staff wearing gowns and gloves during care. The resident expressed confusion and concern about her health status, indicating that no explanation was provided by the nursing staff. During interactions with the staff, including a Licensed Vocational Nurse (LVN) and an Infection Preventionist Nurse (IPN), it was revealed that there was a lack of communication and education regarding the ESP protocols. The LVN incorrectly informed the resident that there was no need for gowns and gloves, contradicting the posted signage. The IPN acknowledged that staff should educate residents about transmission-based precautions and admitted that the facility was still in the process of finalizing their ESP protocols. This lack of communication and proper protocol implementation violated the resident's rights as outlined in the facility's policy and procedures on resident rights.
Failure to Provide Personal Hygiene Assistance
Penalty
Summary
The facility failed to enhance a resident's dignity and respect by not providing necessary personal hygiene and assistance. Resident 1, who was admitted with diagnoses including unspecified dementia, moderate protein-calorie malnutrition, and heart failure, required moderate assistance for activities of daily living (ADLs) due to severely impaired cognitive skills. The resident's care plan indicated a need for extensive assistance with personal hygiene and oral care. However, on a specific date, the ADL log did not show any record of care or assistance provided to the resident during dinner. An observation on the same day revealed Resident 1 lying in bed with food scattered over their clothes and bed. During an interview, CNA 8 confirmed that the resident was not assisted after eating, and food was not removed from the resident's clothes and bed. The facility's policies emphasized providing care that promotes dignity, respect, and a homelike environment, yet these were not adhered to in this instance, potentially affecting the resident's psychosocial well-being.
Failure to Maintain Comfortable Noise Levels
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents by not ensuring that noise levels were kept at a comfortable level, particularly during the night. This deficiency was identified for two residents who reported being unable to sleep due to staff shouting and yelling across the hallway at night. Both residents had moderately intact cognition and required varying levels of assistance with activities of daily living. The issue was raised during a resident council meeting, and previous complaints had been documented in the resident council minutes. Despite the noise issue being brought to the attention of the nursing department, there was no evidence that corrective actions, such as staff in-service training, were implemented. Interviews with the Activity Director and the Director of Staff and Development confirmed that the noise issue was acknowledged but not addressed through staff training. The facility's policy on maintaining a comfortable environment emphasized the importance of comfortable noise levels, yet this was not adhered to, leading to the deficiency.
Failure to Notify MD of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the Medical Director about a significant change in condition for a resident who was not using a humidifier with their oxygen concentrator. This oversight was identified during an observation and interview with the resident, who reported turning off the oxygen due to discomfort and a lack of education on the importance of the humidifier. The resident's medical history includes hemiplegia, hemiparesis following a stroke, diabetes mellitus, and dependence on renal dialysis. The resident was moderately impaired and required assistance with activities of daily living. The Infection Preventionist Nurse noted the resident's non-use of the humidifier and completed a Change of Condition report, acknowledging that the nursing staff should have reported the change sooner. The facility's policy requires prompt notification of the resident, their physician, and family members in the event of a significant change in condition. The failure to notify the Medical Director in a timely manner had the potential to place the resident at risk for dry mucous membranes, which could lead to skin breakdown and infection.
Improper Medication Storage Poses Risk to Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from risks and hazards for a resident by not ensuring that medications were properly stored according to the facility's policy and procedures. Specifically, a resident was found with an opened Desitin cream inside their bedside drawer and eyedrops on top of the bedside table, despite not being approved for self-administration of medications. This oversight was observed during a room inspection and confirmed by the Director of Nursing (DON), who acknowledged that the resident was not allowed to keep medications at the bedside. The resident involved had a history of metabolic encephalopathy, acute respiratory failure, acute kidney failure, and pneumonia, and required maximal to total assistance for daily activities. The facility's policy stated that medications should only be accessible to authorized personnel and that bedside storage is only permitted when it does not pose a risk to confused residents. The presence of these medications at the bedside increased the risk of accidents, under or overdosing, and medication diversion, potentially jeopardizing the health and safety of the resident and others.
Deficiencies in IV Access Care and PPE Use
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) access care for two residents, as per professional standards and facility policy. For Resident 277, the facility did not develop or implement a care plan for the resident's IV therapy, despite the resident having an order for Venofer intravenous solution for iron deficiency. The resident's medical history included hypertensive heart disease with heart failure, muscle weakness, difficulty walking, and anemia. The absence of a care plan was confirmed by the Infection Prevention Nurse during an interview. For Resident 278, the facility did not properly label the peripherally inserted central catheter (PICC) line dressing with the date, time, and initials of the staff member who changed it. The resident had a history of diabetes mellitus, muscle weakness, discitis in the lumbar region, and malignant neoplasm of the breast. The resident was on IV antibiotic therapy and had a PICC line, which required dressing changes every seven days. During an observation, it was noted that the dressing was only labeled with the date and initials, lacking the time of change. Additionally, Registered Nurse 1 failed to wear the required personal protective equipment (PPE) while providing care for Resident 278's PICC line. The nurse did not don a gown as required by the Enhanced Standard Precautions, which were clearly indicated on the signage outside the resident's room. This oversight was acknowledged by the nurse during an interview, where it was confirmed that the facility's policies and procedures were not followed in these instances.
Failure to Provide Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents, Resident 3 and Resident 10, as per their physician's orders. Resident 3, who was admitted with conditions including hemiplegia, Parkinson's disease, and Alzheimer's disease, had a physician's order for oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 93%. However, observations on multiple occasions revealed that Resident 3 was not receiving the prescribed oxygen therapy, and there was no oxygen machine or nasal cannula present in the room. The Director of Nursing (DON) confirmed that the facility was not implementing the care plan regarding oxygen therapy for Resident 3. Resident 10, who was admitted with acute respiratory failure and heart failure, also had a physician's order for oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 93%. During an observation, Resident 10 was found to be receiving oxygen at only 1.5 liters per minute, which was below the prescribed amount. The DON acknowledged that the oxygen machine was not set to the correct level as per the physician's order. The facility's policy and procedure for oxygen therapy, which was reviewed earlier in the year, indicated that oxygen should be administered according to physician's orders. The failure to adhere to these orders for both residents had the potential to deny them the necessary oxygen needed for their health and well-being.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to provide appropriate post-hemodialysis care for a resident, identified as Resident 46, who required hemodialysis treatment due to end-stage renal failure. The deficiency was identified when the facility did not assess and document the resident's condition for complications after hemodialysis treatment, as required by professional standards of practice. The resident, who had a history of diabetes mellitus and generalized muscle weakness, was dependent on hemodialysis and required maximal assistance for activities of daily living. The facility's records showed that the post-dialysis evaluation form for a specific date was missing, indicating a lapse in the required assessment process. During an interview, a Licensed Vocational Nurse (LVN 3) confirmed that residents scheduled for hemodialysis were supposed to be assessed before leaving the facility, during the treatment by the hemodialysis staff, and upon returning to the facility. The nurse stated that the nursing staff was responsible for assessing the resident and documenting the assessment to ensure the resident tolerated the hemodialysis without complications. The facility's policy on dialysis care required all documentation concerning dialysis services to be maintained in the resident's medical record, which was not adhered to in this instance.
Failure to Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to comply with the federal requirement to post daily actual hours worked by the nursing staff in an area accessible to the public. On May 25, 2024, an observation at the nurse's station revealed that the posted nurse staffing hours were dated May 23, 2024, indicating that the information had not been updated for two days. During an interview on May 27, 2024, the Director of Staff and Development (DSD) admitted that the facility was unable to update and post the nursing hours due to his absence on vacation. The facility's policy and procedures require daily posting of the facility name, current date, and total number and actual hours worked by all licensed and unlicensed nursing staff responsible for resident care per shift. This failure resulted in the actual hours worked by the staff not being readily accessible to residents, family, or visitors, potentially leading to inadequate staffing.
Failure to Communicate Pharmacist Recommendations
Penalty
Summary
The facility failed to communicate the consultant pharmacist's recommendations from the Medication Regimen Review (MRR) to the attending physician for two residents, Resident 15 and Resident 53. For Resident 15, the pharmacist recommended re-evaluating the use of cetirizine and loratadine due to potential duplicate therapy, with instructions to document the rationale if the medications were to be continued. However, the Director of Nursing (DON) confirmed that there was no documentation in Resident 15's progress notes regarding the pharmacist's recommendation, and the Nurse Practitioner was unaware of the duplicate antihistamine therapy or the pharmacy recommendation. For Resident 53, the pharmacist recommended adding a 'do not crush' instruction to the Fosamax order. The DON confirmed that this recommendation was not documented in the resident's progress notes, and the 'do not crush' instruction was missing from the active physician's orders. The facility's policy required that recommendations be acted upon and documented by the facility staff and/or the prescriber, which was not followed in these cases.
Failure to Provide Fortified Diet as Ordered
Penalty
Summary
The facility failed to provide a fortified diet as ordered by the physician for a resident who was on a kosher and fortified diet. During an observation of lunch service, it was noted that the resident received a prepackaged kosher meal that was heated in the microwave but did not have butter added to it, which was part of the fortified diet order. The dietary staff responsible for preparing the trays did not communicate or implement the fortified diet order for the resident, resulting in the absence of additional calories intended to prevent weight loss. The dietary supervisor confirmed that the fortified diet orders were not followed for the resident, as the prepackaged kosher meals were not opened to add butter, which was the facility's method of fortifying meals. The resident's dietary profile indicated a preference for kosher food and a need for a fortified diet due to weight loss. The facility's policy on fortified diets emphasized the importance of increasing caloric intake by adding items like butter, but this was not executed for the resident, leading to a deficiency in meeting the resident's nutritional needs.
Uncovered Overhead Light Poses Safety Risk
Penalty
Summary
The facility failed to maintain patient care equipment in safe working condition, as evidenced by an uncovered overhead light with an exposed bulb in the room of a resident. This deficiency was identified during an observation of the resident's room, where it was noted that the overhead light lacked a protective cover. The Maintenance Supervisor confirmed the absence of the cover and acknowledged that the light should always have a protective cover to prevent potential electrical accidents. The resident involved in this deficiency was admitted to the facility with multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction, Parkinson's disease, dysphagia, and Alzheimer's disease. The resident's cognitive skills for daily decision-making were moderately impaired, and they required total dependence on staff for activities of daily living. The facility's policy and procedures indicated that adequate lighting should be provided to promote a safe and comfortable environment, which was not adhered to in this instance.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 out of 34 rooms met the required 80 square feet per resident in multiple resident rooms. Specifically, rooms numbered 3, 4, 8, 9, 11, 14, 15, 16, 17, 18, 20, 22, and 33 did not meet this requirement, with each room providing less than the minimum required space per resident. The Client Accommodation Analysis revealed that these rooms, intended for three residents each, ranged from 69.7 to 73.3 square feet per resident, falling short of the 240 square feet total required for three-bedroom accommodations. Despite these deficiencies, observations indicated that both residents and staff had enough space to move freely, and nursing staff had adequate space to provide care safely. The facility had submitted a room waiver request to address this issue.
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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