Westview Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, California.
- Location
- 12225 Shale Ridge Lane, Auburn, California 95602
- CMS Provider Number
- 055776
- Inspections on file
- 83
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Westview Healthcare Center during CMS and state inspections, most recent first.
A resident who lacked decision-making capacity had an RP/POA spouse and a physician order requiring that any change in medications, treatments, diagnoses, behaviors, or care plan be approved by the spouse. The RP had arranged for the resident’s psychiatric care through an outside psychiatrist and, during a care conference, verbally and in writing withheld consent for any psychiatric, psychological, or mental health services from the facility’s contracted psychiatrist (PD) or other contracted mental health providers, requesting that they be removed from the resident’s provider list. Despite this, the resident’s profile and face sheet continued to list the contracted PD, the ADON acknowledged the RP’s request but did not remove the PD’s name or notify the PD, and the PD later arrived at the resident’s room with a list that included the resident, prompting the RP to intervene. Surveyors found no evidence that the facility acted on the RP’s request or prevented the PD’s access to the resident’s information, contrary to the facility’s resident rights and privacy policies.
A resident with type 2 DM on Jardiance and scheduled insulin, and with a history of stroke and DKA, had only PRN blood glucose monitoring initially and later an order for routine AM and HS checks. Documentation showed multiple blood glucose readings above 200 mg/dL, including several over 400 mg/dL on consecutive days, but there was only one documented MD notification despite these elevations. The resident was later transferred to the hospital with worsening hypoxemia and was found to have blood glucose greater than 500, requiring ICU treatment. The DON reported that blood sugars were expected to be monitored regularly and that MD notification was expected for readings above 200 mg/dL, and the facility’s diabetes protocol called for twice-daily monitoring for residents on insulin and practitioner notification for repeated readings above 250 mg/dL with a change in condition.
A resident with post-stroke hemiplegia, aphasia, and DM with ketoacidosis was admitted for short-term care, with the daughter identified as the responsible party. Social services staff documented voicemail and phone contact to invite the responsible party to a care conference and noted that the party would attend by phone, but there was no follow-up documentation confirming that the conference occurred with the representative’s participation. An IDT conference note later indicated a care conference was held with SSD, ADON, and DOR, but the Nursing Services section was left incomplete and there was no record that the representative was involved. The MDSC confirmed the resident was nonverbal, tube-fed, and bedbound, that SSD schedules conferences within the first week of admission, and that there was no documentation of contact with the representative, contrary to facility policy requiring resident/representative participation and documented notification for care planning.
A document containing residents’ protected health information (PHI), including names, room numbers, cognitive (A&O) status, code status, diagnoses, and medication administration details, was observed left on top of a medication cart in a hallway. A nurse admitted he had left the document there and acknowledged it violated residents’ rights to privacy and confidentiality. When shown photos of the document on the cart, the DON confirmed it should not have been there. Facility policy on PHI requires all personnel to manage and protect resident information to prevent unauthorized disclosure.
A resident with multiple chronic conditions and moderate cognitive impairment had an Advance Health Care Directive (AD) designating two individuals as Power of Attorney for Health Care (POA). The facility failed to maintain the current AD in the electronic record and instead relied on emergency contacts not named in the AD for notifications and decision-making. As a result, the designated agents were not notified of the resident's death by the facility, learning of it only through the mortuary. Staff later confirmed the AD was not uploaded or referenced as required by facility policy.
A resident with significant physical disabilities and intact cognition was struck in the face by another resident with severe cognitive impairment and a history of aggressive behavior. The incident occurred in the smoking area, resulting in physical injury and psychosocial distress for the victim. Witnesses and staff confirmed the altercation, and facility records indicated that preventive measures to monitor and separate residents with aggressive tendencies were not effectively implemented prior to the event.
Care plans were not updated and documentation was incomplete for three residents after two were involved in a physical altercation and another reported abuse by a CNA. Despite the incidents being reported, the required care plan updates and clinical documentation were not completed as per facility policy.
A resident with normal cognition and a history of stroke was physically abused by a roommate with moderate cognitive impairment, who threw a hard plastic cup of thickened liquid at the resident's face during an argument over cigarettes. The incident resulted in the resident being covered in fluid and sustaining a red mark on the cheek, and was confirmed by both residents and the DON. This event represents a failure to protect a resident from physical abuse as required by facility policy.
A cognitively impaired resident with diabetes was subjected to sexual abuse when another resident, known for prior inappropriate behaviors, grabbed and placed the resident's hand on his groin. This incident, witnessed and reported by another resident, was not the first occurrence, and previous inappropriate actions by the perpetrator had not been properly reported or addressed by staff.
Staff failed to report an allegation of abuse involving two residents to enforcement agencies within the required two-hour timeframe. Despite being notified of the incident, the Administrator delayed reporting for three days, contrary to facility policy and federal regulations. The resident involved had a documented history of inappropriate behavior that had not been previously reported or addressed.
A resident with dementia and moderate memory impairment was inappropriately touched by another resident, also with moderate memory impairment, in a hallway after an activity event. The incident was witnessed by staff, and the affected resident was unable to communicate well but showed visible signs of distress. Facility records confirmed the incident, and the DON acknowledged it occurred, but there was no evidence of consent. This resulted in a failure to protect the resident from abuse, contrary to the facility's abuse prevention policy.
Discontinued controlled medications, including a bottle of lacosamide and several blister packs, were found improperly stored with non-controlled and active medications, lacking required count sheets and not secured in the DON's office as per facility policy. Nursing staff confirmed these medications should have been removed from active storage and properly documented until destruction.
Surveyors found expired medications, loose pills, and a misplaced blister pack in medication carts, as well as unlabeled creams left at the bedside of two residents. LNs and the DON confirmed these practices were not in line with facility policies, which require proper labeling, timely disposal of expired drugs, and secure storage of all medications.
Surveyors identified multiple infection control deficiencies, including an unlabeled G-tube water flush bag for a resident with severe cognitive impairment, a medication cart not cleaned of residue from a previously crushed medication, and a CNA providing high-contact care to a resident on Enhanced Barrier Precautions without wearing a gown, despite facility policy and posted signage.
A resident with mild memory impairment was inaccurately assessed as a non-smoker in the MDS and related documentation, despite self-reporting cigar use and staff confirmation. The MDS Coordinator acknowledged the inconsistency between the resident's actual tobacco use and the documented assessments.
A resident with diagnoses of unspecified psychosis and major depressive disorder was not provided with a required PASRR Level II evaluation after readmission. The DON was unaware of the need for the evaluation, and no follow-up was conducted, resulting in the resident not receiving the necessary assessment as indicated by the facility's screening process.
Four residents did not have comprehensive care plans addressing their needs, including three residents who smoked and one with rashes. In several cases, staff confirmed the absence of required care plans or failed to implement existing plans, such as not storing smoking materials as directed. These deficiencies were identified through interviews, record reviews, and direct observation.
A resident with cognitive impairment and hearing loss did not receive needed assistance with hearing aids, which remained unused for two months. The resident repeatedly requested help and education on using and charging the devices, but staff failed to provide support due to unclear communication and lack of documented orders, despite facility policy requiring such assistance.
A resident with severe cognitive deficits and total dependence on staff for ADLs was observed with long, dirty fingernails on her left hand. Despite care plan requirements and facility policy mandating daily grooming and nail care, staff failed to provide this assistance, as confirmed by both a nurse and the DON.
Two residents with severe cognitive and physical impairments were found without accessible call lights, despite care plans and facility policy requiring call lights to be within reach. Staff confirmed the call lights were not positioned appropriately, leaving the residents unable to request assistance as needed.
Several rooms did not meet the required minimum square footage per resident, with some providing only 65 to 78.12 square feet instead of the mandated 80 or 100 square feet. Observations showed the rooms were clutter-free and accessible for residents with mobility aids, and neither residents nor staff reported issues related to space or care delivery.
A resident with long-term kidney disease and breathing problems was not allowed to return to the facility after hospitalization due to the interference of her POA, her daughter, with medical care. Despite the facility's policy allowing return within the bed-hold period, the resident was discharged on the same day she was sent to the hospital, as confirmed by the Administrator and DON.
A resident with COPD and kidney failure was prescribed Prednisone for five days post-hospital discharge, but the LTC facility continued the medication for 17 additional days. This oversight led to severe oral thrush and fluid retention. Despite family communication and multiple NP visits, the error was not corrected, and the facility's policies on medication orders were not followed.
A resident with cognitive impairment was injured during an altercation with another resident who was cognitively intact. The incident involved one resident striking the other with a wheelchair armrest, causing a skin tear. The altercation was witnessed by staff, and the resident admitted to the act. The facility's abuse prevention policy was not effectively implemented to protect the resident from harm.
A facility failed to provide a resident's legal representative with timely access to medical records. The representative requested the resident's vaccination records, but the facility did not provide them within the 72-hour timeframe as per policy. The records were requested on August 2, 2024, but were not provided until August 9, 2024, resulting in a deficiency.
A resident with multiple health issues was discharged without a 30-day notice, limiting their ability to appeal. The discharge was ordered and executed on the same day, with the Social Services Director confirming the notification and discharge times. The DON acknowledged the facility's practice of not issuing 30-day notices, and no documentation of a discharge notice was found.
A resident did not receive routine baths as per their schedule, leading to feelings of discomfort and dissatisfaction. Despite being scheduled for showers twice a week, the resident only received one partial bath in a month. Facility staff confirmed the lack of documentation and adherence to the bathing schedule, contrary to the facility's policy.
The facility failed to maintain effective pest control and sanitary conditions in the kitchen, with flies and worm-like creatures observed in the food preparation area. The Dietary Manager acknowledged the presence of flies and mentioned monthly pest control visits, but live flies were still found near the stove, sink, and storage room. Deteriorating floor tiles and an opening in the wall were noted, with numerous worm-like creatures present. Pest control logs indicated significant insect activity in previous months.
The facility failed to store foods according to professional standards for food safety. Opened and unlabeled food items were found, a stained cutting board was not properly maintained, and brownish puffy substances were observed on storage racks. These issues were acknowledged by the Dietary Manager and had the potential to increase the risk of foodborne illnesses for 164 residents.
The facility failed to protect residents' personal and medical information when dietary tray tickets containing sensitive details were discarded in the general trash. The Dietary Manager and Registered Dietitian acknowledged the issue, recognizing it as a potential HIPAA violation. Facility policies mandate that such information should be kept confidential and disposed of properly.
The facility failed to ensure accurate accountability of controlled medications for three residents, resulting in discrepancies between the MAR and CDR. The DON confirmed these discrepancies and stated that staff are expected to document in both records when administering controlled medications, as per the facility's P&P.
The facility failed to consistently monitor and document side effects and behaviors associated with psychotropic medication use for a resident. The resident, admitted with depression and a psychotic disorder, was not monitored for 50 shifts over several months. The DON confirmed the lack of monitoring, which is required by the facility's policy on psychotropic medication use.
The facility failed to ensure that opened biologicals, eye drops, and ear drops were dated once opened, appropriately labeled, and not available for resident use past their expiration date. Inspections revealed multiple medications either past their use-by dates or without appropriate labeling across various medication carts. Staff confirmed these deficiencies and emphasized the importance of proper labeling and timely removal of expired medications.
The facility failed to maintain effective infection control, with issues including a dusty vent and water collection in the laundry room, unlabeled urinals in shared bathrooms, an unlabeled jug of distilled water in a resident's room, and staff personal belongings in medication carts. These deficiencies were confirmed by staff and pose a risk of cross-contamination and infection.
The facility failed to protect a resident's property during a room transfer when the inventory sheet was not signed or verified for accuracy. The resident's phone was lost, and staff confirmed that inventories were not typically done during room changes, leading to the resident feeling sad and isolated.
The facility failed to update a resident's care plan to include an order for nectar thick fluid consistency, despite the resident's severe cognitive impairment and documented dietary requirements. The DON confirmed the care plan should have been developed within seven days and revised as needed.
A resident with a terminal diagnosis and history of depression expressed suicidal thoughts, but the facility's LNs failed to report this to the physician, DON, and ADON as required by policy. Immediate actions were taken to ensure the resident's safety, but necessary notifications and follow-up actions were not completed.
The facility failed to ensure that a resident was turned and repositioned every two hours as ordered, leading to potential skin breakdown. Despite having orders and being dependent on two-person assistance for bed mobility, documentation showed that the task was not consistently completed or recorded. Observations confirmed redness on the resident's ankle, and the DON verified the lapse in documentation.
The facility failed to implement physician orders for two residents. One resident with severe cognitive impairment was served regular thin coffee instead of nectar-thick liquids, and another resident with bilateral lower extremity edema received more fluids than prescribed, with staff unaware of the fluid restriction order.
The facility failed to follow the physician's order to change the oxygen cannula for two residents with acute respiratory failure and hypoxia. Observations revealed that the oxygen tubing for both residents had not been changed as scheduled, leading to potential contamination and bacterial growth. Staff confirmed the discrepancies and acknowledged the failure to comply with the physician's orders.
The facility failed to monitor and communicate the fluid intake for a dialysis-dependent resident with a fluid restriction, leading to discrepancies in documentation and noncompliance with the prescribed limit. The resident had access to an uncontrolled water bottle, and there was no notification to the physician or nurse practitioner about the noncompliance, increasing the risk of fluid overload.
A resident was prescribed an antibiotic for a UTI, and the order was extended without documented clinical rationale. Both the Pharmacy Consultant Supervisor and the Attending Physician confirmed the lack of documentation, which is against the facility's policy on antibiotic stewardship.
The facility failed to ensure resident rights were maintained when a resident's responsible party was not given the opportunity to consent for a PPD skin test and the addition of D-Mannose to the resident's medication profile. Despite the resident's incapacity to understand rights and responsibilities, the facility proceeded with medical treatments without explicit consent from the RP, contrary to the facility's policy requiring notification of any changes to the resident's plan of care.
The facility failed to provide the required 80 square feet of space per resident in several rooms, housing two residents each with only 65 to 78.12 square feet per resident. Despite no complaints or safety concerns from staff and residents, the facility did not meet regulatory space requirements. The Administrator requested a continuance of the room size waiver, which the Department recommended.
The facility failed to provide adequate supervision for a resident with a history of falls, as outlined in her care plan. The resident was found unattended in her room, unable to reach her call light, despite the care plan requiring her to be at the nurse's station for increased supervision. This was confirmed by multiple staff members and the DON.
The facility failed to provide a resident's medical records via email as requested by the resident's Responsible Party (RP). Despite confirming the request and having the records ready for pick-up, the facility could not provide evidence of the email being sent, violating their policy and state regulations.
Failure to Honor Resident’s Choice of Psychiatric Provider and RP Authority
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose his attending physician and to follow the directions of the resident’s Responsible Party (RP) and Power of Attorney (POA). The resident, admitted in 2016 with multiple diagnoses including aftercare for cerebral infarction, lacked capacity to make health-care decisions. The clinical record identified the resident’s wife as RP/POA, and a physician order dated 6/12/24 directed staff to call the spouse with any changes to medications, treatments, diets, diagnoses, behaviors, or care plan, and to obtain her approval for any and all changes. The resident’s depression care plan also included an intervention to encourage family to actively participate in the resident’s care. During a care conference in December 2025, the RP told the Social Services Assistant (SSA) that she did not want the resident to be seen by the facility’s contracted psychiatrist (PD) or any other psychiatric provider associated with or contracted by the facility, stating that the resident had been followed by an outside psychiatrist through his medical insurance for years. The RP provided a written letter addressed to the DON, Administrator, and nursing staff withholding consent for consultation or evaluation by any psychiatric, psychological, or mental health practitioner associated with or contracted by the facility and requested that such providers be removed from the resident’s list of care providers. Despite this, the resident’s profile and face sheet continued to list the contracted PD as a provider, and there was no documentation that the facility took steps to accommodate the RP’s request or to notify the PD of the restriction. In March 2026, the RP again raised her concerns with the Assistant DON (ADON), who acknowledged that the RP made all treatment decisions and that the resident was managed by an outside psychiatrist selected by the RP. The ADON told the RP that the PD’s name would be removed from the resident’s profile but admitted she did not do so and did not communicate the RP’s request to the PD. Later that same day, the PD came to the resident’s room with a list of residents to see, which included this resident’s name, and the RP intervened to prevent any evaluation. On review of the record on 3/27/26, surveyors confirmed that the PD’s name remained on the resident’s profile and that the facility’s own Resident Rights policy guaranteed the right to choose a physician and treatment, participate in care planning, and to have privacy and confidentiality, and prohibited unauthorized access or disclosure of resident information.
Failure to Monitor and Report Elevated Blood Glucose Levels per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for a resident with type 2 DM, prior DKA, hemiplegia/hemiparesis following cerebral infarction, and aphasia. The resident was admitted in mid-January 2026 with orders for Empagliflozin (Jardiance) via PEG tube once daily and Insulin Glargine 8 units subcutaneously every 12 hours. An order dated 1/18/26 for PRN fingerstick blood glucose testing for hypo/hyperglycemia was present, but there were no blood glucose results documented on the January 2026 MAR. On 2/4/26, a new order was written for blood sugar monitoring every morning and at bedtime. Review of the Blood Sugar Summary showed that 9 of 14 recorded readings were above 200 mg/dL, including multiple readings over 400 mg/dL. Despite these elevated readings, there was only one documented physician notification on 2/2/26 when the blood sugar was 445 mg/dL, and no other evidence of physician notification when blood sugars were over 200 mg/dL or when they exceeded 400 mg/dL on consecutive days (2/4/26 and 2/5/26). An SBAR dated 2/6/26 documented a blood sugar of 405 mg/dL on the night of 2/5/26 and noted that the resident’s O2 saturation remained in the low 80s on 5 liters of oxygen, prompting transfer to the hospital. The hospital discharge summary for the stay from 2/7/26 to 2/18/26 indicated the resident was found to have blood glucose greater than 500 and was treated in the ICU with IV fluids and antibiotics. The DON stated that the resident’s blood sugar order was initially PRN, that an order for AM and HS monitoring was later obtained, and that her expectation was for licensed nurses to notify the physician when blood sugar was above 200 mg/dL. The facility’s diabetes clinical protocol, revised March 2025, indicated that residents receiving insulin who are well controlled should have blood glucose monitored twice daily and that staff should notify the practitioner when there are two or more readings higher than 250 mg/dL within 24 hours accompanied by a new medical problem or change in condition.
Failure to Involve Resident Representative in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident representative was involved in the development and implementation of a person-centered care plan when a scheduled care plan conference was not conducted as planned. The resident was admitted in mid-January 2026 with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, and type 2 diabetes mellitus with ketoacidosis. The admission record identified the resident’s daughter as the responsible party (RP). An IDT note dated 1/19/26 by Social Services Assistant (SSA) 1 documented a voicemail left for the RP requesting a return call. A social service note dated 1/20/26 by SSA 2 documented that the RP was called and asked to attend a care conference at 2:30 p.m. and that the RP would participate over the phone. There was no subsequent social services documentation confirming that the care conference occurred or that the RP participated. An IDT conference note initiated 2/5/26 stated that a care conference was conducted that day with the Social Services Director (SSD), Assistant DON (ADON), and Director of Rehabilitation (DOR), and that the resident planned to discharge home with support; this note was signed by SSA 1 on 2/18/26. SSA 2 later stated she did not know if the RP attended the care plan conference, and SSA 1 stated that SSD 1 had created the IDT care conference note on 2/5/26 and that she completed it on 2/18/26 because SSD 1 had not finished her notes. The Minimum Data Set Coordinator (MDSC) confirmed that the SSD schedules care plan conferences, that the conference should be done within the first week of admission, and that the resident was nonverbal, on tube feeding, and bedbound. The MDSC acknowledged that the IDT conference note for this resident had sections completed by Dietary, Therapy, Activities, and Social Services, but the Nursing Services section was not filled out and there was no documentation that Social Services had spoken with the resident’s representative. The facility’s policy stated that residents and/or representatives are encouraged to participate in care plan development and that the SSD or designee is responsible for notifying them and maintaining records of such notices, including input if they are unable to attend.
Unsecured PHI Document Left on Medication Cart
Penalty
Summary
A deficiency occurred when a document containing residents’ personal and medical information was left unsecured on top of a medication cart in Station 3 hallway during a survey observation. The document included residents’ names, room numbers, cognitive status (A&O status), code status, diagnoses, and information about how they take medications (such as whether they take pills whole). During an interview, a licensed nurse acknowledged that he had left this document on top of the medication cart and stated that he was not supposed to do so and that it was a violation of residents’ rights. Later, when shown photographs of the document on the cart, the DON confirmed that the document should not have been there. The facility’s policy on Protected Health Information (PHI), revised April 2014, states that all personnel with access to resident and facility information are responsible for managing and protecting such information to prevent unauthorized release or disclosure. This failure to secure the document containing PHI for a census of 167 residents had the potential to compromise the privacy of residents, as noted in the survey findings.
Failure to Maintain and Honor Advance Directive Results in Improper Notification of Resident's Death
Penalty
Summary
The facility failed to maintain and utilize the current Advance Health Care Directive (AD) for a resident, resulting in the designated agents for Power of Attorney for Health Care (POA) not being notified of the resident's death. The resident, who had multiple diagnoses including multiple sclerosis, epilepsy, and dysphagia, was admitted in 2012 and had a moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. The resident's AD, dated 2011, named two individuals as designated agents for health care decisions, but the facility's records listed other individuals as emergency contacts and responsible parties. Upon the resident's decline and subsequent death, the facility notified the first emergency contact, who was not listed as a designated agent in the AD, and coordinated post-mortem arrangements with this individual. The actual designated agents, as specified in the AD, were not contacted by the facility and only learned of the resident's death through the mortuary. Interviews revealed that the facility was unable to locate the AD in the electronic record at the time of the incident, despite the document having been faxed to the facility in 2013 and later found in past files. Facility staff, including the DON, Social Services Director, and Medical Records Assistant, confirmed that the AD was not uploaded into the electronic record when the system changed in 2022, and that the staff had been relying on the emergency contact rather than the designated agents for decision-making and notifications. The facility's policy required that advance directives be maintained in a readily retrievable location in the medical record and that the resident's wishes be communicated to direct care staff and physicians, but this was not followed in this case.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with amyotrophic lateral sclerosis, dysphagia, and cachexia, who was cognitively intact but physically dependent and used a wheelchair, was struck in the face by another resident in the facility's smoking area. The incident was reported by the affected resident, who stated that the other resident approached, used expletives, and slapped her on the left side of her face. Documentation indicated that the resident experienced swelling and redness to the left side of her face and a sore to her lower lip that reopened after the slap. The resident expressed psychosocial distress, fear, and a sense of being unsafe in the facility following the incident. The resident who committed the act had a history of hemiplegia, hemiparesis, diabetes, aphasia, and severe cognitive impairment. This resident was unable to provide a clear account of the incident due to communication difficulties. Witnesses, including another resident, confirmed observing the physical altercation, stating that the aggressor willfully struck the victim on the cheek. Staff interviews corroborated that the incident took place in the smoking area and that the aggressor had previously exhibited aggressive behavior. Facility records and staff interviews revealed that, prior to the incident, there were no effective measures in place to prevent the altercation or to monitor the residents for aggressive or inappropriate behaviors as outlined in the facility's abuse prevention and resident-to-resident altercation policies. The affected resident reported ongoing fear and discomfort, noting that the aggressor continued to be present in areas near her room after the incident, which contributed to her distress. The facility's failure to protect the resident from physical abuse resulted in both physical and psychosocial harm.
Failure to Update Care Plans and Document Incidents After Resident Altercations and Abuse Allegation
Penalty
Summary
The facility failed to ensure that care plans were updated and documentation was complete for three residents following significant incidents. Two residents were involved in a resident-to-resident altercation in the smoking area, where one resident, who was cognitively intact and had diagnoses including ALS and dysphagia, reported being struck in the face by another resident. The other resident involved had severe cognitive impairment, hemiplegia, and aphasia, and was unable to provide a personal account of the incident. Despite the altercation being reported and documented in progress notes and communication forms, neither resident had a care plan initiated or updated to address the incident. Additionally, another resident with moderate cognitive impairment, COPD, bipolar disorder, and adult failure to thrive, reported being pushed against the wall by a CNA during a brief change. This incident was reported as suspected abuse, but there was no documentation in the clinical record regarding the event, and no care plan was initiated to address the situation or the resident's needs following the report. Interviews with facility leadership confirmed that these incidents were not reflected in the residents' care plans and that documentation in the clinical records was incomplete or missing. Facility policies require that care plans be updated and incidents documented when there is a significant change in a resident's condition or following an altercation or abuse allegation, but these procedures were not followed for the residents involved.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident's right to be free from physical abuse was not protected. One resident, who had a history of stroke and difficulty speaking but demonstrated normal cognition, was subjected to physical abuse by his roommate. The roommate, who had a seizure disorder, stroke, and moderate cognitive impairment, threw a hard plastic cup filled with thickened liquid at the first resident's face during an argument. This incident resulted in the resident being covered in fluid and left a red mark on his cheek. The event was witnessed and documented by nursing staff, and both residents confirmed the altercation during interviews. The facility's policy states that residents have the right to be free from abuse, neglect, and exploitation. Despite this, the incident occurred following a disagreement between the two residents, with the aggressor stating the action was in response to a dispute over cigarettes. The Director of Nursing confirmed the details of the incident and acknowledged the resulting injury. The report identifies this as a failure to protect the resident from physical abuse as required by facility policy.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A resident with a history of inappropriate behavior towards female residents was observed grabbing and placing another resident's hand on his groin area. This incident was witnessed by a third resident, who reported the event to staff. The resident who was subjected to this behavior was cognitively impaired and had multiple diagnoses, including diabetes mellitus. The resident who committed the act was noted in previous records to have engaged in inappropriate behaviors, such as being found in a female resident's room and touching another resident's arm in the hallway. These prior incidents were not reported or addressed with interventions to prevent further occurrences. Staff interviews confirmed knowledge of the resident's history of inappropriate conduct, and facility documentation acknowledged the abusive nature of the incident. The facility's policy states that residents have the right to be free from abuse, including sexual abuse by other residents. Despite this, the facility failed to implement measures to protect the cognitively impaired resident from abuse, resulting in a violation of the resident's rights.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse within the required regulatory timeframe for two residents. One resident, who had a history of inappropriate behaviors towards female residents and diagnoses including dementia, was reported by another resident to have grabbed and placed a female resident's hand on his groin. The incident was witnessed and reported to the Social Services Assistant, who then notified the Administrator. However, the Administrator did not report the allegation to the California Department of Public Health until three days after being notified, despite facility policy and federal regulations requiring reporting within two hours if the alleged violation involves abuse. Record review and staff interviews confirmed that the Administrator was aware of the incident but delayed reporting, and the Director of Nursing acknowledged that previous inappropriate behaviors by the same resident had not been reported or addressed with interventions. The facility's policy clearly stated that all reports of resident abuse must be promptly reported to the appropriate authorities, but this was not followed in this case.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with dementia and moderate memory impairment was subjected to inappropriate sexual contact by another resident, who also had moderate memory impairment. The incident took place in a hallway after an activity event, where a staff member witnessed one resident fondling the other's breasts without consent. The affected resident was unable to communicate well and appeared surprised and distressed during the incident, as observed by the staff member. The facility's records, including the admission record and Minimum Data Set, confirmed the cognitive impairments of both residents involved. The Interdisciplinary Team note documented the incident based on the staff witness report, but there was no evidence that the affected resident had given consent for any physical contact. When interviewed, the resident who committed the act declined to participate and asked to be left alone. The Director of Nursing confirmed the incident and acknowledged that it was witnessed by staff. The facility's abuse prevention policy states that all residents have the right to be free from abuse, including sexual abuse, by anyone. Despite this policy, the facility failed to protect the resident from abuse by another resident, resulting in a violation of the resident's rights.
Improper Storage and Handling of Discontinued Controlled Medications
Penalty
Summary
The facility failed to maintain consistent pharmacy services for its residents, as evidenced by improper handling and storage of controlled medications. During an inspection, a discontinued bottle of lacosamide, a controlled substance, was found stored with non-controlled medications in the medication storage room and lacked a required count sheet. Licensed nursing staff confirmed that discontinued controlled medications should have been taken to the DON's office for secure storage with proper documentation, in accordance with facility policy. The DON also stated that all discontinued controlled medications were expected to be brought to her office for secure storage until destruction with the facility's pharmacist. Additionally, an inspection of a medication cart revealed seven blister packs of discontinued controlled medications stored alongside active medications. Licensed nursing staff acknowledged that discontinued controlled medications should not remain in the medication cart and should be given to the DON. Facility policies reviewed indicated that all unused controlled substances must be securely locked and documented until disposal, and discontinued drugs should be placed in designated bins for destruction. These findings demonstrate a failure to follow established procedures for the handling and storage of controlled medications.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's medication storage and handling practices. Expired pharmaceutical products, including a multi-dose vial of Humulin R insulin and two multi-dose inhalers, were found in medication carts at both the front and back stations. Licensed nurses confirmed the presence of these expired medications and acknowledged that they should have been discarded according to facility policy and manufacturer guidelines. Facility policies reviewed indicated that staff are required to check expiration dates prior to administration and to place outdated drugs in designated bins for destruction. Additionally, loose pills were discovered in two medication carts, and a blister pack was found behind a drawer in one of the carts. Licensed nurses confirmed these findings and stated that loose pills and misplaced blister packs should not be present in the carts. The Director of Nursing reiterated that medication carts are expected to be free of loose medications and maintained in a clean, safe, and sanitary manner, as outlined in the facility's storage policy. Further deficiencies were observed in resident rooms, where unlabeled medicine cups containing creams were found at the bedside of two residents. Staff interviews confirmed that these creams were intended for the residents' use but should not have been left at the bedside and should have been discarded after use. Facility policy requires that all drugs and biologicals be stored in locked compartments, and the Director of Nursing confirmed that medications should not be left at the bedside.
Infection Control Program Deficiencies Identified
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. In one instance, a resident with severe cognitive impairment and a history of dysphagia and gastrostomy was receiving enteral feeding via a G-tube. The water flush bag used for this resident was found hanging at the bedside without a label, contrary to facility policy and staff expectations, which require labeling with the resident's name and the date and time the bag was started. Both the licensed nurse and the Director of Nursing confirmed that the bag should have been labeled. During a medication administration observation, a licensed nurse was seen using a medication cart that had not been cleaned of white powder residue from a previously crushed medication. The nurse acknowledged that the residue was from a crushed acetaminophen tablet and that medication cart surfaces should be cleaned prior to medication administration. The Director of Nursing also stated that the expectation was to keep medication preparation areas clean and sanitary, as outlined in the facility's policy. Additionally, a certified nursing assistant provided high-contact care to a resident on Enhanced Barrier Precautions (EBP) without wearing a gown, despite clear signage and policy requirements. The resident had an indwelling catheter and was identified as requiring EBP due to risk factors. The CNA admitted to not wearing a gown during activities such as teeth brushing, brief changing, and dressing, and acknowledged awareness of the requirement. The facility's infection preventionist confirmed that gowns and gloves are required during high-contact care for residents on EBP, as specified in the facility's policy.
Inaccurate Assessment of Resident's Tobacco Use
Penalty
Summary
The facility failed to accurately assess a resident's tobacco use during the Minimum Data Set (MDS) assessment process. The resident, who was admitted with diagnoses including high blood pressure and generalized muscle weakness, had a BIMS score indicating mild memory impairment. The MDS documented that the resident was not a smoker, and the smoking observation/assessments also indicated the resident denied smoking or using tobacco products. However, during interviews, the resident stated that he smoked cigars and that the facility was aware of his smoking status, which was confirmed by a licensed nurse. Upon review, the MDS Coordinator acknowledged that both the MDS and the smoking observation/assessment inaccurately reflected the resident's tobacco use. This discrepancy demonstrated that the facility did not conduct a comprehensive and accurate assessment of the resident's health status as required.
Failure to Complete Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to follow up with the required Preadmission Screening and Resident Review (PASRR) Level II evaluation for one resident. The resident was initially admitted in February 2023 and readmitted in November 2024 with diagnoses including unspecified psychosis and major depressive disorder. A review of the resident's PASRR Level I Screening Result, dated 11/19/24, indicated that a Level II evaluation was required. However, the Director of Nursing (DON) confirmed during an interview and record review that she was unaware of the need for a PASRR Level II evaluation for this resident, and acknowledged that no follow-up was conducted for the required evaluation. The facility's policy, revised in March 2023, states that all new admissions and readmissions are to be screened for mental disorders, and if the Level I screen indicates possible mental disorder, the individual should be referred for a Level II evaluation. In this case, the lack of follow-up resulted in the resident not receiving the necessary PASRR Level II evaluation as indicated by the screening process.
Failure to Develop and Implement Comprehensive Care Plans for Smoking and Skin Conditions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, resulting in unmet physical and psychosocial needs. For one resident with a history of orthopedic aftercare and gas gangrene, there was no care plan addressing his smoking habits, despite documentation and staff interviews confirming his regular, unsupervised smoking in the designated area. The Minimum Data Set Coordinator and Medical Records Director both confirmed the absence of a smoking care plan for this resident, even though the resident was identified as a smoker in the assessment. Another resident with acute on chronic congestive heart failure and documented rashes on her upper arms, chest, and back did not have a care plan addressing her skin condition. Physician orders for topical and oral medications to treat the rashes were present, and the resident reported ongoing itching. The Minimum Data Set Coordinator confirmed that no care plan was created for the rashes, despite the presence of skin observations and medication orders. Additionally, a resident with chronic pulmonary lung disease had a care plan stating that cigarettes and lighters should be stored at the nurse's station, but staff interviews and observations revealed that the resident kept these items on his person, and staff did not follow the care plan. Another resident with high blood pressure and mild memory impairment, who smoked cigars daily, also lacked a care plan for smoking. Staff and the Director of Nursing confirmed the absence of a smoking care plan for this resident, despite facility policy requiring documentation of smoking-related privileges and restrictions in the care plan.
Failure to Assist Resident with Hearing Aid Use Due to Communication and Documentation Gaps
Penalty
Summary
The facility failed to provide necessary assistance with the use of hearing aids for one resident who had a cognitive communication deficit and muscle weakness. The resident was admitted with hearing aids for both ears and required help with their use, as documented in the resident's records and assessments. Despite this, the resident reported not receiving any assistance or education on how to charge or use the hearing aids, which remained unused in their box for two months. Multiple observations and interviews confirmed that the resident continued to experience difficulty hearing and repeatedly requested help from staff. Interviews with facility staff revealed a lack of clear communication and documentation regarding the resident's need for hearing aid assistance. There was no physician order for the hearing aids, and staff were unclear about whose responsibility it was to enter such orders or provide the necessary support. The facility's policies required staff to assist residents with hearing aids and ensure competency in their use, but these procedures were not followed for this resident, resulting in unmet care needs.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A resident with a history of an anoxic brain injury, severe cognitive deficits, and a right hand contracture was found to have long fingernails with a brownish substance underneath the fingernails on her left hand. The resident was non-verbal, dependent on staff for all activities of daily living (ADLs), and unable to make her needs known. Her care plan required staff to provide extensive to total assistance with all personal care, including daily grooming and nail care, as she was unable to participate in her own care. During observation, staff noted the resident's left hand fingernails were dirty and confirmed that nail care should have been performed. Both a licensed nurse and the DON verified that the resident had not refused nail care and that staff were expected to ensure nails were clean as part of routine hygiene and infection control. Facility policy also required staff to provide appropriate grooming for residents unable to perform ADLs independently. The failure to provide nail care resulted in the resident having visibly dirty fingernails, contrary to her care plan and facility policy.
Call Lights Not Within Reach for Residents with Severe Impairments
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents with severe cognitive and physical impairments. One resident, admitted after an anoxic brain injury and noted to be non-verbal and dependent on others for all mobility and care needs, was observed sitting in a wheelchair next to her bed with her call light left in the bed, out of her reach. Staff confirmed that the call light was not accessible and acknowledged that the expectation was for call lights to always be within reach, especially for non-verbal residents who cannot call out for help. The resident's care plan specifically indicated that the call light should be within reach due to her inability to verbalize needs and poor mobility. Another resident, admitted with dysphagia following a stroke and requiring maximal assistance for mobility, was also found with her call light out of reach on multiple occasions. Staff interviews confirmed that the call light was not positioned appropriately and should have been within the resident's arm reach. The resident's care plan included an intervention to encourage the use of the call light for assistance, and facility policy required call lights to be within easy reach when residents are in bed or confined to a chair. These observations and staff confirmations demonstrate that the facility did not consistently follow care plans or policy regarding call light accessibility for residents with significant care needs.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum room size of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms, as specified by regulations. Specifically, rooms 302, 303, 304, 305, 306, 307, 309, 310, 312, and 314 were identified as not meeting these requirements, with several rooms providing only 65 to 78.12 square feet per resident. This deficiency was identified through document review, which included a letter to the California Department of Public Health, and was confirmed by direct observation of the rooms and interviews with residents and staff. Despite the deficiency in room size, observations noted that the rooms were clutter-free and allowed for the movement of residents using walkers and wheelchairs. Residents and staff interviewed did not report any issues or complaints related to the lack of space, and there were no validated safety concerns or problems with the delivery of care due to room size. The Director of Maintenance confirmed that no alterations had been made to these rooms since the last recertification survey.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to protect a resident's right to return to the facility following hospitalization, resulting in an unanticipated discharge. The resident, who had long-term kidney disease and breathing problems, was admitted to the facility in the fall of 2024. On December 20, 2024, the resident experienced an acute change in mental status and was sent to the hospital due to extreme lethargy and low blood sugar. Despite the resident having the capacity to make her own decisions, her Power of Attorney (POA), her daughter, was involved in all healthcare and financial decisions. The facility's policy required that residents be allowed to return following hospitalization within the bed-hold period. However, the facility did not permit the resident to return, citing the daughter's interference with care as the reason. The Administrator and Director of Nursing confirmed that the daughter's actions, which included withholding consent and interfering with medical procedures, hindered the facility's ability to provide care. Consequently, the facility discharged the resident on the same day she was sent to the hospital, without taking any bed-hold money, and informed the POA of the discharge after it occurred.
Failure to Follow Prednisone Orders Leads to Resident Complications
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was prescribed Prednisone following a hospital discharge. The resident, who had a history of chronic obstructive pulmonary disease and kidney failure requiring dialysis, was readmitted to the facility with a prescription for Prednisone 60 mg daily for five days. However, the facility continued administering the medication at the same dosage for an additional 17 days beyond the prescribed period. The resident experienced significant side effects due to the prolonged use of Prednisone, including severe oral thrush and fluid retention, which were not addressed by the facility. Despite multiple visits from a Nurse Practitioner, the issue with the Prednisone dosage was not identified or corrected. The resident's family member expressed concern over the facility's failure to follow the physician's orders and provided documentation to the facility's management, which was not acted upon. The facility's Director of Nursing acknowledged the oversight, stating that the stop date for the Prednisone was not entered into the resident's orders upon readmission. Additionally, there was no documented evidence that the Prednisone order was verified with the resident's physician. The facility's policies on medication orders and therapy were not followed, leading to the resident's prolonged exposure to high doses of Prednisone and subsequent health complications.
Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse during an altercation between two residents. Resident 1, who was cognitively intact and had a history of hemiplegia and hemiparesis, struck Resident 2 on the arm with a wheelchair armrest, resulting in a skin tear. Resident 2, who had moderate cognitive impairment and a history of paraplegia and an unruptured cerebral aneurysm, was engaged in a conversation with Resident 1 when the incident occurred. The altercation was reported by the facility's administrator, and the injury was documented in Resident 2's nurse's notes. Interviews and observations revealed that Resident 1 admitted to hitting Resident 2 after being called a liar and insulted. The Director of Staff Development witnessed the verbal exchange and confirmed that Resident 1 admitted to the physical altercation. Resident 2 expressed feeling both safe and unsafe in the facility due to the incident, indicating a potential emotional impact. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, including from other residents, highlighting a failure to adhere to this policy in this instance.
Delay in Providing Medical Records to Resident's Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with timely access to the resident's medical records. Resident 1 was admitted in May 2021, and a family member was designated as the resident's representative. The representative submitted a written request for the resident's complete vaccination records on August 2, 2024, at 2:45 p.m. According to the facility's policy, medical records should be provided within 72 hours of a request, excluding weekends and holidays. However, the facility did not provide the requested records until August 9, 2024, which was beyond the stipulated timeframe. During an interview and documentation review on August 12, 2024, the Medical Record Director confirmed that the facility received the request on August 2, 2024, and acknowledged that the records were provided electronically on August 9, 2024. This delay in providing the medical records was a deviation from the facility's policy, resulting in a deficiency.
Failure to Provide 30-Day Discharge Notice
Penalty
Summary
The facility failed to provide a 30-day discharge notice to a resident, which compromised the resident's ability to appeal the discharge. The resident was admitted with multiple diagnoses, including diverticulitis, gastrointestinal hemorrhage, breast cancer, difficulty in walking, and muscle weakness. On the same day as the discharge, the resident received a physician's order for discharge with home health services, physical and occupational therapy, and an aide. The Social Services Director confirmed that the resident was notified of the discharge on the same day at 3:12 p.m., and the discharge occurred at 5 p.m. The Director of Nursing admitted that the facility does not issue 30-day notices, and there was no documented evidence of a written or verbal notice of intent to discharge provided to the resident.
Failure to Adhere to Resident's Bathing Schedule
Penalty
Summary
The facility failed to ensure the dignity of a resident by not adhering to the resident's bathing schedule, resulting in the resident feeling upset, angry, and dirty. The resident, who was admitted in 2021 with diagnoses including a leg fracture, hypertension, and cancer, reported not receiving a bath for three weeks. The resident expressed dissatisfaction with their appearance and hygiene, stating that their hair was dirty and matted, which made them feel uncomfortable. A review of the resident's bathing task sheet revealed that the resident had only received one partial bath in a 30-day period, with several scheduled bathing days missed. The care plan indicated that the resident was supposed to receive showers at least twice a week. Interviews with facility staff, including a licensed nurse and the assistant director of nursing, confirmed the lack of documentation and adherence to the bathing schedule. The facility's policy required staff to document bathing and notify supervisors if a resident refused a bath, which was not consistently followed in this case.
Pest Control and Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program and sanitary conditions in the kitchen, as evidenced by the presence of several flies and small worm-like creatures in the food preparation area. During an interview, the Dietary Manager (DM) acknowledged the presence of flies, noting that they were more prevalent in the summer. The DM mentioned that a pest control company visited monthly to replace fly trappers and spray outside the facility, and additional visits were arranged if serious issues arose. However, during a kitchen tour, live flies were observed near the stove, sink, and dry storage room. The DM admitted that flies should not be present in the kitchen and hoped they would be caught in traps overnight. Further inspection revealed deteriorating floor tiles under the sink, with a white plastic substance and blackish residue on the tiles. An opening was noted where the sink pipe entered the wall, and the floor was wet and cluttered with food debris and numerous black worm-like creatures. The DM and Kitchen Staff confirmed the presence of these creatures, which were approximately 1 cm long. The DM was unable to identify them but suggested they might be small worms from beneath the tiles. The Infection Control Nurse also observed the creatures and acknowledged their presence, along with a fly on the wet floor. Pest control logs from previous months indicated significant flying insect activity, and the facility's policies emphasized the importance of pest control and sanitation in the kitchen.
Failure to Store Foods According to Professional Standards
Penalty
Summary
The facility failed to store foods according to professional standards for food safety. During an initial kitchen tour, the Dietary Manager (DM) acknowledged several opened and unlabeled food items, including a gallon of milk in the refrigerator, an opened box of cookie dough in the freezer, and three cans of vegetable oil spray in the cooking area. The facility's policy requires all food items to be labeled with an opened date and used by date, which was not followed in these instances. Additionally, a yellow cutting board was found stained with black markings from the rubber stand, which the DM acknowledged. According to the FDA Food Code, cutting surfaces that can no longer be effectively cleaned and sanitized should be resurfaced or discarded, which was not adhered to in this case. Furthermore, the DM acknowledged the presence of brownish puffy substances at the bottom of four metal storage racks in the dry storage room, identified as dust. The facility's policy mandates routine cleaning, which was not followed. The FDA Food Code emphasizes that food contact surfaces must be clean to sight and touch to prevent contamination. These failures had the potential to increase the risk of foodborne illnesses for the 164 residents who received food from the kitchen.
Improper Disposal of Dietary Tray Tickets Compromises Resident Confidentiality
Penalty
Summary
The facility failed to ensure the protection of residents' personal and medical information when dietary tray tickets containing sensitive information were discarded in the general trash. During a kitchen tour, tray tickets with residents' names, ID numbers, room numbers, diet orders, food preferences, and allergies were found in the general trash bin. The Dietary Manager acknowledged the issue and recognized it as a potential HIPAA violation. The Registered Dietitian confirmed that tray tickets should be disposed of in a shred box to maintain confidentiality. Facility policies on confidentiality and residents' rights were reviewed, indicating that access to personal and medical records should be limited to authorized staff and that unauthorized disclosure of resident information is prohibited.
Failure to Ensure Accurate Accountability of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for three residents, resulting in discrepancies between the Medication Administration Record (MAR) and the Controlled Drug Record (CDR). For Resident 30, the MAR indicated that Morphine was administered, but the CDR did not reflect this, and there was an inconsistency in the tablet count. For Resident 119, the MAR and CDR did not match on multiple occasions, with the MAR showing administration of Norco that was not recorded in the CDR and vice versa. Similarly, for Resident 120, the MAR indicated Norco was administered, but the CDR did not reflect this. During an interview and record review, the Director of Nursing (DON) confirmed these discrepancies and stated that the expectation is for staff to document in both the MAR and CDR when administering controlled medications. The facility's Policy and Procedure (P&P) on Controlled Medications, revised in April 2023, requires that the date, time, amount administered, and the nurse's signature be recorded in both the MAR and CDR. The failure to follow this procedure resulted in the facility not having accurate accountability of controlled medications, raising concerns about whether the medications were administered as ordered.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to consistently monitor and document side effects and behaviors associated with psychotropic medication use for one resident. Resident 91, who was admitted in the winter of 2021 with diagnoses including depression and a psychotic disorder, was prescribed multiple psychotropic medications. The Medication Administration Record (MAR) indicated that Resident 91 was not monitored for the listed behaviors and side effects for a total of 50 shifts from February 2024 to May 2024. This lack of monitoring was confirmed by the Director of Nursing (DON), who stated that if the monitoring was not signed, it was not done. The facility's policy requires staff to observe, document, and report the effectiveness of interventions and any side effects or adverse consequences of psychotropic medications to the attending physician or nurse practitioner. During an observation and interview, Resident 91 was found calm and conversant in his room, with his call light within reach. However, the DON verified that several shifts of behavior and side effects monitoring were not signed, indicating that the monitoring was not performed. The facility's policy on psychotropic medication use, revised in October 2023, mandates that nursing staff monitor and report any side effects and adverse consequences of psychotropic medications. The failure to adhere to this policy had the potential for unnecessary use of psychotropic medications for Resident 91.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that opened biologicals, eye drops, and ear drops were dated once opened, appropriately labeled to correctly identify which resident they were for, and were not available for resident use past their expiration date. During an inspection of the Station 4 Back Hall Medication Cart, it was found that a bottle of Artificial Tears eye drops and a bottle of LubriFresh P.M. Nighttime eye ointment were past their recommended use-by dates. Licensed Nurse (LN) 6 confirmed these observations and stated that both medications were only good for 60 days after opening and were past their recommended use-by dates. Further inspections revealed additional deficiencies. At Station 2 Back Hall Medication Cart, a bottle of GoodSense Eye Drops, Mucus-ER tablets, and an Iron Supplement liquid were found either past their use-by dates or without appropriate labeling. LN 9 confirmed these findings and stated that medications without labels or open dates would not be administered. Similarly, at Station 2 Front Hall Medication Cart, several medications including Ayr Nasal gel, sunscreen lotion, Visine eye drops, and Tetrahydrozoline HCL eye drops were found without appropriate labeling. LN 10 confirmed these observations and emphasized that each resident should have their own labeled medications. At Station 3 Back Hall Medication Cart, multiple medications including Zinc tablets, Senna tablets, Loratadine tablets, Micro-Guard antifungal powder, Tetrahydrozoline HCL eye drops, Systane lubricant eye drops, and Carbamide Peroxide ear drops were found either past their expiration dates or without appropriate labeling. LN 11 confirmed these findings. The Infection Prevention Nurse (IP) and the Director of Nursing (DON) both acknowledged the deficiencies, with the DON stating that expired medications should be removed and destroyed before they expire. The facility's policies and procedures were reviewed and indicated that medications should be checked for expiration dates and labeled appropriately before administration.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. In the laundry room, a dusty vent was observed above a table with clean laundry, and water was found collected behind the washers. The Maintenance Director confirmed these observations and acknowledged the potential for cross-contamination. Additionally, the wall in the clean clothing room had peeled paint and stains from old water leakage, further indicating unsanitary conditions. The Infection Prevention Nurse and Infection Preventionist Consultant confirmed these issues during their inspection, noting that the laundry room should not be in such a state and that the vent should be clean. In shared bathrooms, unlabeled urinals were found, which could lead to cross-contamination. In Resident 15's shared bathroom, two unlabeled urinals were observed on top of the toilet bowl tank. Licensed Nurses confirmed that these urinals should be labeled and dated to prevent cross-contamination. Similar observations were made in other shared bathrooms, where used urinals with dried brownish substances were found without labels. The Director of Nursing confirmed that urinals should be labeled and placed appropriately to avoid cross-contamination and infection. In Resident 119's room, an unlabeled and undated jug of distilled water was found on the floor beside the nightstand. The resident confirmed that the jug was used for his CPAP machine. Licensed Nurses and the Infection Prevention Nurse confirmed that the jug should be labeled, dated, and not placed on the floor to prevent contamination. Additionally, staff personal belongings and a cigarette lighter were found in medication carts, which were confirmed by Licensed Nurses and the Director of Nursing as inappropriate and a potential source of contamination. The facility's policies and procedures were not followed, leading to these deficiencies in infection control and prevention.
Failure to Protect Resident's Property During Room Transfer
Penalty
Summary
The facility failed to protect Resident 106's property from loss when the resident's inventory sheet was not signed and not verified for accuracy. Resident 106, who was admitted in November 2021 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, reported that her phone was lost during a room transfer. The inventory sheet dated 11/2/21 listed the phone but lacked signatures from staff and the resident's representative, verifying the accuracy of the list. The facility did not conduct an inventory during the room transfer, and the last inventory was done upon admission in 2021. Interviews with staff, including LN 6, the Social Services Director, and the Director of Nursing, confirmed that inventories were not typically done during room changes and that the inventory sheet for Resident 106 was incomplete and unsigned. The facility's policy required that personal belongings be inventoried and documented upon admission, but this procedure was not followed during the room transfer, leading to the loss of Resident 106's phone and her subsequent feelings of sadness and isolation.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for one resident when the care plan did not address the order for nectar thick fluid consistency when it was initiated. Resident 126, who was admitted with diagnoses including cerebral infarction with residual effects and seizures, had a diet order for finger food regular chopped meat texture with thickened liquids nectar consistency. Despite this order being documented in the resident's clinical record and nutritional risk review, the care plan was not updated to reflect this dietary requirement. The Director of Nursing confirmed that the care plan should have been developed within seven days and revised as the resident's condition changed, as stipulated by the facility's policy and procedure on care plans.
Failure to Report Suicidal Ideation
Penalty
Summary
The facility failed to meet professional standards of quality for a resident who expressed suicidal ideation. Resident 59, admitted under hospice services with a terminal diagnosis including cognitive deficits, dementia, bipolar disorder, and depression, verbalized a desire to commit suicide to a CNA. Licensed Nurses 12 and 13 documented the resident's suicidal thoughts and took immediate actions such as removing sharp objects and conducting frequent checks. However, they failed to report the incident to the facility's physician, Director of Nursing (DON), and Assistant Director of Nursing (ADON), as required by the facility's policy and procedure on suicide threat management. Interviews with the ADON, DON, and Social Services Director (SSD) confirmed that the appropriate notifications and follow-up actions, including creating a care plan and documenting a change of condition, were not completed. The facility's policy mandates immediate reporting of suicidal threats to the charge nurse, who should then notify the attending physician and responsible party. The failure to follow these procedures had the potential to adversely affect the safety of Resident 59.
Failure to Reposition Resident as Ordered
Penalty
Summary
The facility failed to ensure that Resident 43 received care in accordance with professional standards when the resident was not turned and repositioned every two hours as ordered. Resident 43, who was admitted with diagnoses including contractures of the upper extremities, hips, and ankles, and a history of a left ankle pressure ulcer, was observed lying flat on his back with both legs bent to the side on multiple occasions. The Minimum Data Set (MDS) indicated that Resident 43 was dependent on two-person assistance for bed mobility. Despite having orders for turning and repositioning every two hours, documentation showed that this task was not consistently completed or recorded as required. During an observation and interview, Licensed Nurse 3 (LN 3) acknowledged that the left posterior of Resident 43's ankle had developed redness again, indicating potential skin breakdown. The Director of Nursing (DON) confirmed that the documentation for turning and repositioning was not done as ordered. The facility's policies and procedures for repositioning and carrying out physician orders were not followed, leading to this deficiency. The failure to adhere to these orders increased the risk of skin breakdown for Resident 43.
Failure to Implement Physician Orders for Fluid Consistency and Restriction
Penalty
Summary
The facility failed to provide necessary care and services for two residents. For Resident 126, who had severe cognitive impairment and was unable to make her own healthcare decisions, the facility did not implement the physician's order for thickened fluid consistency. Despite the order for nectar-thick liquids, Resident 126 was served regular thin coffee by a Certified Nurse Assistant (CNA). This was confirmed by both the CNA and a Licensed Nurse (LN), and later verified by the Director of Nursing (DON), who acknowledged that the staff should have followed the doctor's order to prevent accidents. For Resident 153, who was admitted with bilateral lower extremity edema and fluid retention, the facility did not maintain and accurately monitor the fluid restriction order. The resident was observed receiving more fluids than prescribed, and the CNA assigned to her was unaware of the fluid restriction order. The Licensed Nurse confirmed that the resident's fluid intake exceeded the physician's order, and the DON noted that the nursing staff should have monitored and documented the fluid intake accurately. Additionally, a care plan for non-compliance should have been developed if the resident refused to follow the doctor's order.
Failure to Change Oxygen Cannula as Ordered
Penalty
Summary
The facility failed to follow the physician's order to change the oxygen cannula for two residents, Resident 27 and Resident 99. Resident 27 was admitted with acute respiratory failure with hypoxia and had a physician's order to change the nasal cannula every Sunday night and as needed. However, observations on 5/21/24 revealed that Resident 27's oxygen tubing was last changed on 5/12/24, indicating non-compliance with the order. The Licensed Nurse confirmed the discrepancy and acknowledged that the tubing should have been changed weekly as per the physician's order. The Infection Prevention Nurse also confirmed that failing to change the tubing as scheduled could lead to contamination and bacterial growth. Similarly, Resident 99, who was also admitted with acute respiratory failure with hypoxia, had an order for continuous oxygen use via nasal cannula, with the tubing to be changed every Sunday night and as needed. Observations on 5/21/24 showed that Resident 99's oxygen tubing, which had yellowish discoloration and water inside, was last changed on 5/12/24. The Certified Nurse Assistant and Licensed Nurse both confirmed the tubing change date and acknowledged the failure to follow the physician's order. The Director of Nursing stated that staff are expected to follow physician orders accurately and on time. The facility's policy and procedure also indicated that oxygen tubing should be changed at least weekly and labeled with the date it was changed.
Failure to Monitor and Communicate Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to accurately monitor and communicate the fluid intake for a resident with end-stage renal disease who was dependent on renal dialysis. The resident had a physician's order for a fluid restriction of 1 liter per day, broken down into specific amounts for each shift. However, observations and interviews revealed that the resident had access to a water bottle at the bedside, which was not controlled by the staff, leading to noncompliance with the fluid restriction. The resident was readmitted to the facility after a hospital stay for acute respiratory failure secondary to fluid overload, indicating the severity of the issue. Interviews with Certified Nursing Assistants (CNAs) and the Nurse Supervisor (NS) confirmed discrepancies in the documentation of the resident's fluid intake. The CNAs and Licensed Nurses (LNs) documented different amounts of fluid intake, and there was no communication between them to reconcile these differences. Additionally, there was no notification made to the resident's Attending Physician (AP) or Nurse Practitioner (NP) regarding the resident's noncompliance with the fluid restriction, as required by the facility's policy. The facility's policy on encouraging and restricting fluids mandates that staff verify physician's orders for fluid restrictions, record fluid intake accurately, and inform the physician or NP if the resident is noncompliant. The failure to adhere to this policy resulted in the resident's fluid intake exceeding the prescribed limit on multiple occasions, increasing the risk of fluid overload and related complications. The NS acknowledged the discrepancies and the lack of communication and documentation regarding the resident's fluid intake and noncompliance.
Failure to Ensure Resident's Drug Regimen was Free from Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication. Resident 10, who was admitted with multiple diagnoses including overactive bladder, chronic kidney disease, and a urinary tract infection (UTI), was prescribed Macrobid, an antibiotic, for the UTI. The initial order for Macrobid was for 7 days, but the order was later extended without documented clinical rationale. The extension of the antibiotic was not supported by any documented symptoms or clinical criteria, which is against the facility's policy on antibiotic stewardship. During interviews, both the Pharmacy Consultant Supervisor and the Attending Physician confirmed that there was no documented reason for extending the antibiotic. The facility's policy requires documentation of specific criteria supporting the use of antibiotics, which was not followed in this case. This failure resulted in Resident 10 receiving unnecessary medication, potentially increasing the risk of antibiotic resistance and exposure to side effects associated with prolonged antibiotic use.
Failure to Obtain Proper Consent for Medical Treatment
Penalty
Summary
The facility failed to ensure resident rights were maintained for one resident when the responsible party (RP) was not given the opportunity to consent for a placement of a PPD skin test and the addition of D-Mannose to the resident's medication profile. The resident, who was incapable of understanding rights and responsibilities, received medical treatment without proper consent from the RP. The resident's medical history included hemiparesis, hemiplegia, dysphagia, and functional quadriplegia following a cerebral infarction. Despite the RP's previous indication that the resident was a known reactor to tuberculin skin tests, the facility proceeded with the PPD skin test without obtaining explicit consent from the RP. Interviews with various staff members, including the Infection Prevention Nurse (IP), Assistant Director of Nursing (ADON), and Director of Nursing (DON), revealed that the facility relied on the general consent to treatment signed during admission. However, the facility's policy and the resident's care profile required notifying the RP of any changes to the resident's plan of care. The DON confirmed that the RP was not contacted regarding the addition of D-Mannose, and the expectation was that the RP should be notified of any changes in treatment or medication. The facility's policy on resident rights emphasized the resident's right to be informed of and participate in their plan of care and treatment, which was not upheld in this case.
Failure to Provide Adequate Room Space
Penalty
Summary
The facility failed to provide the required 80 square feet of space per resident in rooms 302, 303, 304, 305, 306, 307, 309, 310, 312, and 314. Each of these rooms housed two residents but only provided between 65 to 78.12 square feet per resident, which is below the regulatory requirement. Despite the rooms being uncluttered and having sufficient space for personal effects, entrance, egress, and maneuvering of equipment, the facility did not meet the minimum space requirements. Interviews with staff and residents indicated no issues or complaints regarding the room sizes, and no safety concerns were reported. The Maintenance Director confirmed that there had been no alterations in the rooms, and measurements taken during the survey confirmed the insufficient space. The facility's Administrator requested a continuance of the room size waiver, noting that there had been no complaints from residents or issues raised in Resident Council meetings. The Department recommended continuing the room size waiver for the specified rooms.
Failure to Provide Adequate Supervision for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision for Resident 7, who had a history of multiple falls and was identified as a fall risk. Despite the care plan indicating that Resident 7 should be out of bed and at the nurse's station during the day for increased supervision, she was found unattended in her room, sitting in a Geri chair and unable to reach her call light. This situation was observed by a Certified Nursing Assistant (CNA) and confirmed by a Licensed Nurse (LN) and the Director of Nursing (DON), all of whom acknowledged that Resident 7 should not have been left alone in her room and that her call light should have been within reach at all times. Resident 7's clinical records indicated she required assistance from two or more staff members for transfers and had a history of repeated falls. On two separate occasions, Resident 7 had fallen while attempting to self-transfer. The facility's policies on fall risk management and comprehensive person-centered care plans were not followed, as evidenced by the failure to keep Resident 7's call light within reach and to ensure she was supervised as required by her care plan. This lack of adherence to the care plan increased the risk of falls for Resident 7.
Failure to Provide Medical Records via Requested Method
Penalty
Summary
The facility failed to provide a copy of medical records for one resident when the resident's Responsible Party (RP) did not receive the medical record via electronic mail as requested. The admission record indicated that the resident was initially admitted with diagnoses including chronic respiratory failure with hypoxia. The resident had a Responsible Party and Power of Attorney (POA) who authorized the disclosure of health information via email. Despite the request being received and confirmed by the Social Services Director, the facility was unable to provide documented evidence of the email being sent to the RP. The Medical Records staff stated that the medical chart was copied and ready for pick-up, but this did not align with the RP's request for electronic delivery. The facility's policy indicated that residents could access their records within two working days of a written request. However, the facility failed to comply with this policy, as there was no documented evidence of the email being sent. This failure decreased the facility's potential to provide resident medical records consistent with state laws and regulations.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
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