Whitney Oaks Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmichael, California.
- Location
- 3529 Walnut Avenue, Carmichael, California 95608
- CMS Provider Number
- 056410
- Inspections on file
- 48
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Whitney Oaks Care Center during CMS and state inspections, most recent first.
A resident with complex medical needs did not receive physician-ordered wound care on one occasion, as documented by a blank entry in the TAR. The lapse occurred when the usual treatment nurse was absent, and there was no documentation of refusal or explanation for the missed care, contrary to facility policy. Interviews with nursing staff and the DON confirmed the missed treatment and lack of required documentation.
Two residents were involved in a physical altercation, resulting in one resident with paraplegia sustaining a forehead abrasion and broken nails. The other resident, who had severe dementia and a history of altercations, was previously noted to have behavioral issues. Staff witnessed the incident and responded after it occurred. Facility policy states residents must be free from physical abuse.
A resident with a history of depression and anxiety was unable to leave with family for a holiday dinner because an LOA order was not obtained, and the nurse did not attempt to contact the physician as required. The resident was not informed in advance about the need for a doctor's order, and the facility lacked a clear policy for LOA requests, despite the resident's care plan identifying risks for social isolation and psychosocial decline.
A resident with depression and documented decision-making capacity had her mail withheld by staff for seven months due to staff's mistaken belief about her capacity. The resident reported waiting for important correspondence, and the DON confirmed that mail should be delivered directly to residents per facility policy.
A resident with type 2 diabetes was not given glipizide as ordered by the physician, as a nurse administered the medication after the resident had finished breakfast instead of 30 minutes before meals. The nurse acknowledged the error, and the DON confirmed that medications are expected to be given as prescribed.
A CNA did not receive required abuse prevention training for over a year, despite facility policy and prior incidents of inappropriate behavior. This lapse was identified after a resident reported multiple instances of sexual abuse by the same CNA, and review of records showed the CNA had a history of inappropriate conduct toward staff.
A resident with multiple medical conditions and intact cognition reported a verbal threat by a CNA, which was documented by the facility. However, the administrator did not recognize the incident as abuse and failed to report the allegation to the Department within the required timeframe, contrary to facility policy and federal regulations.
Surveyors identified multiple deficiencies in food safety practices, including improper air-drying and storage of kitchenware, worn can opener blades, incorrect thawing and storage of raw and cooked meats, staff unable to verbalize correct manual dishwashing procedures, and failure to maintain safe temperatures in resident food refrigerators and freezers. These issues were confirmed through observation, interviews, and review of facility policies.
The facility did not follow the planned menu for therapeutic diets during a lunch meal service, resulting in several residents on small portion diets receiving larger meat portions than prescribed, and others on fortified diets not receiving the required extra butter or margarine. Additionally, over half of the residents served did not receive the specified parsley garnish, as required by the menu. These failures were confirmed by dietary staff and through review of facility documentation.
Staff did not follow proper hand hygiene protocols during medication administration and meal service, including failing to wash hands before preparing medications and not ensuring residents cleaned their hands before eating. Facility policy required these infection control measures, but observations and interviews confirmed they were not followed.
A nurse failed to knock, communicate, or provide privacy for a resident with dementia and quadriplegia during tube feeding care. The nurse left the resident uncovered and did not explain procedures, contrary to the care plan and facility policy, resulting in a lack of dignity and respect.
A resident was incorrectly coded as having an active MDRO diagnosis on the MDS, despite laboratory and medical records confirming no MDRO was present. The error occurred when the MDS was completed while lab results were pending and was not corrected after results showed the absence of MDRO. Staff interviews confirmed the inaccuracy and lack of a specific MDS policy.
A resident with type 2 diabetes did not receive insulin lispro as ordered before meals; instead, a nurse administered the medication after the resident had finished breakfast, contrary to the physician's order and facility policy.
A resident with severe memory impairment and a language barrier was not provided with communication devices or translation services, resulting in ineffective communication attempts by staff and family concerns about the resident's ability to express needs. Staff and the physician confirmed the lack of communication aids, and there was no care plan addressing the resident's communication needs.
Two residents did not receive necessary assistance with personal hygiene, including nail care and cleaning of a neck brace foampad. One resident had long, dirty, and fungus-like fingernails despite requesting help, while another wore a visibly soiled neck brace that had not been cleaned since admission. Staff confirmed these lapses, and facility policy required such care for residents unable to perform these tasks independently.
A resident with respiratory failure and COPD was found to have overgrown toenails that extended past her toes, which she reported were catching on bed linens and causing concern. Both an LN and the DON acknowledged the need for toenail trimming and confirmed it was within the LN's scope of practice, but the required nail care had not been provided according to facility policy.
A resident with an indwelling urinary catheter was found to have accumulated whitish urine sediments in the catheter tubing on multiple occasions, despite physician orders and facility policy requiring regular monitoring and maintenance. Staff confirmed the presence of sediment and acknowledged that the tubing should be free from such accumulation.
A resident recovering from cervical spinal fusion surgery did not receive a physician-ordered incentive spirometer (IS) to be used three times daily for ten days to prevent pneumonia. Observations and interviews confirmed the IS was not available or provided, and the DON verified the order was not followed. The facility also lacked a policy on IS use and failed to maintain required medical equipment.
A nurse disposed of prescription medications by placing them in a used glove inside a med cart instead of using a drug buster, as required by facility policy. The DON confirmed that all carts should have a drug buster for proper medication disposal. Additionally, an opened narcotic e-kit was not reordered or replaced in a timely manner after use, contrary to facility procedures. Both deficiencies were confirmed through interviews and policy review.
A consultant pharmacist did not identify or recommend necessary lab monitoring for a resident prescribed quetiapine, despite the resident's diagnoses of diabetes and hyperlipidemia. The resident's medical record lacked baseline A1C and lipid panel results, and the pharmacist's medication regimen reviews did not address this omission, contrary to facility policy and FDA guidelines.
Surveyors found that staff failed to properly label, date, and remove expired or soiled medications from medication carts. Multiple medications, including nitroglycerine, inhalers, and ear drops, were found without pharmacy or resident-specific labels, and several opened medications were not dated or discarded according to manufacturer instructions. Nursing staff and the DON confirmed that facility policy required proper labeling and removal of expired medications, but these procedures were not consistently followed.
Three residents with significant mobility limitations, including hemiplegia, quadriplegia, and muscle atrophy, were found to have their call lights out of reach, making them unable to notify staff if needed. Both a CNA and the DON confirmed that call lights should be accessible, and facility policy requires call lights to be within reach when residents are in bed.
The facility failed to maintain a clean and sanitary environment in the dining area, where a dirty birdcage containing four birds was placed next to the kitchen doors. This unsanitary condition, confirmed by a resident, the Infection Preventionist, and the Activities Director, posed a risk of cross-contamination of resident meals. Resident 4, with chronic obstructive pulmonary disease and asthma, expressed concern about potential food contamination. The Administrator acknowledged the failure to maintain cleanliness standards.
A resident with bipolar disorder was not administered the correct dose of Seroquel as per the physician's order, receiving only 400 mg instead of the prescribed 800 mg. The error was identified after the resident's family member noticed unusual behavior and reported it. The facility confirmed the error, which was due to an orientee nurse administering only one tablet instead of two.
A resident with intact cognition and specific food dislikes was served broccoli, contrary to their documented preferences. Despite facility policies requiring adherence to resident food preferences, staff failed to follow the tray cards, leading to the resident not receiving a meal aligned with their dislikes.
Two residents were physically attacked by another resident in the facility's courtyard, resulting in significant injuries. The attacker, who had schizophrenia, used a walker to inflict harm. Despite being cognitively intact, the residents were unable to defend themselves. The incident was witnessed by a CNA, who called for emergency services, and the attacker was taken into police custody.
The facility failed to keep garbage dumpsters closed, as they were overfilled, making them accessible to insects and vermin. This was confirmed by the Housekeeping Manager and Assistant Manager of Maintenance, who noted that the dumpsters' lids could not be closed due to overfilling. The facility's policy required dumpsters to be covered and free of litter, which was not adhered to, potentially affecting the facility's census of 123.
The facility failed to develop baseline care plans within 48 hours for two residents with urinary catheters and one resident using a BiPAP machine. Observations confirmed the presence of catheters and BiPAP use, but care plans were not initiated in time. Interviews with staff confirmed the oversight, highlighting the importance of timely care plans for effective resident care.
The facility failed to create comprehensive care plans for several residents, omitting necessary details for indwelling urinary catheters, psychotropic medications, and Enhanced Barrier Precautions (EBP). Observations and interviews revealed that residents with conditions like severe chronic kidney disease, cellulitis, and pressure ulcers did not have appropriate care plans, despite facility policies requiring such plans within seven days of admission.
The facility failed to update the activity care plans for five residents, impacting their ability to evaluate the effectiveness of interventions for improving residents' well-being. Residents with various diagnoses, including depression, dementia, and quadriplegia, had care plans that were not revised to reflect person-centered approaches. Interviews confirmed that care plans were not reviewed and revised as required by the facility's policy.
The facility failed to provide adequate respiratory care for three residents. A resident using a BiPAP machine lacked specific pressure parameters in her orders, and staff were untrained in its use. Another resident's oxygen concentrator was set incorrectly due to a malfunction, and a third resident was not encouraged to use an ordered incentive spirometer. These deficiencies were confirmed by staff and highlighted a lack of adherence to care plans and physician orders.
The facility failed to document and replace emergency medications in their E-kits, leading to potential unavailability during emergencies. An inspection revealed incomplete logs and missing items in the kits, with staff unsure of the replacement policy. The DON confirmed the expectation for staff to log and reorder used medications, but the facility's policy was not followed.
A facility was found to have a 24.14% medication error rate during a medication pass, involving three residents. Errors included failure to administer insulin before meals, incorrect medication administration, and improper measurement of liquid doses. These actions were contrary to physician orders and facility policies.
A resident received two doses of expired Lantus insulin, which was identified during an inspection of a medication cart. The insulin had expired 28 days after opening, but was still administered, potentially affecting blood sugar control. The DON confirmed that staff should check expiration dates as part of medication administration protocols.
A facility failed to ensure proper medication administration and storage, as a nurse left a resident with a partially consumed medication unattended, and expired medications were found in storage. Additionally, refrigerated medications were stored at incorrect temperatures, with staff failing to take corrective action.
The facility failed to meet food safety standards, with open food packages in the freezer, insufficient sanitizer concentration, and staff unable to describe dishwashing procedures. Peeling paint in the kitchen and expired, improperly labeled food in resident refrigerators were also noted, posing risks for contamination and resident safety.
The facility failed to provide necessary equipment for staff to heat resident food, as microwaves were removed and using staff breakroom microwaves was not allowed due to cross-contamination risks. This deficiency was confirmed through staff interviews and observations, contradicting the facility's policy that required a microwave for reheating resident food.
The facility failed to ensure proper infection control practices, as a nurse did not perform hand hygiene and wore artificial nails against CDC guidelines. Enhanced Barrier Precautions were not followed for residents with infections, as PPE was not consistently used. The facility also lacked infection prevention training and did not review its Infection Prevention and Control Program annually.
The facility failed to maintain an adequate supply of linens for resident care, impacting 123 residents. A resident expressed concern over frequent linen shortages, and CNAs confirmed the issue, noting empty linen storage rooms. The Maintenance Supervisor could not explain the system for calculating linen needs. This deficiency compromised the facility's policies on dignity and infection prevention.
The facility failed to perform accurate assessments for two residents, leading to deficiencies in care. One resident, legally blind since birth, was inaccurately assessed as having adequate vision. Another resident with chronic pain and polyneuropathy experienced a change in condition with swollen feet and a rash, which was not documented or assessed. These failures were confirmed through interviews and record reviews.
A resident with multiple diagnoses, including diabetic foot ulcers, did not receive pressure relief heel boots as ordered by the physician. Despite the resident's preference and the facility's policies, the boots were not applied while the resident was in bed, as confirmed by staff interviews and observations.
A resident with multiple health conditions, including diabetes and peripheral vascular disease, was found to have dirty, long, and untrimmed toenails. Despite a podiatry consult being initiated, there was no timely intervention by a podiatrist. Facility staff, including the Treatment Nurse, Registered Nurse Consultant, and Director of Nursing, acknowledged the inappropriate condition of the resident's toenails, which were not addressed according to the facility's foot care policy.
A resident with multiple diagnoses, including shoulder pain and hemiplegia, had bed rails improperly installed without informed consent or a physician's order. The resident reported pain and restricted movement due to the rails. Facility policies requiring consent and evaluation for bed rail use were not followed, leading to a deficiency.
A facility failed to ensure that a resident's MD notes were signed, potentially leading to inadequate care. The resident, with dementia and depressive disorder, had no MD notes for two months after being readmitted from a hospital. The MRD confirmed the absence of signed notes, and the DON emphasized the need for dated and signed entries. Facility policies require physician supervision and detailed documentation.
A newly admitted resident with dementia and other conditions was not seen by a Medical Doctor every 30 days as required for the first 90 days. Facility staff confirmed the policy mandates such visits, but documentation showed only two visits occurred, potentially risking inadequate care.
A resident was prescribed buspirone as needed for anxiety for 14 weeks, contrary to the facility's policy requiring a 14-day limit on PRN psychotropic medications. The consultant pharmacist noted the need for a 14-day stop date, but this was not followed. Both a registered nurse and the medical director confirmed the oversight, acknowledging the order should have been re-evaluated after 14 days.
Missed Physician-Ordered Wound Care Due to Documentation and Communication Failure
Penalty
Summary
A resident with multiple complex medical conditions, including diabetes mellitus, bullous pemphigoid, diabetic ulcers, bipolar disorder, and obsessive-compulsive disorder, was admitted with physician orders for specific wound care treatments to be performed three times a week and as needed. The resident had a documented history of refusing wound care from nurses other than a specific treatment nurse. On one occasion, the Treatment Administration Record (TAR) showed a blank entry, indicating that the prescribed wound care was not provided on that day. There was no documentation that the resident refused care on that date, and the facility's policy required notification of the supervisor if a resident refused a dressing change. Interviews with nursing staff and the Director of Nursing confirmed that the wound care was missed on the identified date, with staff attributing the lapse to a treatment nurse calling off work and the charge nurse providing care instead. However, there was no record of the resident refusing treatment or any documentation explaining the missed care. The facility's policy also required reporting of refusals and other relevant information, which was not followed in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when two residents were involved in a physical altercation. One resident, who had complete paraplegia and no memory impairment, was found on the floor holding the leg of another resident near a hallway. This resident sustained a superficial abrasion to the forehead and broken nails on the right hand as a result of the incident. The resident reported feeling overwhelmed and experiencing a headache following the altercation. The other resident involved had a diagnosis of unspecified dementia with severe memory impairment and PTSD, and had a documented history of previous resident-to-resident altercations, including an incident where this resident grabbed or punched another. Facility records and interviews confirmed that staff witnessed the altercation and responded after the event. Facility policies reviewed indicated residents have the right to be free from all forms of abuse, including physical abuse.
Failure to Facilitate Resident's Right to Leave for Family Event
Penalty
Summary
A deficiency occurred when a licensed nurse failed to initiate necessary interventions to allow a resident to leave the facility for a Thanksgiving dinner with her family. The resident, who had diagnoses including major depressive disorder and general anxiety but no memory impairment, was denied the opportunity to go out because there was no Leave of Absence (LOA) order from a physician. The nurse did not attempt to contact the physician for an LOA order, citing instructions not to call doctors on weekends. As a result, the resident was not able to participate in the planned family event, despite expressing her desire to do so and her frustration at not being informed of the LOA requirement in advance. The resident's care plan identified her as being at risk for psychosocial well-being concerns and social isolation, with interventions to encourage socialization and minimize decline in mood and behavior. The Director of Nursing confirmed that the nurse should have attempted to obtain an LOA order and acknowledged that the resident was not included in preparations to secure LOA orders before the holiday weekend. Additionally, the facility did not provide a policy or procedure for obtaining LOA or out-on-pass orders when requested, despite having a policy affirming residents' rights to self-determination and access to persons and services outside the facility.
Failure to Ensure Resident Access to Mail
Penalty
Summary
The facility failed to protect a resident's right to send and receive mail when staff withheld the resident's mail for a period of seven months. The resident, who had a diagnosis of depression and was determined to have capacity to make her own decisions, reported waiting for important correspondence from her insurance and law enforcement, which caused her distress. The Activities Director confirmed that activities staff had been withholding the resident's mail since her admission, based on an incorrect belief about her decision-making capacity, despite documentation indicating otherwise. The Director of Nursing acknowledged that residents have the right to receive mail and that mail should be delivered directly to residents when appropriate. Facility policy required mail to be delivered to residents within 24 hours of receipt.
Failure to Administer Diabetes Medication as Prescribed
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes was not administered glipizide as prescribed by the physician. The physician's order specified that the medication should be given 30 minutes before meals and held if the resident's blood glucose was less than 100. During a medication administration observation, a licensed nurse gave the resident glipizide after the resident had already finished breakfast, contrary to the physician's instructions. The licensed nurse confirmed during an interview that the medication was not administered according to the order. The Director of Nursing also stated that nursing staff are expected to administer medications as ordered by the physician. A review of the facility's policy indicated that medications should be administered as prescribed and in accordance with good nursing practices.
Failure to Provide Timely Abuse Prevention Training to CNA
Penalty
Summary
The facility failed to ensure that abuse prevention training for staff was sufficient, as evidenced by a review of training records and interviews. Specifically, one Certified Nurse Assistant (CNA) had not received abuse prevention training for over a year, with the last documented training occurring more than twelve months prior to the survey. The facility's policy required staff orientation and ongoing training in abuse prevention, identification, and reporting, but this was not adhered to for the CNA in question. The Director of Nursing confirmed that abuse training was offered quarterly, in line with state regulations, but the records did not support that this particular CNA had received the required training. Further review of the CNA's performance records revealed prior incidents of inappropriate and harmful sexual behavior towards other employees, including unwarranted comments and non-consensual physical contact. Additionally, a report of suspected dependent adult/elder abuse documented that a resident alleged multiple instances of sexual abuse by the same CNA during personal care. The administrator acknowledged that abuse prevention training should be sufficient to protect residents, but the lack of timely training for the CNA contributed to the deficiency.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse made by a resident against a certified nursing assistant (CNA) to the Department within the required regulatory timeframe. The incident was documented in a grievance/complaint report, which stated that a family member reported the CNA had threatened to hurt the resident. The administrator received and acknowledged the complaint but did not recognize the verbal threat as abuse at the time and therefore did not report it as required. Both the administrator and the director of staff development later confirmed that a verbal threat constitutes abuse and should have been reported according to facility policy and federal regulations. The resident involved had multiple medical diagnoses, including polyneuropathy, chronic obstructive pulmonary disease, schizoaffective disorder, moderate protein-calorie malnutrition, and substance use disorders. The resident was assessed as cognitively intact. Facility policy required immediate reporting of abuse allegations to the appropriate authorities, with specific timeframes depending on the severity of the incident. Despite these policies, the verbal abuse allegation was not reported, and the required follow-up investigation report was not submitted within the mandated period.
Deficiencies in Food Safety Practices and Storage
Penalty
Summary
The facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food safety. During a kitchen tour, several metal pans were found stacked while still wet in the clean and ready-to-use storage area. Both the Dietary Manager and Registered Dietitian confirmed that dishes and pans should be completely air-dried before storage to prevent bacterial growth, as supported by facility policy and the FDA Food Code. Additionally, the blade of the can opener was observed to be worn, with the metal surface worn off, which could lead to physical contamination of food. The Dietary Manager acknowledged the blade should be replaced, and facility policy requires proper maintenance and replacement of worn blades. In the walk-in refrigerator, raw ground turkey was found thawing next to cooked deli meats, with some cooked meats placed below the raw meat. Both the Dietary Manager and Registered Dietitian confirmed this was improper, as raw meats should be stored below cooked or ready-to-eat foods to prevent cross-contamination. Facility policies require the use of drip pans under thawing meats and proper arrangement of raw and cooked foods based on cooking temperature requirements. The improper arrangement and lack of drip pans were confirmed during interviews and policy review. Further deficiencies were noted in the manual dishwashing process, where a Dietary Aide was unable to accurately verbalize the correct immersion time for sanitizing dishes in the 3-compartment sink. The posted instructions and facility policy required a 60-second immersion, but the aide stated 15-30 minutes, and the Dietary Manager stated 15 seconds. Additionally, resident food refrigerators and freezers at nursing stations were not maintained at safe temperatures, with logs showing repeated out-of-range temperatures and no corrective actions documented. Some temperature logs were prefilled before the appropriate shift, and staff were unaware that the temperature ranges used were for medication storage, not food. These failures were confirmed through observation, interviews, and policy review.
Failure to Follow Therapeutic Diet Menus and Portion Controls
Penalty
Summary
During a lunch meal service, the facility failed to follow the planned menu for therapeutic diets as prescribed. Six residents on small portion diets received three ounces of roast beef instead of the two ounces specified in the menu. Additionally, six residents on fortified diets did not receive the planned extra one ounce of melted butter or margarine on their mashed potatoes. These discrepancies were confirmed by kitchen staff and through review of the facility's menu spreadsheet, which outlined the correct portions and fortification requirements for each diet type. Furthermore, 57 out of 113 residents who received lunch meals did not receive the required parsley garnish, as indicated on the menu. Interviews with the Dietary Manager and Registered Dietitian confirmed that the menu was not followed as planned, and that the small portion and fortified diets were intended to address specific nutritional needs, such as weight loss or inadequate caloric intake. The facility's diet manual, menu planning policy, and job descriptions for dietary staff all required adherence to the planned menu and portion control, which was not observed during this meal service.
Failure to Ensure Hand Hygiene During Medication Pass and Meal Service
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by staff not adhering to proper hand hygiene protocols during medication administration and meal service. During medication passes, a licensed nurse prepared and administered medications to two residents without performing hand hygiene or wearing gloves as required. One nurse handled a resident's partially eaten meal tray and then prepared medication without washing hands, incorrectly stating that gloves could be used in place of handwashing. The Infection Preventionist and Director of Nursing both confirmed that facility policy requires hand hygiene before and after resident contact and before medication preparation, and that gloves are not a substitute for handwashing. Review of facility policy corroborated these expectations. Additionally, staff did not ensure that residents performed hand hygiene before eating lunch in the dining room. Observations showed that none of the 24 residents present were offered hand hygiene before receiving their meals, and residents confirmed that their hands were not washed or wiped prior to eating. Staff interviews revealed that the expectation was for residents to clean their hands with a moist towelette provided on their meal trays, but no such towelettes were present. Facility policy also indicated that residents should be encouraged to practice hand hygiene. These lapses in infection control practices were confirmed through interviews and policy review.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
Licensed Nurse 3 failed to promote dignity and respect for a resident with dementia and functional quadriplegia during care activities. The nurse entered the resident's room without knocking or verbally acknowledging the resident, and did not explain the purpose for entering. While preparing for tube feeding administration, the nurse uncovered the resident's abdomen to access the gastrostomy site and then left the room without covering the resident's body. The nurse returned several minutes later and continued the procedure without communicating or explaining the task to the resident. The resident's care plan required verbal and tactile cues, as well as explanations during activities of daily living. The nurse admitted to not communicating with the resident or maintaining bodily privacy during the procedure. Facility policy required staff to knock before entering, address residents by name, explain procedures, and protect resident privacy at all times. These actions were inconsistent with both the resident's care plan and facility policy, resulting in a failure to provide care in a dignified and respectful manner.
Inaccurate MDS Coding of MDRO Status
Penalty
Summary
The facility failed to accurately complete the quarterly Minimum Data Set (MDS) for one resident, resulting in an inaccurate record regarding the resident's Multi-Drug Resistant Organism (MDRO) status. The resident was admitted with diagnoses including diabetes mellitus, peripheral vascular disease, and resistance to multiple antimicrobial drugs. The MDS indicated the presence of an active MDRO diagnosis, but a review of the resident's transfer form, hospitalization record, and microbiology cultures showed no evidence of MDRO or need for isolation. The microbiology cultures specifically indicated a urinary infection with bacteria sensitive to multiple antibiotics, confirming the absence of MDRO. Observations revealed that there was no signage for contact-based precautions in the resident's room, and interviews with facility staff confirmed that the MDRO status was incorrectly marked on the MDS when laboratory results were still pending. Staff acknowledged that the MDS should have been updated once the lab results confirmed the absence of MDRO. The Director of Nursing also stated that the MDRO status should have been coded accurately and verified, and noted the absence of a facility policy specific to MDS completion.
Insulin Not Administered Per Physician Order
Penalty
Summary
A deficiency occurred when a licensed nurse failed to administer insulin lispro to a resident with type 2 diabetes according to the physician's order. The order specified that the insulin should be given subcutaneously before meals. During a medication pass observation, the nurse was seen preparing and administering the insulin after the resident had finished eating breakfast, rather than before the meal as prescribed. The nurse confirmed that the medication was given after the meal, despite the order and facility policy requiring administration before meals unless otherwise specified. The resident involved had a diagnosis of diabetes and was admitted to the facility in Fall 2022. Facility records and interviews with staff, including the DON, confirmed that insulin and blood sugar checks were expected to be performed prior to meals. The facility's medication administration policy also required medications to be given as prescribed and in accordance with good nursing practices, specifically noting that before or after meal orders should be administered based on mealtimes. The failure to follow these protocols resulted in the identified deficiency.
Failure to Provide Communication Support for Non-English Speaking Resident
Penalty
Summary
A deficiency occurred when the facility failed to meet the communication needs of a resident who was admitted with a right femur fracture, muscle weakness, and severe memory impairment. The resident's preferred language was Russian, and the Minimum Data Set indicated a significant language barrier. Despite this, there were no communication devices or materials available in the resident's room, and staff were observed and interviewed confirming the absence of communication boards or use of translation services. The resident was seen responding to questions with gestures rather than verbal communication, and staff were unsure of the resident's language or how to effectively communicate with her. Interviews with staff, the resident's family member, and the physician revealed that communication was primarily attempted through gestures, which were not effective. The family member had requested an interpreter upon admission but was told none was available, and expressed concern about the resident's inability to communicate, especially given her cognitive impairment. The physician relied on the family member to interpret during assessments and had discussed the need for translation services with staff. The Director of Nursing confirmed that there was no communication care plan in place for the resident, despite facility policy requiring assistance with communication needs in the resident's preferred language.
Failure to Provide Adequate Nail and Device Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living for two residents who were unable to perform these tasks independently. One resident with depression, left-sided weakness, and cognitive impairment had long, jagged, and dirty fingernails, with some nails curled inward and showing a fungus-like appearance. The resident reported requesting nail care from staff, but it was not provided. Observations by staff confirmed the poor nail condition, and the nurse acknowledged the need for a physician's order for treatment. The DON stated that nurses are expected to provide nail care and notify the physician if there are signs of fungal infection. Another resident, who had undergone cervical spinal fusion and was required to wear a neck brace at all times, was observed with a neck collar foampad that was discolored and dirty. The resident stated that the foampad had not been cleaned or changed since admission, and staff confirmed the lack of cleaning. The DON indicated that regular cleaning of the foampad is necessary to prevent skin irritation and infection. Facility policies reviewed indicated that residents unable to perform activities of daily living should receive assistance to maintain good grooming and hygiene, and that resident care equipment should be cleaned regularly.
Failure to Provide Timely Toenail Care
Penalty
Summary
A resident admitted in July 2024 with respiratory failure and COPD was observed to have overgrown toenails extending past the edge of her toes. The resident reported that her toenails frequently became caught on bed linens and expressed concern about scratching herself. During observations and interviews, both a licensed nurse and the Director of Nursing acknowledged that the resident's toenails needed trimming and confirmed that it was within the licensed nurse's scope of practice to provide this care. Review of facility policy indicated that nail care should include daily cleaning and regular trimming, but the resident had not received appropriate toenail care as required.
Failure to Maintain Catheter Tubing Free from Sediment
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed to have accumulated whitish urine sediments in the catheter tubing on multiple occasions. The resident had a history of urine retention and an enlarged prostate, with physician orders specifying regular monitoring of the catheter, cleansing, and irrigation as needed for clogging. Despite these orders, observations revealed that the catheter tubing was not free from sediment, and this was confirmed by a licensed nurse who acknowledged the presence of accumulated sediments and stated that it should not be present. Interviews with facility staff, including the DON and the administrator, confirmed that the expectation was for nurses to monitor for and address any accumulation of urine sediments in catheter tubing to prevent complications. The facility's policy also indicated that catheters should be changed before blockage is likely to occur, especially for residents prone to encrustations. The failure to maintain the catheter tubing free from sediment represented a lapse in following both physician orders and facility policy for catheter care.
Failure to Provide Ordered Incentive Spirometer for Post-Surgical Resident
Penalty
Summary
The facility failed to provide a prescribed incentive spirometer (IS) to a resident who had recently undergone cervical spinal fusion surgery and was at risk for pulmonary complications. The resident's physician had ordered the use of the IS three times per day for ten days to prevent pneumonia and other lung issues. Observations on multiple occasions revealed that the IS device was not present or available for the resident's use, and the resident confirmed he had not used the device. A licensed nurse acknowledged the absence of the IS and confirmed that it had not been provided as ordered. Further review with the Director of Nursing confirmed the existence of the physician's order for IS use and the expectation that nursing staff would provide the necessary care and equipment. The facility was unable to produce a policy regarding the use of breathing devices such as the IS. Additionally, a review of the RN's duties indicated a requirement to maintain adequate medical supplies and equipment to meet residents' needs, which was not met in this instance.
Failure to Properly Dispose of Medications and Replace Emergency Kit
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the destruction of prescription medications and the timely replacement of the narcotic emergency kit (e-kit) after use. During an observation, a licensed nurse was found to have placed amiodarone and another unidentified loose pill inside a used latex glove and stored it in the medication cart, rather than disposing of the medications immediately in a drug buster as required. The nurse confirmed that there was no drug buster available on her cart at the time. The Director of Nursing also confirmed that all medication carts were supposed to be equipped with a drug buster and that staff were expected to use it for medication disposal, not a glove. Review of the facility's policy indicated that all non-controlled drugs eligible for disposal should be placed in an approved waste container. Additionally, an inspection of a medication storage room revealed an e-kit with a broken seal, indicating it had been opened, but it had not been reordered from the pharmacy as required. The log inside the e-kit showed that medication had been removed, and the registered nurse confirmed that the e-kit should have been reordered as soon as it was opened. The facility's policy stated that opened e-kits must be replaced with sealed kits within 72 hours and that the nurse who uses the medication is responsible for notifying the pharmacy for replacement. The Director of Nursing confirmed that the expectation was for opened e-kits to be replaced promptly according to policy.
Consultant Pharmacist Failed to Identify Need for Lab Monitoring with Antipsychotic Use
Penalty
Summary
The facility's consultant pharmacist failed to identify and address drug-related issues for one resident during the monthly drug regimen review. Specifically, a resident with diagnoses including anxiety disorder, schizoaffective disorder, depression, diabetes mellitus II, and hyperlipidemia was prescribed quetiapine, an antipsychotic medication. The resident's medical record did not include baseline laboratory tests such as glycated hemoglobin (A1C) or a lipid panel, which are recommended for monitoring due to the resident's diagnoses and the known side effects of quetiapine. The consultant pharmacist's medication regimen reviews from January 2025 to the present did not include any recommendations for these necessary lab tests. During an interview and record review, the DON confirmed that there were no lab orders or recommendations for a lipid panel or hemoglobin A1C for the resident, despite facility policy and FDA guidelines indicating the need for such monitoring. The facility's policies require monitoring for metabolic side effects, including changes in cholesterol, triglycerides, and blood sugar, and specify that the consultant pharmacist should review laboratory results as part of the medication regimen review. This omission was identified through observation, interview, and record review, and was found to have the potential for unsafe medication use for all residents in the facility.
Failure to Properly Label, Date, and Remove Expired Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and storage of drugs and biologicals. During inspections of medication carts, multiple medications were found without pharmacy labels, open and undated multi-dose medications, and expired medications that had not been removed. Specific examples included two bottles of nitroglycerine without pharmacy labels, several inhalers and vials that were opened but not dated, and a bottle of ear wax removal drops labeled only with a room number rather than a resident-specific label. Additionally, a COVID-19 antigen rapid test was found to be expired, and an over-the-counter medication was not properly labeled. Nursing staff confirmed these findings and acknowledged that medications were not labeled with open or discard dates as required, and that expired or soiled drugs had not been removed from the carts. Interviews with nursing staff and the Director of Nursing revealed that the facility's policy required medications to be labeled with open dates, resident-specific or pharmacy labels, and for expired or soiled medications to be promptly removed and disposed of. The staff confirmed that these procedures were not consistently followed, resulting in the presence of expired, improperly labeled, and potentially contaminated medications in medication storage areas. The facility's written policy also specified that medications should be stored and labeled according to professional standards and manufacturer's recommendations, which was not adhered to in these instances.
Call Lights Out of Reach for Residents with Mobility Impairments
Penalty
Summary
The facility failed to ensure that call lights were accessible to three residents with significant mobility impairments. One resident with hemiplegia and diabetes mellitus was unable to locate his call light, which was found hanging over the bed rail and lying under the bed, out of reach. Another resident with quadriplegia and spinal fusion had his call light wrapped around the bed rail, also out of reach. A third resident with hemiplegia and muscle atrophy similarly had his call light wrapped around the bed rail and could not access it. All three residents confirmed during interviews that they could not reach their call lights and would be unable to notify staff in an emergency. A Certified Nursing Assistant (CNA) confirmed that the call lights for these residents were out of reach and acknowledged that call lights should be placed by the resident's hand for safety. The Director of Nursing (DON) also confirmed that call lights should always be within reach to allow residents to call for assistance or in case of emergency. Review of the facility's policy indicated that call lights are to be accessible to residents when in bed.
Unsanitary Birdcage in Dining Area Poses Contamination Risk
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the dining area, which posed a risk of cross-contamination and infection. A birdcage containing four birds was observed to be dirty and unsanitary, located next to the walkway of the kitchen doors where food carts carrying resident meals passed through. The birdcage had a white plastic container and paper at the bottom, both stained with brown-to-whitish material, and the surrounding floor was littered with feathers, specks of material, and seed-like dirt. This unsanitary condition was confirmed by multiple parties, including a resident, the Infection Preventionist, and the Activities Director, all of whom expressed concerns about the potential for contamination of resident meals. Resident 4, who had chronic obstructive pulmonary disease and asthma, confirmed the unsanitary condition of the birdcage and expressed concern about the dirt potentially contaminating food. The Infection Preventionist and Activities Director both acknowledged the unsanitary state of the birdcage and the surrounding area, noting the lack of a cleaning log for the birdcage. The Administrator also agreed that the birdcage was not sanitary and should have been clean, acknowledging the facility's failure to maintain the birdcage to standard. The facility's policy on maintaining a homelike environment emphasized the importance of a clean, sanitary, and orderly setting, which was not upheld in this instance.
Medication Administration Error for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for a resident when the prescribed dose of Seroquel, a medication used to treat mental/mood disorders, was not administered according to the physician's order. The resident, who was admitted with a diagnosis of bipolar disorder, was supposed to receive 800 mg of Seroquel at bedtime but was only given 400 mg. This discrepancy was noted in the resident's Medication Administration Record and was confirmed by the Director of Nursing during an interview. The error was attributed to an orientee nurse who administered only one tablet instead of the prescribed two. The resident's family member reported the medication error after noticing the resident was wide awake in the evening, which was unusual. The facility's documentation, including the Health Status Note and the Interdisciplinary Team's late entry note, confirmed the medication error. The facility's policy on medication administration emphasizes that medications should be administered as prescribed by the attending physician, which was not adhered to in this instance. The Nursing Practice Act Rules and Regulations also highlight the importance of administering medications as part of direct patient care services.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 2, who was served broccoli during a lunch meal despite having documented dislikes for broccoli. Resident 2, who was admitted in June 2024 with diagnoses including transient ischemic attack and cerebral infarction, had intact cognition as per the Minimum Data Set. The dietary interview/pre-screen document dated July 12, 2024, clearly indicated that Resident 2 disliked broccoli and cabbage. However, during a lunch observation on July 18, 2024, Resident 2 was served broccoli, which was confirmed by both the resident and a family member present. The Registered Dietitian and the Director of Nursing both confirmed that Resident 2's records indicated a dislike for broccoli, and acknowledged that the staff should have followed the tray cards reflecting these dislikes. The facility's policy on resident food preferences, revised in July 2017, mandates that individual food preferences be assessed upon admission and communicated to the interdisciplinary team. Despite this policy, the staff failed to adhere to the documented food preferences, resulting in Resident 2 not receiving a meal that aligned with their stated dislikes.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in significant injuries. Resident 1, who was cognitively intact and had no behavioral symptoms, was attacked by Resident 3 with a walker after attempting to intervene in an altercation. This attack led to Resident 1 sustaining a laceration to the head, blunt head trauma, and a chest wall contusion. Resident 1 was admitted to the facility with diagnoses including cellulitis and congestive heart failure. Resident 2, also cognitively intact, was initially attacked by Resident 3, resulting in multiple skin tears and a laceration to the back of the head. Resident 2 was admitted with diagnoses including aortic aneurysm and chronic obstructive pulmonary disease. The altercation occurred in the facility's courtyard, where Resident 2 was first attacked, and Resident 1 was subsequently assaulted when trying to assist. Resident 3, who had a diagnosis of schizophrenia, was described as cognitively intact with no behavioral symptoms noted in the admission records. The incident was witnessed by a CNA, who called for emergency services. Resident 3 was taken into police custody following the altercation. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, yet this incident highlights a failure to protect residents from harm by another resident.
Improper Garbage Disposal and Overfilled Dumpsters
Penalty
Summary
The facility failed to ensure that garbage dumpsters were not accessible to insects and vermin due to the lids not being closed. This was observed when two blue-colored garbage dumpsters and one green-colored recycling bin were found to be overfilled, preventing the lids from being closed. The surrounding area was also littered, which was confirmed by the Housekeeping Manager and the Assistant Manager of Maintenance during interviews. Both managers acknowledged that the dumpsters were overfilled, which prevented the lids from being closed tightly. A review of the facility's policy and procedure on garbage and refuse disposal indicated that all garbage containers should have tight-fitting lids and be kept covered when not in continuous use. The policy also stated that garbage containing food waste should be stored in a manner inaccessible to pests, and outside dumpsters should be kept closed and free of surrounding litter. The failure to adhere to these policies had the potential to harbor pests and vermin capable of spreading disease, affecting the facility's census of 123.
Failure to Develop Timely Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop baseline care plans for three residents within 48 hours of their admission, as required by their policy. Resident 364 and Resident 366, both of whom had indwelling urinary catheters, did not have care plans addressing the management of their catheters. Observations confirmed the presence of urinary catheters for both residents, yet their care plans lacked any mention of catheter care. Interviews with RN 1 and the Director of Nursing (DON) confirmed the absence of these care plans and emphasized the importance of including urinary status in the baseline care plan. Additionally, Resident 320, who was dependent on a BiPAP machine for breathing due to asthma and chronic respiratory failure, did not have a care plan for the BiPAP initiated within the required timeframe. The resident expressed concerns about staff not knowing how to operate the BiPAP, and her breathing had worsened since admission. The Case Manager Nurse confirmed that the care plan for the BiPAP was initiated later than the 48-hour requirement. The facility's policy mandates that baseline care plans, including physician orders, be developed within 48 hours to ensure effective, person-centered care.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for eight out of 29 sampled residents, which included the use of indwelling urinary catheters, psychotropic medications, and Enhanced Barrier Precautions (EBP). This deficiency was identified through observations, interviews, and record reviews. For instance, Resident 366, admitted with severe chronic kidney disease and benign prostatic hyperplasia, was observed with a urinary catheter, yet their care plan lacked any mention of the catheter or EBP interventions. Similarly, Resident 364, admitted with cellulitis and severe sepsis, also had a urinary catheter without a corresponding care plan, and EBP was not implemented until later. Resident 94, admitted with a right femur fracture and muscle weakness, had a medication order for buspirone, a psychotropic medication, but their care plan did not include this medication. Additionally, Resident 48, admitted with stage 4 pressure ulcers, lacked EBP interventions in their care plan. Other residents, such as Residents 62, 102, 103, and 361, also had care plans that were missing EBP interventions, despite their medical conditions that warranted such precautions. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of necessary care plans for urinary catheters and EBP. The facility's policy and procedure documents indicated that comprehensive care plans should be developed within seven days of admission, addressing the resident's physical, psychosocial, and functional needs. However, the facility failed to adhere to these guidelines, resulting in incomplete care plans for the affected residents.
Failure to Update Activity Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the activities care plan for five residents, which impacted their ability to evaluate the effectiveness of interventions aimed at improving the residents' physical and social well-being. Resident 11, who was diagnosed with depression and chronic respiratory failure, was admitted to hospice care. Despite her capability to understand her rights and responsibilities, her activity care plan was not updated to address her episodes of social isolation, as indicated by her response to the Minimum Data Set (MDS) assessment. Resident 42, diagnosed with depression, generalized muscle weakness, and bipolar disorder, was found incapable of understanding his rights and responsibilities. His care plan did not incorporate person-specific approaches from the physician's monthly progress notes, which suggested organizing activities and using therapeutic communication. Similarly, Resident 52, with Parkinson's and dementia, had a care plan that lacked updates to prevent social isolation, despite her symptoms of feeling lonely and isolated. Resident 67, diagnosed with dementia and quadriplegia, required significant assistance for activities of daily living. His care plan did not reflect a person-centered approach to stimulate his senses, as he was mostly bedbound and nonverbal. Lastly, Resident 76, with obesity, major depressive disorder, and a history of adult emotional abuse, expressed dissatisfaction with the facility's activity offerings. Her care plan was not revised to address her depressed and isolated mood. Interviews with the MDS nurses and the Activity Director confirmed that the care plans were not reviewed and revised as required by the facility's policy and procedure.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide proper respiratory care services for three residents, leading to deficiencies in their care. Resident 320, who was dependent on a BiPAP machine for breathing due to conditions like asthma and chronic respiratory failure, did not have specific pressure parameters outlined in her physician's orders. Additionally, the staff was not trained in handling the BiPAP equipment, as confirmed by multiple licensed nurses and the Director of Nursing. Observations revealed that the BiPAP machine's water reservoir was empty, and staff were unsure how to refill it, further indicating a lack of training and understanding of the equipment. Resident 81, diagnosed with emphysema and other respiratory conditions, had a physician's order for oxygen at 2 liters per minute via nasal cannula. However, the oxygen concentrator was set at only 0.5 liters per minute, and the machine was reportedly broken, preventing the adjustment to the correct setting. This discrepancy was acknowledged by the registered nurse and the RN Supervisor, who confirmed that the care provided did not meet the resident's needs. The Director of Nursing emphasized the importance of ensuring equipment functionality and adherence to physician orders. Resident 42, with diagnoses including generalized muscle weakness and COVID-19, had an order to use an incentive spirometer every waking hour. Despite this, observations over several days showed that the resident was not encouraged to use the device, and it was not found at the bedside. A CNA and a licensed nurse confirmed the absence of the spirometer and the lack of encouragement for its use. The RN Supervisor stated that all physician orders should be carried out, and any refusals should be communicated to the doctor, highlighting a failure in executing the care plan for Resident 42.
Failure to Document and Replace Emergency Medications
Penalty
Summary
The facility failed to accurately document and replace emergency medications in their emergency kits, which are essential for immediate use during medical emergencies. During an inspection, it was observed that a First Dose Emergency Kit was opened, and the logs inside were incomplete, with one log missing the date of medication removal. The Infection Preventionist (IP) confirmed the finding but was unsure of the facility's policy for replacing the E-kit after use. Licensed Nurse 5 (LN 5) acknowledged that nursing staff were expected to fill out the logs completely and reorder the E-kit from the pharmacy when medications were depleted. Additionally, an IV ER Box was found with a missing extension valve port, which was not documented in the E-kit log. The IP confirmed that nursing staff did not notify the pharmacy to reorder a replacement E-kit after using emergency supplies. The Director of Nursing (DON) stated that nursing staff were expected to complete E-kit logs and notify the pharmacy for replacements. The facility's policy indicated that used medications should be replaced within 72 hours, but this procedure was not followed, leading to a lack of accountability and potential unavailability of emergency medications.
High Medication Error Rate Observed
Penalty
Summary
The facility was found to have a 24.14% medication error rate during a medication pass observation, which is significantly higher than the acceptable threshold of 5%. This was observed when seven medication errors occurred out of 29 opportunities. The errors involved three residents, with medications not being administered according to the prescriber's orders, potentially affecting the residents' clinical conditions. For Resident 43, Licensed Nurse 6 (LN 6) failed to administer Novolog insulin before breakfast as required, did not check the resident's pulse before giving amlodipine, and crushed potassium chloride ER tablets despite a clear warning not to do so. These actions were contrary to the physician's orders and the facility's policy, which requires medications to be administered as prescribed and not to crush long-acting medications. Resident 39's medication administration was also mishandled by LN 6, who did not measure the resident's pulse before administering valsartan, gave vitamin D3 instead of the prescribed vitamin D2, and failed to administer Auryxia with a meal. Additionally, LN 5 inaccurately measured a liquid dose of potassium chloride for Resident 96, using a medicine cup instead of a syringe for precise measurement. These errors highlight a lack of adherence to the facility's policies and procedures for medication administration.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a resident received Lantus, a long-acting insulin, two times past its expiration date. During an inspection of Medication Cart 1, a vial of Lantus labeled with an opened date was found to be expired. Licensed Nurse 5 confirmed that the insulin had expired 28 days after opening and acknowledged that it was administered to the resident on two occasions after its expiration date. The resident's medical record indicated a physician's order for insulin glargine to be administered at bedtime for managing Diabetes type II. The Medication Administration Record confirmed the administration of expired Lantus, which could be less effective in controlling blood sugar levels. The Director of Nursing stated that nursing staff should never administer expired insulin and are expected to check expiration dates as part of the five rights of medication administration. The facility's policies also emphasized the removal and disposal of outdated medications.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and storage practices, as observed during a medication pass. A licensed nurse left a resident unattended with a partially consumed medication, ClearLax, on the bedside table, contrary to the facility's policy that requires medications to be administered at the time of preparation and residents to be observed to ensure complete ingestion. The Director of Nursing confirmed that the resident did not have the necessary assessments or physician's orders to self-medicate, highlighting a breach in protocol. During an inspection of the medication storage room, expired and discontinued medications were found available for use. Expired administration sets and IV tubing for discontinued medications were not removed from the facility's supply, and an expired vial of Lantus insulin was found in a medication cart. Additionally, an unused Novolin FlexPen lacked a date indicating when it was brought to room temperature, making it impossible to determine its expiration status. The facility's policy requires expired medications to be removed and destroyed, and insulin pens to be dated when removed from refrigeration. The facility also failed to maintain proper storage temperatures for refrigerated medications. The medication storage room refrigerator was observed to be below the required temperature range on multiple occasions, and staff did not take appropriate action to adjust the temperature or verify the safety of the medications. The facility's policy mandates that refrigerated medications be stored between 36 and 46 degrees Fahrenheit, and staff are expected to notify maintenance or adjust temperatures if they fall out of range.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. In the walk-in freezer, multiple food packages were found to be improperly stored with bags left open, exposing the food to air. This was confirmed by the Dietary Supervisor, who acknowledged that staff had been trained to reseal bags after use. The Registered Dietitian noted that such exposure could lead to bacterial contamination and food drying out. The facility's policy on food storage mandates that opened food items must be tightly closed, which was not followed in this instance. Additionally, the facility did not maintain proper sanitation practices. A red sanitizer bucket used for cleaning food surfaces was found to have an insufficient sanitizing concentration, as demonstrated by the Diet Aide during a test. The solution had been prepared two hours prior and had lost its effectiveness, falling below the required 200 parts per million concentration. The facility's policy requires that the concentration be tested every shift and replaced if it falls below the standard. Furthermore, dietary staff were unable to correctly describe the setup for manual dishwashing in the three-compartment sink, indicating a lack of understanding of the required water temperature and sanitizing procedures. The physical condition of the kitchen also posed a risk for food contamination, with peeling paint observed on the ceiling and walls. The Registered Dietitian concurred that this could lead to contamination. In addition, expired and improperly labeled food was found in resident refrigerators, with one instance involving expired yogurt and another involving grapes that were not suitable for a resident on a pureed diet. The facility's policy requires that perishable foods be labeled with the resident's name, room number, and date, and discarded after two days, which was not adhered to in these cases.
Deficiency in Heating Resident Food
Penalty
Summary
The facility failed to provide staff with the necessary equipment to assist residents in safely accessing and consuming outside food, as staff were unable to heat foods to the correct serving temperatures. This issue was identified during observations and interviews with various staff members, including a Licensed Nurse, a Registered Nurse Supervisor, a Dietary Supervisor, a Registered Dietitian, and an Infection Preventionist. It was noted that the resident microwave had been removed, and there was no alternative means for staff to heat resident food, as using staff microwaves in the breakroom was not allowed due to cross-contamination risks. The facility's policy on foods brought by family or visitors indicated that a refrigerator and microwave should be available for staff to store and rewarm residents' food. However, this policy was not being followed, as confirmed by staff interviews. The Dietary Supervisor and Registered Dietitian were unaware of the removal of microwaves, and the Infection Preventionist confirmed that there was no way for nursing staff to reheat resident food. This deficiency had the potential to limit food intake, leading to malnutrition or weight loss, and increased the risk of foodborne illness for the residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by nursing staff, as observed during a medication pass. A licensed nurse was seen with artificial nails, which are discouraged by the CDC, and did not perform hand hygiene before and after glove use while preparing and administering medications to residents. The nurse admitted to not following the facility's policy due to being late, and the infection preventionist acknowledged the policy on artificial nails was unclear, despite CDC guidelines discouraging their use. Enhanced Barrier Precautions (EBPs) were not properly implemented for several residents with conditions such as stage 4 pressure ulcers, urinary tract infections, and methicillin-resistant staphylococcus aureus. Observations revealed that personal protective equipment (PPE) like gowns and masks were not consistently used by staff during high-contact care activities, despite EBP signs being posted. Interviews with staff confirmed the lack of adherence to EBP protocols, and the infection preventionist stated that residents with chronic wounds and indwelling devices should be on EBP, requiring gowns, gloves, and masks during care. The facility also failed to provide infection prevention training or inservices to staff despite identifying trends of urinary tract and respiratory infections through infection surveillance. The Director of Nursing acknowledged the need for staff education based on infection trends to prevent further spread. Additionally, the facility's Infection Prevention and Control Program (IPCP) had not been reviewed annually, with the last revision noted in 2018, contrary to the policy requiring annual review by key clinical and administrative staff.
Linen Shortage Affects Resident Care and Dignity
Penalty
Summary
The facility failed to ensure a sufficient supply of linens was available for staff to use during residents' daily care, affecting a census of 123 residents. This deficiency was identified through observations, interviews, and record reviews. During an initial tour, a resident expressed concern about the frequent linen shortages, which staff often discussed. The resident was worried about the facility's management. Concurrently, a Certified Nurse Assistant (CNA) observed the linen storage room to be empty and expressed frustration over the lack of linens available for resident care. Further observations and interviews with other CNAs confirmed the ongoing issue of insufficient linen supplies. The Maintenance Supervisor was unable to explain the system or formula used to calculate the necessary volume of linens per shift per day to meet residents' needs. The facility's policies on dignity and infection prevention emphasize providing a safe, sanitary, and comfortable environment, yet the linen shortage compromised these standards, impacting residents' self-esteem and well-being.
Inaccurate Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care. Resident 33, who was admitted with multiple diagnoses including legal blindness, was inaccurately assessed in the social services progress note as having adequate vision, despite being legally blind since birth. This discrepancy was confirmed during an interview with the Social Services Director, who acknowledged the error in the assessment. Resident 23, admitted with chronic pain and polyneuropathy, experienced a change in condition with swollen feet and a new rash, which was not documented or assessed as required. During an interview and record review, RN 1 confirmed the absence of a change of condition assessment for Resident 23's new symptoms, despite the facility's policy mandating complete and accurate documentation of all services provided to residents.
Failure to Apply Pressure Relief Boots as Ordered
Penalty
Summary
The facility failed to provide resident-centered care for a resident when it did not ensure the application of pressure relief heel boots as per the comprehensive assessment, plan of care, physician's order, and the resident's preferences. The resident, who was readmitted with multiple diagnoses including cellulitis, diabetic foot ulcers, and chronic embolism, required pressure-reducing devices for skin and ulcer treatment. Despite the physician's order to apply pressure relief boots to both lower extremities while in bed, the boots were not on the resident as observed during a survey. During interviews, the resident expressed that the boots were prescribed by a podiatrist and should have been worn to protect the feet. The treatment nurse confirmed that the boots were not on the resident as ordered, and the Director of Nursing acknowledged that the skin care plan and treatment orders were not followed. The facility's policies emphasized the importance of following orders and providing person-centered care, which were not adhered to in this instance.
Inadequate Foot Care for Resident
Penalty
Summary
The facility failed to provide appropriate foot care for Resident 261, whose toenails were observed to be dirty, long, and untrimmed. Resident 261 was admitted with multiple diagnoses, including diabetes, Alzheimer's Disease, altered mental status, malnutrition, abnormal gait and mobility, and peripheral vascular disease. During observations and interviews, both the Treatment Nurse and the Registered Nurse Consultant confirmed the inappropriate condition of the resident's toenails, acknowledging that they should have been cleaned and trimmed. The Registered Nurse Supervisor and the Director of Nursing also recognized the inadequacy of the toenail care provided. Despite a podiatry consult being initiated per family request, there was no documented evidence that the resident's toenails were addressed by a podiatrist in a timely manner. The facility's policy on foot care, revised in October 2022, emphasizes the importance of maintaining good foot health and assisting residents in making appointments with a podiatrist. However, interviews revealed that no referral for podiatry was made from social services promptly, contributing to the deficiency in care for Resident 261.
Failure to Obtain Consent and Order for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper installation and authorization for the use of bed rails for a resident, identified as Resident 13. The resident was readmitted with multiple diagnoses, including shoulder pain, arm fractures, and hemiplegia affecting the left side. Despite these conditions, the facility did not obtain informed consent or a physician's order for the use of bed rails, which were observed to be up during a visit. The resident expressed discomfort and pain due to the bed rails, indicating they were restricting movement and causing additional pain. The facility's policies require an interdisciplinary evaluation and informed consent for the use of bed rails, which were not followed in this case. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of informed consent and a physician's order for the bed rails. The facility's documentation policies also emphasize the need for complete and accurate records, which were not maintained in this instance, leading to a deficiency in care for Resident 13.
Unsigned MD Notes Lead to Documentation Deficiency
Penalty
Summary
The facility failed to ensure that the Medical Doctor's (MD) notes for a resident were signed, which could lead to confusing, inaccurate, and inadequate care. The resident, who was admitted with diagnoses of unspecified dementia, major depressive disorder, and disorientation, was readmitted from an acute hospital. The clinical records showed that the resident was seen by the MD on a specific date, but there were no other MD notes for the following two months. This lack of documentation was confirmed by the Medical Records Director (MRD) during an interview. The MRD accessed the acute care hospital's website and found an unsigned MD note for a 60-day visit. The MRD confirmed that all medical notes must be timed, dated, and signed, either manually or electronically. The Director of Nursing (DON) also stated that all entries in the resident's clinical records must be dated, timed, and signed with the individual's title. The facility's policy on physician services and documentation requires that all medical care be supervised by a licensed physician and that documentation includes specific details such as the date, time, and signature of the individual providing care.
Failure to Ensure Timely Physician Visits for Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a newly admitted resident, identified as Resident 99, was seen by a Medical Doctor (MD) once every 30 days for the first 90 days following their admission. Resident 99, who was readmitted to the facility from an acute hospital with diagnoses including unspecified dementia, major depressive disorder, and disorientation, was only documented as being seen by the MD on two occasions: 3/21/24 and 6/19/24. There were no MD notes for April or May, indicating a lapse in the required monthly visits. Interviews with facility staff, including the Case Manager Nurse, Registered Nurse Supervisor, and Director of Nursing, confirmed that the facility policy mandates newly admitted residents must be seen by an MD within 72 hours of admission and then every 30 days for the first 90 days. The facility's policy, aligned with OBRA regulations, also allows for Nurse Practitioners or Physician Assistants to see the resident during this period. However, the documentation did not reflect compliance with these requirements, leading to a potential risk of inadequate and inaccurate care for Resident 99.
Failure to Limit PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident, who was admitted with a right femur fracture and muscle weakness, was prescribed buspirone as needed for anxiety for 14 weeks. This prescription did not comply with the facility's policy, which requires PRN orders for psychotropic medications to be limited to 14 days and then re-evaluated. The consultant pharmacist had indicated that the order needed a 14-day stop date, but this was not implemented. During interviews and record reviews, it was confirmed by a registered nurse and the medical director that the order should have been written for 14 days and then re-evaluated. The medical director acknowledged the error, stating the intention was to have a long-term solution, but the order was not correctly documented according to the policy. The facility's policy on psychotropic medication use clearly states that PRN orders are limited to 14 days unless extended with documented prescriber rationale and a specified duration.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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