Whittier Pacific Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Whittier, California.
- Location
- 7716 S Pickering Avenue, Whittier, California 90602
- CMS Provider Number
- 055764
- Inspections on file
- 47
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Whittier Pacific Care Center during CMS and state inspections, most recent first.
A resident with contractures, muscle weakness, and impaired decision-making capacity had physician orders and care plans directing that a low air loss mattress (LALM) be set according to current weight for wound management and pressure ulcer prevention. The resident weighed 88 lbs, but during surveyor observation the LALM was found set at 120 lbs, despite nursing staff and the DON acknowledging it should be set lower than the resident’s weight (around 80 lbs) to allow proper pressure redistribution. The resident subsequently experienced a change in skin condition with reopening of fragile scar tissue and development of an in-house acquired Stage 1 pressure injury on the right trochanter, even though facility policy and the LALM manual required adjustment of the support surface based on the patient’s weight and care plan.
A resident with bilateral nephrostomy tubes, anoxic brain damage, and a persistent vegetative state experienced multiple episodes of nephrostomy tube malfunction and dislodgement associated with UTIs, each requiring hospital evaluation and tube exchange. The existing care plan only addressed securing the tubing with anchors and was not revised with new, individualized interventions despite repeated dislodgements, hospitalizations, and documentation of empty drainage bags, displaced tubing, and saturated dressings. Nursing staff and the DON acknowledged that the care plan was not updated and that no IDT meeting or root cause analysis was conducted to determine why the nephrostomy tubes continued to become dislodged, contrary to facility policy requiring ongoing assessment and care plan revision when outcomes are not met and after hospital readmissions.
A resident with severe cognitive impairment and a Foley catheter was observed with an uncovered urinary drainage bag, exposing its contents. Facility staff, including an LVN, DSD, and DON, confirmed that the bag should have been covered to maintain dignity, as required by facility policy. This failure violated the resident's right to be treated with dignity and respect.
The facility posted inaccurate CNA staffing information for the overnight shift, listing more CNAs and hours than were actually present according to sign-in sheets. Both the DSD and DON confirmed the discrepancy, acknowledging that the posted data did not match actual staffing records and could mislead residents and visitors.
The facility failed to keep two outdoor refuse containers closed with tight-fitting lids, as observed during an interview with the Dietary Supervisor. The containers were open, full, and overflowing, with one propped open by a red stick. The Maintenance Supervisor explained that staff used the stick to keep the lid open due to the height of the containers, but forgot to remove it. The facility's policy requires containers to be covered when not in use.
The facility failed to provide sufficient staffing for Restorative Nursing Assistant (RNA) services, leading to residents with limited range of motion not receiving prescribed exercises. RNA staff were often reassigned to Certified Nursing Assistant (CNA) duties due to staffing shortages, resulting in missed RNA sessions. Interviews with staff confirmed the issue, and the facility's staffing policy was not adhered to, causing a deficiency in care.
The facility's QAA committee failed to effectively identify and monitor a deficiency related to insufficient RNA staffing, affecting 19 residents who required RNA services to prevent mobility decline. The Administrator and DON were unaware of ongoing issues, such as RNAs being reassigned to CNA tasks and incorrect transcription of physician orders in the EMR system. This lack of oversight and ineffective QAPI processes contributed to the deficiency not being addressed.
The facility failed to adhere to infection control policies, resulting in deficiencies involving five residents. A resident's catheter bag and another's feeding tubing were found on the floor, posing contamination risks. A CNA did not perform hand hygiene between resident care, and family members of a resident did not follow Enhanced Barrier Precautions, increasing the risk of infection spread.
A facility failed to maintain a medication error rate below five percent when an LVN did not flush a G-Tube between administering medications to a resident, resulting in a 33.3% error rate. The resident, with a history of metabolic encephalopathy and sepsis, was dependent on staff for daily activities. The LVN admitted the error, and the ADON confirmed the correct procedure, highlighting the importance of flushing to prevent medication errors.
The facility failed to provide consistent restorative nursing care for four residents, leading to missed RNA services and exercises as ordered by physicians. Observations and interviews revealed that residents were often without necessary supports, and documentation confirmed missed sessions. Staffing shortages and transcription errors contributed to the deficiencies.
A resident with a high risk for falls fell over a Wet Floor sign placed in front of their room, highlighting inadequate supervision and safety measures. The resident, with a history of falls and unsteady gait, was not monitored at the time of the incident, and the placement of the sign created a hazard. The facility's policy on maintaining a safe environment was not followed.
A resident with an indwelling Foley catheter for wound care management was not provided appropriate care, as the catheter was not properly secured and had sediment in the urine, indicating a possible UTI. The facility failed to document urine characteristics and did not report the sediment to a physician, contrary to its policies.
A facility failed to use appropriate alternative interventions before installing side rails for a resident with acute respiratory failure and hemiplegia. The resident's informed consent was incomplete, and there was no evidence of alternative measures being attempted. Staff interviews revealed a practice of automatically using side rails without documented alternatives, contrary to facility policy.
The facility failed to offer and provide information on Advance Directives to two residents during their admission and re-admission. One resident, with conditions including ventilator dependence and epilepsy, had no advance directive noted in their POLST form. Another resident, with muscular dystrophy and quadriplegia, had no signed Advance Healthcare Directive Acknowledgement form, despite discussions with Social Services. The absence of these directives was confirmed by facility staff.
A facility failed to transmit a resident's Discharge MDS to CMS within the required 30-day period. The resident, who had multiple diagnoses including metabolic encephalopathy and heart failure, was discharged to an Assisted Living Facility. The MDS Nurse admitted to forgetting to complete the discharge MDS, and the DON highlighted the importance of timely submissions for accurate reporting.
A facility failed to follow professional standards for G-Tube medication administration for a resident by not checking gastric residuals and not flushing the tube with water between medications. The resident, with severe cognitive impairment and multiple diagnoses, was at risk due to these oversights. The facility's policy requires flushing with water and checking residuals to prevent complications.
A resident at high risk for falls, with conditions including spinal stenosis and lack of coordination, fell over a wet floor sign while attempting to use the restroom unassisted. Despite requiring partial assistance for daily activities and having a history of falls, the facility did not initiate a bowel and bladder training program. Staff confirmed the oversight, acknowledging the need for such a program to prevent unassisted attempts to use the restroom.
A facility failed to maintain a functioning call light system for three residents, including one with Alzheimer's and another with hemiplegia. Despite pressing the call lights, the system did not signal at the nurse's station or outside the rooms. The issue was confirmed by the ADON and IPN, and the Maintenance Supervisor noted the malfunction had not been reported, despite daily checks.
The facility failed to ensure that an LVN and a CNA completed their annual competency assessments, with lapses noted in 2024. The DON and DSD were unaware of the reasons for these omissions, despite facility policy requiring annual evaluations.
A facility failed to provide required specialized rehabilitation services for a resident by not conducting annual and quarterly joint mobility assessments. The resident, with conditions including hemiplegia and diabetes, had not received an OT joint mobility screening since 2022, and no PT or OT screenings were documented for 2024. The Director of Rehab acknowledged the oversight, and the DON highlighted the importance of these assessments in preventing contractures and maintaining independence.
A facility failed to explain an arbitration agreement to a resident's responsible party, who was unable to make an informed decision about the resident's care. The responsible party, who signed the document without understanding it, reported that the forms were handed over without explanation. The Admissions Coordinator stated the document was self-explanatory, while the Administrator acknowledged the need for proper explanation as per regulations.
The facility was found deficient in providing adequate room size, with 11 rooms measuring less than the required 80 square feet per resident. Despite this, residents and staff reported no adverse effects on care or mobility, as adjustments were made to accommodate space needs.
The facility failed to respond to call lights in a timely manner for four residents, leading to delays in assistance for personal hygiene and other needs. Residents reported waiting 1-2 hours for help, contrary to the facility's policy of responding within five minutes. This delay increased the risk of harm and discomfort for the residents.
A resident with acute respiratory failure and cerebral aneurysm was not properly offered the influenza vaccine, and the facility failed to provide necessary education or document the refusal with the required signature. The resident denied refusing the vaccine, contradicting the LVN's account. The facility's policy requires informed consent and documentation, which was not adhered to in this instance.
A resident with acute respiratory failure and cerebral aneurysm was not offered the Covid-19 vaccine, nor educated on its benefits and risks, contrary to facility policy. The resident's refusal was not properly documented, leading to a deficiency. Interviews revealed inconsistencies in the vaccine offer process, with the resident denying refusal and lack of informed consent.
A resident with severe cognitive impairment expressed discomfort with a male CNA providing pericare, but the facility failed to investigate or report the incident as required. The resident's preference for female CNAs was not reflected in staffing assignments, leading to the same male CNA being assigned again, causing the resident to feel unsafe. Communication breakdowns and non-adherence to abuse prevention policies were evident among facility staff.
A resident's rosary was lost due to the facility's failure to document it on the inventory list, despite being acknowledged by staff. The resident, with severe cognitive impairment, received the rosary from a priest, but it was not listed when the resident was transferred to another care unit. Interviews with staff revealed that the facility's policy required documentation of new items, but items from church services were not typically recorded, leading to the oversight.
A resident with severe cognitive impairment and anoxic brain damage did not receive a recommended dental x-ray due to a communication breakdown among staff. The dentist's recommendation was missed, and the facility's policy requiring social services to obtain needed services was not followed, potentially causing the resident to experience pain.
The facility failed to follow its infection prevention and control practices in handling dirty linens, affecting six residents. Isolation linens were not double-bagged or labeled, leading to potential cross-contamination. Interviews revealed discrepancies between staff practices and facility policies, increasing the risk of infection spread.
A resident with cognitive impairment fell from a shower chair, and the facility failed to notify the physician or responsible party. The ADON was unaware of the incident until two weeks later, and no documentation of required assessments or notifications was found, contrary to the facility's policy.
A facility failed to update care plans for two residents, one with a history of falls and another with behavioral issues. The first resident's fall was not documented, and their care plan was not revised to prevent future incidents. The second resident's disruptive behavior was not addressed in their care plan, leading to unawareness among staff about monitoring needs. These deficiencies highlight a lack of documentation and communication in care planning.
Two residents with pressure ulcers received inadequate care due to the use of rough, reusable washcloths instead of disposable wipes, as required by the facility's policy. The facility's insufficient supply of disposable wipes contributed to this issue, potentially hindering wound healing and causing discomfort.
A resident with a history of falls experienced a recurrent fall due to inadequate supervision and lack of intervention. The resident, diagnosed with muscle weakness, osteoarthritis, and dementia, fell after standing from a shower chair without shoes. The incident was not documented or investigated, and the facility's fall protocol was not followed, resulting in a deficiency in care and supervision.
The facility failed to provide adequate staffing for RNA services, leading to a resident not receiving prescribed exercises for two months. CNAs were assigned RNA duties without proper scheduling, affecting 19 residents. The facility lacked a clear list of residents in the RNA program, resulting in inconsistent care.
The facility did not update and post daily staffing information in a visible location, as required. On a specific day, the staffing information was outdated, showing data from several days prior. A last-minute change in RN staffing assignments led to the delay in updating the posting. The facility's policy mandates that direct care daily staffing numbers be posted for every shift, which was not followed, resulting in this deficiency.
A resident with diabetes and a below-knee amputation did not receive accurate documentation of RNA-assisted exercises due to a Restorative Nurse Assistant (RNA) documenting care she did not provide. The RNA admitted to documenting exercises at the request of a CNA, despite not being on duty. Facility records confirmed the RNA's absence, and interviews with staff highlighted that this practice was against facility policy.
A resident with a history of self-decannulation removed their tracheostomy tube multiple times, but the facility failed to notify the physician and family on one occasion. Despite having a care plan that required notification, the incident was not documented, and the physician and family were not informed. Interviews confirmed the oversight, highlighting a deficiency in the facility's care practices.
A facility failed to update a care plan for a resident with a tracheostomy who had a history of self-decannulation. Despite the resident's impaired cognition and physician's orders to monitor anxiety and use interventions like Ativan and a freedom splint, the care plan was not updated after three self-decannulation incidents. The Director of Nursing acknowledged the lack of documentation and the need for updated interventions, highlighting the facility's failure to adhere to their policy for comprehensive, person-centered care plans.
A resident with a G-tube was observed without an abdominal binder, contrary to physician orders, due to the binder being laundered and no spare available. The resident, with severe cognitive impairment and multiple medical conditions, required the binder to prevent G-tube dislodgement, as outlined in their care plan.
The facility failed to document the rationale for extending PRN psychotropic medications for two residents, as required by policy. One resident was prescribed Valium for anxiety, and another was prescribed Lorazepam for anxiety, both without documented justification for continued use beyond 14 days. The Director of Nursing confirmed the absence of necessary documentation from the prescribing physicians.
The facility failed to investigate and resolve a grievance regarding a missing specialized wheelchair for a resident with chronic respiratory failure and quadriplegia. Despite the resident's representative's complaints, the facility did not document or address the issue promptly, contrary to its policies and procedures.
The facility failed to update and revise the care plans for two residents. One resident's care plan was not updated to reflect isolation requirements after testing positive for CRAB, and another resident's care plan did not include specific music preferences despite being identified. Both residents had severe impairments and were dependent on others for all activities of daily living.
Improper Low Air Loss Mattress Setting Leads to Trochanter Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a low air loss mattress (LALM) was set according to a resident’s weight as ordered and care planned, resulting in an alteration in skin and reopening of fragile scar tissue on the right trochanter. The resident was initially admitted with diagnoses including sepsis, bilateral knee contractures, and muscle weakness, and a history and physical documented that the resident lacked capacity to understand and make decisions. Physician orders and active care plans for alteration in skin integrity and risk for pressure ulcers directed that the LALM be set according to the resident’s weight for wound management and pressure redistribution. Record review showed that the resident’s weight was 88 lbs, and the Treatment Administration Record for the month indicated that on one day shift the LALM was documented as set according to the resident’s weight. However, during observation in the resident’s room, surveyors found the LALM set at 120 lbs rather than at or below the resident’s current weight. Treatment nurses interviewed at the time of observation stated that the LALM setting should be based on the resident’s weight, that settings higher than the resident’s weight make the mattress firmer, and that for this resident a setting of 80 would have been appropriate, while 120 could be too firm. The DON similarly stated that the resident’s weight should always be higher than the LALM setting and that a higher setting could defeat pressure redistribution and potentially increase pressure on the skin. A change-of-condition assessment documented that the resident was noted with a change in skin condition during routine treatment, with the right trochanter area observed to be reopened at the site of previous fragile scar tissue, described as a small open area with minimal drainage and fragile surrounding skin. A subsequent skin issues document identified an in-house acquired Stage 1 pressure ulcer/injury on the rear right trochanter, with specific measurements and wound characteristics recorded. The facility’s policy on support surfaces directed staff to review the care plan and use redistributing support surfaces to prevent skin breakdown and provide pressure relief or reduction, and the LALM operator’s manual indicated that the mattress should be adjusted according to the patient’s weight or a health care professional’s suggestion. Despite these directives, the LALM was not maintained at a setting consistent with the resident’s weight and care plan interventions.
Failure to Revise Care Plan and Perform IDT Root Cause Analysis for Recurrent Nephrostomy Tube Dislodgement
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive, individualized care plan addressing recurrent nephrostomy tube dislodgement for a resident with bilateral nephrostomy tubes and complex medical conditions. The resident had diagnoses including anoxic brain damage, persistent vegetative state, artificial openings of the urinary tract (nephrostomy tubes), pyelonephritis, urinary calculi, and UTI. On admission and subsequent review, the care plan identified an alteration in urinary elimination and risk for UTI related to indwelling catheters (nephrostomy tubes), with an intervention to secure the left and right nephrostomy tubing with anchors each shift to minimize dislodgement. Despite this, the resident experienced multiple episodes of nephrostomy tube malfunction and dislodgement requiring hospital evaluation and tube exchanges. On one occasion, facility records and GACH documentation showed the resident was admitted with percutaneous nephrostomy malfunction and UTI, underwent right and left nephrostomy tube exchange, received antibiotics, and was then readmitted to the facility. Later, a Change of Condition note documented that the treatment nurse notified an RN that the resident’s right nephrostomy tube was dislodged, with hematuria noted in the left nephrostomy bag, and the resident was again sent to the hospital, where records indicated admission for UTI and dislodged right nephrostomy tube and a right nephrostomy tube exchange with IV antibiotics. Subsequent Change of Condition documentation described a CNA reporting that the left nephrostomy tube appeared out of place, the urine collection bag was empty, and the gauze dressing used to keep the tube in place was off and saturated with urine. The RN observed the nephrostomy tube inside the stoma but 13.5 cm out with urine leaking from the stoma, and the physician was notified with a request to transfer the resident for replacement. Further documentation showed another Change of Condition entry noting no urine output in the left nephrostomy bag and a new order from the physician to send the resident to the hospital for exchange. GACH records indicated the resident had multiple dislodged nephrostomies over the past few months, was paraplegic and bedbound, and had been seen at another hospital two to three days earlier for similar issues, with a subsequent left nephrostomy tube placement and antibiotics. Interviews with RN staff and the DON confirmed that, despite these recurring dislodgements, the care plan was not revised to include new or individualized interventions to prevent further nephrostomy tube dislodgement. RN 2 acknowledged that the care plan had not been updated with new interventions and stated it was important to keep the care plan updated. The DON stated that the IDT did not hold a meeting regarding the recurring nephrostomy tube dislodgements, that a root cause analysis was not done, and that it was never determined why the nephrostomy tubes continued to become dislodged, despite facility policy requiring ongoing assessment, IDT review, and care plan revision when desired outcomes are not met or after hospital readmissions. The facility’s written policy on comprehensive person-centered care plans stated that the IDT, in conjunction with the resident and representative, develops and implements a comprehensive care plan derived from thorough assessment, reflecting recognized standards of practice, and addressing underlying causes of problem areas. The policy further required that assessments be ongoing and care plans revised as residents’ conditions change, with IDT review and updates when there is a significant change in condition, when desired outcomes are not met, and when a resident is readmitted from a hospital stay. In this case, despite multiple nephrostomy tube dislodgements, repeated hospital admissions for nephrostomy malfunction and UTI, and documentation from hospital providers noting multiple dislodgements over months, the facility did not conduct an IDT meeting, did not perform a root cause analysis, and did not revise the resident’s care plan with individualized, preventative interventions specific to nephrostomy tube dislodgement.
Uncovered Foley Catheter Bag Violates Resident Dignity
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, dementia, benign prostatic hyperplasia, and acute kidney failure was observed with an uncovered Foley catheter urinary drainage bag. The resident required significant assistance with daily activities and had a Foley catheter in place for urinary retention. During an observation, the urinary drainage bag was visibly exposed, showing yellow urine, and was not covered as required by facility policy. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, confirmed that the urinary drainage bag should have been covered to protect the resident's dignity, in accordance with facility policy and procedures. Review of the facility's policies further indicated that all residents are to be treated with dignity and respect, and that staff are expected to help residents keep urinary catheter bags covered. The failure to cover the urinary drainage bag constituted a violation of the resident's right to dignity and respect.
Inaccurate Posting of CNA Staffing Information
Penalty
Summary
The facility failed to ensure the accuracy of nurse staffing information posted daily, specifically regarding the number of certified nurse assistants (CNAs) working the 11 PM to 7 AM shift on several dates. The Daily Skilled Nursing Facility (SNF) Staffing Posting indicated that four CNAs worked these shifts, totaling 32 hours, while a review of the Nursing Staffing Assignment and Sign-In Sheets showed that only three CNAs actually worked, totaling 24 hours. This discrepancy was confirmed during interviews with both the Director of Staff Development (DSD) and the Director of Nurses (DON), who acknowledged that the posted information was inaccurate and did not reflect the actual staffing levels for those shifts. The facility's policy required accurate daily posting of nurse staffing data, including the number and type of nursing personnel providing direct care, to be displayed in a prominent location accessible to residents and visitors. The inaccurate postings had the potential to misinform residents and visitors about the actual number of CNAs available to provide care during the affected shifts. The DSD, who was responsible for completing the staff posting, and the DON both recognized that the posted information did not match the actual staffing records for the specified dates.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two of four outdoor refuse containers were closed with tight-fitting lids and kept covered. During an observation and interview with the Dietary Supervisor, it was noted that the refuse containers were open, full, and overflowing with closed plastic bags of garbage hanging outside. One container had a red stick propping the lid open. The Dietary Supervisor acknowledged that the lids should be closed at all times. In a subsequent observation and interview with the Maintenance Supervisor, the red stick was removed, and the container was closed. The Maintenance Supervisor explained that the refuse containers' openings were too high for some staff, leading them to use the red stick to keep the lid open, but they forgot to remove it afterward. The facility's policy, dated October 2017, requires all garbage and refuse containers to have tight-fitting lids and be kept covered when not in continuous use.
Insufficient Staffing for RNA Services
Penalty
Summary
The facility failed to ensure sufficient staffing to perform Restorative Nursing Assistant (RNA) services and exercises as ordered by physicians for residents with limited range of motion (ROM). On multiple occasions, RNA staff were reassigned to perform Certified Nursing Assistant (CNA) duties due to insufficient CNA staffing, resulting in residents not receiving their prescribed RNA programs. This deficiency was observed through a review of the facility's Daily Staffing Assignments, which showed that on several dates, either no RNA was assigned, or RNAs were reassigned to CNA duties, leaving residents without the necessary RNA services. Interviews with RNA staff and the Director of Staff Development (DSD) confirmed that when the facility was short-staffed, RNAs were often pulled to cover CNA duties. This led to situations where residents did not receive their RNA programs, as RNAs did not work overtime to cover the missed sessions. The DSD acknowledged the importance of having two RNAs scheduled daily to ensure all residents receive their RNA treatments, but admitted that finding coverage was sometimes challenging. The Assistant Director of Nursing (ADON) and the Director of Rehab (DR) also emphasized the importance of having sufficient RNA staff to prevent contractures and improve residents' mobility. The facility's policy on staffing, dated August 2022, indicated that sufficient numbers of nursing staff should be provided to meet residents' needs, but the observed staffing practices did not align with this policy, leading to the deficiency in care for residents requiring RNA services.
Deficiency in RNA Services Due to Ineffective QAA System
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain an effective system to identify, monitor, and evaluate the implementation of a plan of correction for a previously cited deficiency. This deficiency, initially identified on 8/1/2024, was related to insufficient staffing of Restorative Nursing Assistants (RNAs) and Certified Nurse Assistants (CNAs) to provide necessary exercises and devices as ordered by physicians to prevent decline in residents' mobility. The deficiency affected 19 residents who were receiving RNA services, putting them at risk for further decline in range of motion, mobility, and contractures. During interviews, the Administrator and Director of Nursing (DON) were unaware of the continued issues related to RNA services, such as RNAs being reassigned to perform CNA tasks and residents not receiving RNA-assisted exercises and services as ordered. The DON admitted that the RNA services program was a collaboration between the Director of Staff Development (DSD) and the Director of Rehabilitation (DOR) services, but they were unaware of incorrect transcription of physician orders into the RNA record in the Electronic Medical Records (EMR) system. The facility's policies and procedures for Quality Assurance and Performance Improvement (QAPI) were reviewed, indicating a lack of effective tracking, measuring, and monitoring of performance, which contributed to the deficiency not being addressed in a timely manner.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control policies and procedures, leading to several deficiencies involving five residents. For Resident 62, the suprapubic catheter drainage bag was found on the floor, which is against the facility's policy that requires catheter bags to be kept off the floor to prevent contamination. The Infection Control Nurse confirmed that the floor is dirty and could lead to contamination, potentially making the resident sick. For Residents 67 and 92, a Certified Nursing Assistant (CNA) did not perform hand hygiene before and after providing care to these residents. The CNA admitted to being too busy and forgetting to perform hand hygiene, which is crucial to prevent the spread of infection. The facility's policy mandates hand hygiene before and after direct contact with residents and handling food, which was not followed in this instance. Resident 78's feeding tubing was observed touching the floor, which poses an infection control risk. The Licensed Vocational Nurse acknowledged that the tubing should not be on the floor due to infection concerns. Additionally, Resident 77's family members were not following Enhanced Barrier Precautions (EBP) while in close contact with the resident, despite the resident being at high risk for infection. The family members were observed not wearing personal protective equipment (PPE) and handling dirty linens without gloves, increasing the risk of spreading multi-resistant drug organisms (MRDO).
Medication Administration Error Due to Improper G-Tube Flushing
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as observed during a medication pass involving a Licensed Vocational Nurse (LVN) and a resident with a gastrostomy tube (G-Tube). The LVN did not flush the G-Tube with water between administering nine medications, resulting in a 33.3% medication error rate. This practice was contrary to the facility's policy, which requires flushing with at least 15 ml of water between medications to ensure safe administration. The resident involved had a history of metabolic encephalopathy and sepsis and was dependent on staff for daily living activities due to severely impaired cognitive skills. The LVN acknowledged the error during an interview, admitting that the lack of flushing could lead to drug reactions that might deactivate the medications. The Assistant Director of Nursing confirmed the correct procedure, emphasizing the importance of flushing to prevent medication errors.
Failure to Provide Consistent Restorative Nursing Care
Penalty
Summary
The facility failed to provide restorative nursing care, treatments, and services to minimize decline in joint range of motion (ROM) for four residents. These residents were ordered by their physicians to receive Restorative Nursing Assistant (RNA) assisted exercises and services. However, the facility did not ensure that these services were consistently provided as ordered. For instance, Resident 30 did not receive RNA services on multiple specified dates, and observations showed that the resident was often without the prescribed ankle-foot orthosis (AFO) and knee splints. The responsible party expressed concerns about the resident's condition deteriorating due to lack of proper care. Resident 70's physician order was inaccurately transcribed, leading to the resident receiving RNA services only three times a week instead of the ordered five times. Observations confirmed that the resident was not receiving the necessary exercises and AFO application as frequently as required. The RNA staff confirmed that the transcription error led to the resident not being scheduled for the correct number of sessions, and staffing shortages further exacerbated the issue. Resident 72 and Resident 14 also experienced similar deficiencies, with RNA services not being provided as frequently as ordered. Observations and interviews revealed that these residents were often without necessary splints and supports, and the documentation confirmed missed sessions. The facility's staffing issues, where RNAs were reassigned to CNA duties, contributed significantly to the failure in providing consistent restorative care. The Director of Staff Development and other staff acknowledged the scheduling and documentation issues, which led to residents missing essential RNA programs.
Inadequate Supervision and Hazardous Environment Lead to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures to prevent a fall for a resident identified as high risk for falls. The resident, who had a history of falls and was diagnosed with spinal stenosis and lack of coordination, was observed falling over a plastic Wet Floor sign placed in front of his room. The resident's care plan indicated a need for frequent supervision and monitoring due to his unsteady gait and balance issues. However, during the incident, the Licensed Vocational Nurse (LVN) responsible for monitoring was on the other side of the station, preparing to pass medication, and was not present to prevent the fall. The housekeeper had placed the Wet Floor sign in front of the resident's door after mopping, intending to alert others of the wet floor. However, this action inadvertently created a hazard for the resident, who was known to have poor safety awareness and an unsteady gait. The Director of Nursing acknowledged that the environment should be free of clutter and hazards, especially for high fall-risk residents, and that the placement of the Wet Floor sign was inappropriate in this context. The facility's policy emphasized the importance of maintaining a safe environment and providing supervision to prevent accidents, which was not adhered to in this instance.
Inadequate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate assessments, treatments, and services for a resident who was incontinent of bladder and had an indwelling Foley catheter for wound care management. The resident's Foley catheter was not properly secured to her leg, which could lead to dislodgement and potential trauma. Additionally, sediment was observed in the urine, indicating a possible urinary tract infection (UTI), but there was no documentation of the urine's color and consistency for a month. The resident was admitted with diagnoses including respiratory failure, a stage 4 pressure ulcer, and sepsis. The care plan included monitoring for signs of UTI and maintaining proper catheter alignment. However, during observations, the catheter was found unstrapped and with sediment, and there was no evidence of catheter flushing as ordered. Interviews with staff revealed that the licensed nurses were responsible for assessing the urine characteristics and ensuring the catheter was properly secured, but these actions were not consistently documented or performed. The facility's policy required immediate reporting of unusual findings to a physician, but there was no documented change of condition evaluation for the sediment in the catheter. The Assistant Director of Nursing confirmed that sediment in the catheter was not normal and should have been reported to the physician. The facility's failure to adhere to its policies and procedures for catheter care and change in condition reporting contributed to the deficiency.
Failure to Use Alternatives Before Side Rails
Penalty
Summary
The facility failed to use appropriate alternative interventions before installing bilateral upper half side rails for a resident, identified as Resident 298. The resident was admitted with acute respiratory failure, hemiplegia, hemiparesis, and was receiving surgical aftercare. The facility's documentation indicated that side rails were used due to the resident sliding down in bed, related to an elevated head of bed for tube feeding. However, there was no documented evidence of alternative interventions being attempted prior to the use of side rails. The informed consent document for the use of side rails was incomplete, lacking a physician's signature and only indicating verbal consent from the resident, who was noted to lack the capacity to understand and make decisions. The facility's assessment and care plan documents also failed to show any attempts at alternative measures before resorting to side rails. Observations confirmed the use of side rails, and interviews with staff revealed a practice of automatically placing residents on side rails upon admission, without documented evidence of alternative interventions. The facility's policy required attempts to use alternatives before side rails, but this was not followed. Interviews with staff, including a CNA, LVN, and RN, indicated a lack of documentation and monitoring for side rail use, and the ADON confirmed that alternatives were not attempted. The facility's failure to adhere to its own policies and procedures regarding bed safety and side rail use resulted in a deficiency, as it did not ensure the safety and proper assessment of the resident's needs before implementing side rails.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that two residents, Resident 16 and Resident 39, were offered the opportunity to formulate and receive information related to Advance Directives during their initial admission and subsequent re-admission. Resident 16, who has diagnoses including ventilator dependence, epilepsy, and a persistent vegetative state, did not have an advance directive noted in their Physician Orders for Life-Sustaining Treatment (POLST) form. The Social Services Director confirmed that Resident 16 had not been offered an advance directive since their first admission. Resident 39, diagnosed with ventilator dependence, muscular dystrophy, and quadriplegia, also did not have an advance directive on file. The Medical Records Director noted the absence of a signed Advance Healthcare Directive Acknowledgement (AHDA) form in Resident 39's medical record. Although the Social Services staff discussed advance directives with Resident 39, the AHDA form remained unsigned as Resident 39 wished to wait for a family member to sign on their behalf. The Social Services Director acknowledged that information regarding advance directives should have been provided to Resident 39 and their responsible party during the initial admission.
Failure to Transmit Discharge MDS Timely
Penalty
Summary
The facility failed to ensure the timely transmission of the Discharge Minimum Data Set (MDS) to the Centers for Medicare and Medicaid Services (CMS) for one resident, identified as Resident 87. This deficiency was identified during a review of Resident 87's records, which showed that the resident was originally admitted on January 30, 2024, and readmitted on July 14, 2024, with diagnoses including metabolic encephalopathy, heart failure, diabetes mellitus, and hyperlipidemia. The resident was discharged to an Assisted Living Facility on August 30, 2024, but the discharge MDS was not completed or transmitted within the required 30-day period. During an interview, the Minimum Data Set Nurse (MDSN) admitted to forgetting to complete the discharge MDS for Resident 87. The Director of Nursing (DON) emphasized the importance of completing and submitting all MDS assessments on time to ensure accurate reporting to CMS. The facility's failure to complete and transmit the discharge MDS in a timely manner had the potential to affect the quality-of-care monitoring system, which is crucial for ensuring safe and efficient resident-centered care.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
The facility failed to adhere to professional standards of practice in nursing care for Resident 86 by not checking for gastric residual volume before administering medications via a Gastrostomy Tube (G-Tube) and not flushing the G-Tube with water between each medication. During a medication pass observation, a Licensed Vocational Nurse (LVN) was seen administering medications to Resident 86 without checking for residuals and without flushing the G-Tube with water between medications. This practice was contrary to the facility's policy, which requires flushing with at least 15 mL of water before and between medications, and checking for residuals to ensure proper digestion and reduce the risk of complications. Resident 86, who was admitted to the facility with diagnoses including metabolic encephalopathy and sepsis, had severely impaired cognitive skills and was dependent on staff for daily living activities. The facility's policy on administering medications through an enteral tube emphasizes the importance of verifying tube placement and flushing with water to prevent complications such as aspiration and clogged tubes. The Assistant Director of Nursing (ADON) confirmed the necessity of these procedures, highlighting the potential for drug interactions and the importance of proper medication administration techniques.
Failure to Implement Bowel and Bladder Training Leads to Resident Fall
Penalty
Summary
The facility failed to initiate routine bowel and bladder training programs for a resident, identified as Resident 198, who was assessed as being at high risk for falls. Resident 198, who was admitted with diagnoses including spinal stenosis and lack of coordination, required partial assistance for activities of daily living, including toileting. Despite being identified as high risk for falls due to factors such as intermittent confusion, poor safety awareness, and a history of falls, the facility did not implement a bowel and bladder toileting program for the resident. On the day of the incident, Resident 198 was observed walking out of his room and falling over a plastic wet floor sign placed in front of his room. The resident was attempting to use the restroom unassisted, which led to the fall. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that Resident 198 was not on a bowel and bladder training program, despite having episodes of continence and incontinence and being able to make his needs known. The staff acknowledged that such a program should have been initiated after the resident's second fall in the facility. The facility's policy and procedure for behavioral programs and toileting plans for incontinence, which includes bladder rehabilitation and toileting plans, was not followed for Resident 198. The failure to implement these programs contributed to the resident's fall, as the resident attempted to find a restroom without assistance. The incident highlights the facility's oversight in addressing the resident's toileting needs and ensuring a safe environment to prevent falls.
Non-Operational Call Light System for Multiple Residents
Penalty
Summary
The facility failed to maintain a functioning call light system for three residents, which was identified during an observation and interview process. Resident 5, who has chronic obstructive pulmonary disease and Alzheimer's disease, was unable to alert staff for assistance due to a non-operational call light. Despite having the call light in hand and pressing it repeatedly, the system did not signal at the nurse's station or outside the room. Similarly, Residents 48 and 62, both with conditions affecting mobility and communication, were also found to have non-functioning call lights, preventing them from effectively requesting assistance. The issue was confirmed during an interview with the Assistant Director of Nursing and the Infection Preventionist Nurse, who verified that the call lights for all three residents were not functioning properly. The Maintenance Supervisor later stated that the malfunction had not been reported to the maintenance department, despite daily checks being conducted. The Director of Nursing emphasized the importance of operational call lights for resident safety and timely care, as outlined in the facility's maintenance policy.
Failure to Complete Annual Competency Assessments for Staff
Penalty
Summary
The facility failed to ensure that one Licensed Vocational Nurse (LVN 2) and one Certified Nursing Assistant (CNA 3) completed their annual competency assessments and evaluations. LVN 2 was hired on April 3, 2020, and their competency checklist was dated November 17, 2023, indicating a lapse in the annual assessment for the previous year. Similarly, CNA 3, hired on January 28, 2005, had a competency checklist dated December 3, 2023, also showing a failure to complete the annual assessment in 2024. During interviews, the Director of Nursing (DON) acknowledged that all licensed nurses should complete competency skills upon hire and annually, but was unaware of why LVN 2's assessment was not completed the previous year. The Director of Staff Development (DSD) confirmed that competency evaluations are conducted via written tests and return demonstrations upon hiring and annually for all staff, but could not explain why CNA 3's assessment was not completed in 2024. The facility's policy, revised in August 2022, states that the facility provides sufficient numbers with the appropriate skills and competency necessary to provide nursing-related care and services for all residents.
Failure to Conduct Required Joint Mobility Assessments
Penalty
Summary
The facility failed to provide required specialized rehabilitation services for a resident, specifically in the area of joint mobility assessments. Resident 14, who has diagnoses including hemiplegia and diabetes mellitus, was not assessed for potential joint mobility concerns annually and quarterly as required. The last documented occupational therapy (OT) joint mobility screening for the resident was completed in 2022, and no subsequent screenings were found in the resident's medical record for 2024. This oversight was acknowledged by the Director of Rehab, who confirmed that the annual physical therapy (PT) joint mobility assessment for 2024 was missed, and the last OT assessment was completed in 2022. The Director of Nursing emphasized the importance of joint mobility assessments in preventing contractures and maintaining residents' functional independence. The facility's policy requires joint mobility assessments to be conducted upon admission, readmission, and annually, in conjunction with the Minimum Data Set (MDS) assessment schedule. The failure to conduct these assessments as per policy was identified during a review of the facility's policy and procedure, which mandates that joint mobility screenings be completed by PT and/or OT. This deficiency had the potential to negatively impact the resident's physical and mobility function.
Failure to Explain Arbitration Agreement to Resident's Responsible Party
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to the responsible party of a resident, identified as Resident 198, who was admitted with diagnoses including dementia and cognitive communication deficit. The responsible party, listed as Family Member 1, reported not understanding the arbitration agreement or the rights to make informed decisions about the resident's care. Despite signing the arbitration documents, Family Member 1 stated that the forms were handed over without explanation, and she was not informed about the meaning of the arbitration agreement. The Admissions Coordinator indicated that the arbitration information document was self-explanatory and that the responsible party could read it themselves, but was not allowed to answer any questions. The Administrator acknowledged that the arbitration agreement should have been explained in a manner that the responsible party could understand, as per the State Operations Manual Appendix PP. The failure to ensure comprehension of the arbitration agreement resulted in the responsible party being unable to make an informed decision regarding the resident's care.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required minimum size of 80 square feet per resident in multiple resident rooms. Specifically, 11 out of 39 resident rooms were found to be below this standard, with rooms 5, 6, 8, 9, 11, 12, 14, 15, 16, 17, and 18 measuring less than the required square footage per resident. This deficiency was identified through observation, interviews, and record reviews, which revealed that the rooms did not meet the necessary space requirements for safe nursing care and resident privacy. Despite the deficiency, interviews with residents and staff indicated that the current room sizes did not adversely affect the residents' care or their ability to move freely. Residents reported that they could ambulate and transfer without issues, and staff confirmed that they could provide care by adjusting furniture to create necessary space. The facility's variance request suggested that the room sizes did not negatively impact residents' health, safety, or well-being.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to accommodate the needs of four residents by not responding to call lights in a timely manner. Resident 1, who was admitted with hemiplegia affecting both sides of the body and had moderately impaired cognition, reported that it took at least two hours for staff to respond to his call light. Resident 3, who was dependent on assistance for daily activities, also experienced delays of 1-2 hours during the night shift for diaper changes. Resident 4, with intact cognition but requiring moderate assistance, reported similar delays during the night shift. Resident 5, who required substantial assistance due to a fibula fracture, experienced delays of at least an hour for diaper changes, leading to feelings of neglect and discomfort. The Resident Council Meeting minutes indicated that residents had previously voiced concerns about the untimely response to call lights. The Director of Staff Development confirmed that call lights should be answered within five minutes, as per the facility's policy. However, the facility's failure to adhere to this policy resulted in increased risk for harm to the residents, as they were left waiting for assistance with personal hygiene and other needs.
Failure to Follow Influenza Vaccination Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure for influenza immunization for one of the residents. The resident, who was admitted with acute respiratory failure and cerebral aneurysm, was not properly offered the influenza vaccine. The facility did not provide the necessary education regarding the benefits and potential side effects of the vaccine, nor did it document the resident's refusal with the required name and signature on the Vaccine Consent Form. This oversight was identified during a review of the resident's records and interviews with the staff and the resident. The Licensed Vocational Nurse (LVN) claimed to have offered the influenza and Covid-19 vaccines to the resident, who allegedly refused them. However, the resident denied this, stating that the nurse did not present a Vaccine Consent Form or discuss the risks and benefits. The Director of Nursing (DON) confirmed that the facility's policy requires residents to sign a refusal form with two witnesses if they decline vaccination. The facility's policy also mandates that residents be informed and educated about the vaccine's benefits and side effects, which was not followed in this case.
Failure to Offer and Document Covid-19 Vaccine for Resident
Penalty
Summary
The facility failed to adhere to its Covid-19 policy and procedure for a resident by not offering the Covid-19 2024/2025 vaccine, not providing education about the vaccine's benefits and risks, and not properly documenting the resident's refusal. The resident, who was admitted with acute respiratory failure and a cerebral aneurysm, had moderately impaired cognition and required substantial assistance with daily activities. Despite a Vaccine Consent Form indicating refusal, it lacked the resident's name and signature, and the resident later tested positive for Covid-19. Interviews revealed discrepancies in the facility's handling of the vaccine offer. A Licensed Vocational Nurse claimed to have offered the vaccine, which the resident allegedly refused, but the resident denied this, stating they were not shown a consent form or informed about the vaccine's risks and benefits. The Director of Nursing confirmed the facility's policy of offering vaccines and requiring a signed refusal form with witnesses if declined. However, the facility's failure to document the refusal properly and provide education as per policy led to the deficiency.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies and procedures regarding the prevention of abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified when a resident expressed discomfort with a male Certified Nursing Assistant (CNA) providing pericare, yet the facility did not investigate or report the incident as required by federal regulations. The resident had informed a Registered Nurse (RN) that she did not want the male CNA to provide care, but the CNA was assigned to her again the following day, which made the resident feel unsafe. The resident, who was admitted with diagnoses including acute chronic respiratory failure and severe cognitive impairment, was dependent on facility staff for personal care. Despite the resident's clear preference for female CNAs, the facility's staffing assignments did not reflect this preference, leading to the same male CNA being assigned to her care again. The Assistant Director of Nursing (ADON) was only informed of the resident's preference after the CNA had been reassigned, indicating a breakdown in communication and adherence to the facility's abuse prevention policies. Interviews with facility staff revealed that the RN who was initially informed of the resident's discomfort did not report the incident to the Director of Nursing (DON) or the Administrator, who is the abuse coordinator. Additionally, the Director of Staff Development (DSD) was unaware of the resident's preference when making staffing assignments. The facility's policies require immediate reporting and investigation of any allegations of abuse, but these procedures were not followed, resulting in the resident's continued distress and the facility's failure to protect her from potential abuse.
Failure to Document Resident's Belongings Leads to Loss
Penalty
Summary
The facility failed to document a resident's belongings, specifically a rosary, leading to its loss. The resident, who had severe cognitive impairment and was dependent on facility staff for personal care, was admitted and readmitted with various diagnoses, including anoxic brain damage. During the resident's stay, a family member reported that the rosary, given by a priest, was missing after the resident was transferred to a different care unit. The facility's inventory list did not include the rosary, although it was acknowledged by a CNA that the resident had it along with other personal items. Interviews with facility staff, including a CNA, LVN, DON, and SSD, revealed that the facility's policy required new items to be documented on the inventory list, but this was not done for the rosary. The DON stated that items from church services were not typically documented, which contributed to the oversight. The facility's grievance report confirmed the missing items and noted attempts to contact the family for descriptions to replace them. The facility's policy emphasized the importance of documenting personal belongings upon admission and updating the inventory as necessary.
Failure to Follow Up on Dental X-ray Recommendation
Penalty
Summary
The facility failed to provide medically related social services for a resident by not following up on a dentist's recommendation for an x-ray to evaluate an aching tooth. The resident, who was admitted and readmitted to the facility with diagnoses including anoxic brain damage and severe cognitive impairment, was dependent on staff for personal care. The dentist recommended an x-ray to confirm the source of the resident's pain, but the x-ray was not performed as of the review date. Interviews with facility staff revealed a breakdown in communication and responsibility. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) both stated they were unaware of the dentist's recommendation for an x-ray. The Social Services Director (SSD) acknowledged that it was their responsibility to follow up on dental recommendations, but the recommendation for the x-ray was missed. The facility's policy indicated that social services staff were responsible for obtaining needed services, but this was not executed, potentially leading to the resident experiencing pain and further dental issues.
Deficient Infection Control Practices in Linen Handling
Penalty
Summary
The facility failed to adhere to its infection prevention and control practices, specifically in the handling and storage of dirty linen, which affected six residents. The deficiency was identified during a survey where it was found that dirty linens, including those from isolation rooms, were not being managed according to the facility's policy. Certified Nursing Assistant (CNA) 1 reported that isolation linens were placed in single black bags without being double-bagged or labeled, which could lead to cross-contamination and the spread of infection. Interviews with the Laundry Personnel (LP) revealed that isolation linens were supposed to be double-bagged and labeled with the resident's room and bed number to distinguish them from regular dirty linens. However, the LP noted that both types of linens were placed in black bags, and without proper labeling or double-bagging, it was challenging to identify isolation linens, increasing the risk of infection spread. The Director of Nursing (DON) stated that all linens were considered dirty and that the washing process should eliminate microorganisms, but this did not align with the facility's policy for handling isolation linens. The facility's policies on standard precautions, laundry handling, and infection control emphasized the need for proper handling and processing of soiled linens to prevent contamination and the spread of infections. Despite these policies, the facility's practices did not ensure that isolation linens were managed in a manner that prevented the transfer of microorganisms, as required by their infection control program. This oversight had the potential to increase the spread of infections within the facility.
Failure to Notify Physician After Resident Fall
Penalty
Summary
The facility failed to notify the physician after a resident fell from a shower chair on August 1, 2024. This incident involved a resident who was admitted to the facility on January 25, 2019, and readmitted on August 9, 2024, with diagnoses including muscle weakness, osteoarthritis of the left ankle and foot, and unspecified dementia. The resident was moderately impaired cognitively and required supervision during showering. Despite the fall, there was no documented evidence in the resident's electronic medical chart indicating that the physician or the responsible party was notified of the incident. During an interview, the Assistant Director of Nursing (ADON) stated that he was unaware of the fall until August 15, 2024, and confirmed that there was no documented evidence of a Change of Condition assessment, SBAR Communication Form, skin assessment, 72-hour neurological checks, or an interdisciplinary team meeting conducted after the fall. The facility's policy and procedure require prompt notification of the resident's attending physician and representative in the event of an accident or incident, which was not followed in this case.
Failure to Update Care Plans for Residents with Falls and Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. For the first resident, who had a history of falls and was at risk due to muscle weakness, osteoarthritis, and dementia, the facility did not document a fall that occurred on 8/1/2024. Despite the resident's care plan indicating a risk for falls and requiring frequent supervision, the plan was not updated after the fall incident. The Assistant Director of Nursing acknowledged that the care plan was not revised to address the fall and prevent future incidents. The second resident, who had acute respiratory failure, cerebral palsy, and Type 2 Diabetes Mellitus, was involved in a grievance related to disruptive behavior in their shared room. The facility's records showed a grievance about the resident's behavior of playing with privacy curtains and having the television volume too loud, which disturbed another resident. Although the facility recommended that nursing supervisors conduct rounds to monitor safety and noise levels, these recommendations were not documented in the resident's care plan. Nursing staff were unaware of the need to monitor the behavior and noise levels, as the care plan was not updated to reflect these concerns. The facility's policy on care plans requires ongoing assessments and updates when there are significant changes in a resident's condition. However, in both cases, the care plans were not revised to address the incidents and recommendations, leading to potential risks for the residents involved. The lack of documentation and communication among staff contributed to the deficiencies in care planning and implementation.
Inadequate Pressure Ulcer Care Due to Insufficient Supplies
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for two residents. Resident 1, who was admitted with a stage 4 pressure ulcer in the sacral region, had a care plan that included specific interventions such as administering treatment as ordered and monitoring for signs of infection. However, during incontinent care, the facility did not follow its policies and procedures, which included using appropriate materials to clean the resident. Instead, a reusable washcloth was used, which was rough and could potentially cause skin irritation or tears. Resident 2, who had a stage 3 pressure ulcer, also experienced inadequate care. The care plan for this resident included similar interventions to minimize the risk of complications and promote healing. However, during an observation, a CNA used a reusable washcloth to clean the resident after a bowel movement, which was against the facility's policy. The CNA was unaware of where to find disposable cleansing wipes, which were supposed to be used to prevent skin irritation and promote healing. The facility's supply of disposable wipes was insufficient, as noted during an interview with the Central Supply staff. The facility had recently used a significant portion of its supply due to a water shut-off, and there were concerns about not having enough wipes if the water was shut off again. This lack of supplies contributed to the use of inappropriate cleaning materials, which could hinder wound healing and cause discomfort to the residents.
Failure to Investigate and Address Fall Risk
Penalty
Summary
The facility failed to investigate and implement interventions for a resident with a history of falls, who experienced a recurrent fall on 8/1/2024. The resident, who was admitted with diagnoses including muscle weakness, osteoarthritis, and unspecified dementia, was found to have fallen after attempting to stand from a shower chair without shoes. The resident's Minimum Data Set indicated a need for supervision during certain activities, yet the fall was not documented or investigated, and no interventions were implemented to address the resident's fall risk factors. The incident occurred when a CNA left the resident unattended in a shower chair while moving a wheelchair that was blocking the path to the resident's bed. The CNA heard a noise and found the resident on the floor, having slipped and hit her head. Despite the incident, there was no documentation in the resident's electronic medical chart, and the Assistant Director of Nursing was unaware of the fall until two weeks later. The facility's fall protocol, which includes incident reporting, physician and family notification, and post-fall assessments, was not followed. The facility's policies require thorough documentation and investigation of falls, including assessments of vital signs, neurological status, and pain, as well as an evaluation of precipitating factors. However, these procedures were not adhered to in this case, as there was no evidence of a Change of Condition assessment, SBAR communication, care plan update, or interdisciplinary team meeting following the fall. This lack of action and documentation represents a significant deficiency in the facility's care and supervision of the resident.
Deficiency in Restorative Nursing Assistant Services
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents requiring Restorative Nursing Assistant (RNA) services. Specifically, the RNA, who is a certified nursing assistant with specialized training in rehabilitation skills, was assigned to perform regular CNA duties instead of focusing on RNA-specific tasks such as range of motion exercises. This affected 19 residents on the RNA program, including a resident with a physician's order for RNA-assisted exercises, who reported not receiving these services for the past two months. The resident's medical history includes muscle weakness, functional quadriplegia, and an acquired absence of the left leg below the knee, necessitating regular RNA exercises to maintain mobility and prevent joint stiffness. Interviews with staff revealed that when no RNA was scheduled, CNAs attempted to provide RNA exercises during their regular duties, but this was inconsistent and not in line with specific physician orders. The Director of Staff Development and the Director of Rehabilitation had differing views on whether ADL activities could substitute for RNA exercises, with the latter emphasizing the need for dedicated RNA services. The facility's policy stated that restorative nursing care should be individualized and resident-centered, but the lack of a clear list of residents in the RNA program and the absence of scheduled RNAs led to a failure in delivering these essential services.
Failure to Update and Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was updated and posted in a visible and prominent place, as required. On July 31, 2024, it was observed that the staffing information posted in front of the Subacute Nursing Station was outdated, displaying information from July 25, 2024. This was verified with a Registered Nurse (RN) who explained that the posting was not updated in the morning due to a last-minute change in RN staffing assignments. An RN called off for the Skilled Nursing Facility (SNF) Station, necessitating a reassignment of staff, which delayed the update of the staffing information. According to the facility's policy, direct care daily staffing numbers should be posted for every shift, but this was not adhered to, resulting in the deficiency.
Inaccurate Documentation of Care by RNA
Penalty
Summary
The facility failed to maintain accurate clinical records in accordance with professional standards for a resident, identified as Resident 6. The Restorative Nurse Assistant (RNA) 1 admitted to documenting that she provided range of motion exercises to Resident 6 on specific dates, even though she was not present at the facility on those days. This inaccurate documentation was done at the request of CNA 4, who claimed to have completed the tasks but asked RNA 1 to document them. The facility's records, including staffing assignments and punch details, confirmed that RNA 1 was not on duty on the dates in question. Resident 6, who had a history of diabetes mellitus and a below-knee amputation, required substantial assistance with daily activities and was ordered by a physician to receive RNA-assisted exercises. The facility's policy stated that documentation should include the name and title of the individual providing care, which was not adhered to in this case. Interviews with the Director of Staff Development and the Director of Nursing confirmed that the practice of documenting care not personally provided was against the facility's standards and policies.
Failure to Notify Physician and Family of Self-Decannulation
Penalty
Summary
The facility failed to notify the physician and family of a resident who self-decannulated their tracheostomy tube multiple times. The resident, who had a history of self-decannulation, was readmitted to the facility with several diagnoses, including cerebral infarction, aphasia, and respiratory failure. The resident's care plan included interventions for tracheostomy tube care and required notification of the physician and family in case of decannulation. However, the facility did not document or notify the physician or family when the resident self-decannulated on one occasion. The resident's physician orders included monitoring for anxiety and the use of a freedom splint to prevent pulling out life-sustaining tubes. Despite these measures, the resident managed to remove the tracheostomy tube on multiple occasions. On one specific incident, the resident removed the tube at 3:30 AM, and although the respiratory therapist successfully reinserted it, there was no documented evidence of a change of condition or notification to the physician or family. Interviews with the Director of Nursing and a Licensed Vocational Nurse confirmed the lack of documentation and notification. The facility's policy required prompt notification of changes in a resident's condition to the physician and family, but this was not followed. The failure to notify the physician and family of the resident's self-decannulation was identified as a deficiency in the facility's care practices.
Failure to Update Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to implement a care plan consistent with professional standards of practice for a resident with a tracheostomy, who had a history of self-decannulation. The resident, who had moderately impaired cognition and lacked the capacity to make decisions, had self-decannulated three times while at the facility. Despite the resident's history and the physician's orders to monitor anxiety and use interventions like Ativan and a freedom splint, the care plan was not updated to address the self-decannulation incidents. The resident's care plan, initiated on 6/7/2024, acknowledged the risk of accidental decannulation but only included notifying the physician and responsible party if decannulation occurred. The facility's Director of Nursing (DON) acknowledged that there was no documented evidence of an updated care plan following the self-decannulation incidents on 6/9/2024 and twice on 6/23/2024. The DON emphasized the importance of updating the care plan to prevent further incidents, indicating that the existing interventions were insufficient. The facility's policy and procedure for comprehensive, person-centered care plans require measurable objectives and timetables to meet residents' needs. However, the care plan for this resident did not reflect the necessary updates or interventions to address the repeated self-decannulation events. The facility's failure to update the care plan as required by their policy and procedure contributed to the deficiency identified in the report.
Failure to Ensure Use of Abdominal Binder for G-tube Resident
Penalty
Summary
The facility failed to provide necessary care and services to a resident with a Gastrostomy tube (G-tube) by not ensuring the use of an abdominal binder as ordered by the physician. During an observation, it was noted that the resident's G-tube was not anchored, and the abdominal binder was not in use. The Licensed Vocational Nurse (LVN) explained that the resident's abdominal binder was sent to the laundry because it was soiled, and there was no spare binder available for use during this time. The resident, who was admitted with multiple diagnoses including cardiac arrest, anoxic brain damage, respiratory failure, and tracheostomy status, was severely impaired cognitively and required extensive assistance for daily activities. The resident's care plan and physician orders specifically indicated the use of an abdominal binder to prevent G-tube dislodgement. However, the absence of the binder due to laundry needs and lack of a replacement posed a risk of G-tube dislodgement, which could lead to complications.
Failure to Document Rationale for PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the prescribing physician documented the rationale for extending the use of two PRN psychotropic medications for two residents, as required by the facility's policy and procedure on psychotropic medication use. This deficiency was identified through observation, interview, and record review. The facility's policy mandates that psychotropic medications are not prescribed or given on a PRN basis unless necessary to treat a diagnosed specific condition documented in the clinical record. Furthermore, if the prescriber believes it is appropriate to extend the PRN order beyond 14 days, they must document the rationale for extending the use and include the duration for the PRN order. Resident 1 was admitted with diagnoses including unspecified psychosis and anxiety disorder and was dependent on assistance for daily activities. The physician ordered Valium 2 mg to be administered via G-tube every 4 hours as needed for anxiety, with the order set for 14 days. However, there was no documented evidence from the attending physician providing a reason or rationale for reordering and continuing the Valium every 14 days. The Director of Nursing (DON) confirmed the absence of such documentation during a record review. Resident 2, who was readmitted with diagnoses of unspecified major depressive disorder and anxiety disorder, required substantial assistance with daily activities. The physician ordered Lorazepam 0.5 mg to be given via G-tube every 12 hours as needed for anxiety, also for 14 days. Similar to Resident 1, there was no documented rationale from the attending physician for reordering and continuing the Lorazepam every 14 days. The DON acknowledged that the facility nurses were reordering the psychotropic PRN medications without documentation from the prescribing physicians, which was against the facility's policy that requires residents to be evaluated by their attending physician before renewing PRN psychotropic medications.
Failure to Investigate and Resolve Grievance Regarding Missing Specialized Wheelchair
Penalty
Summary
The facility failed to review and investigate the allegations made by a resident's representative (RP 1) regarding a missing specialized wheelchair for Resident 1. Despite RP 1's complaint, the facility did not make prompt efforts to resolve the problem or provide a written response to RP 1. The facility's inaction was contrary to its policies and procedures, which require prompt resolution and written communication of grievances. Resident 1, who had chronic respiratory failure and quadriplegia, was dependent on others for daily living activities and had no discernible consciousness according to the Minimum Data Set (MDS) dated 3/21/24. RP 1 reported that Resident 1's specialized wheelchair was missing and that the facility had thrown it away without informing RP 1. During an interview, a Certified Nurse Assistant (CNA 1) confirmed that the wheelchair was deemed unsafe and was no longer in use, but she did not know its current location. The Assistant Director of Nursing (ADON) acknowledged that RP 1 had raised the issue during an Interdisciplinary Meeting (IDT) on 2/20/24, but the grievance was not documented or addressed. The Maintenance Director also confirmed that the previous administrator had disposed of the wheelchair. The Social Services Director (SSD) stated that she filled out a Grievance Report on 3/26/24 after being informed by RP 1 about the missing wheelchair. Her investigation revealed that the wheelchair was discarded due to its poor condition. However, there was no prior grievance record on file before March 2024. The facility's policy requires that any grievance be reviewed, investigated, and a written report submitted to the administrator within five working days, which was not followed in this case.
Failure to Update and Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to update and revise the care plan for two residents, leading to deficiencies in their care. For Resident 1, the care plan was not updated after the resident tested positive for Carbapenem-resistant Acinetobacter baumannii (CRAB) and required isolation. Despite the physician's order for isolation, the care plan continued to include out-of-room activities without reflecting the isolation requirement. This oversight occurred even though the resident had been diagnosed with chronic respiratory failure and quadriplegia and was dependent on others for all activities of daily living. The care plan had not been updated since the isolation order was given, failing to provide the necessary information for staff to follow the isolation protocol effectively. For Resident 3, the care plan was not revised to include the resident's specific music preferences, despite the facility identifying that the resident enjoyed listening to the Black Eyed Peas. The care plan only mentioned general activities of interest such as music, outdoor activities, exercise, reading, and television, without specifying the resident's preference for the Black Eyed Peas. This omission occurred even though the resident had severe cognitive impairment and was dependent on others for all activities of daily living. Interviews with the Activity Director, MDS Coordinator, and Director of Nursing confirmed that care plans should be person-centered and updated to reflect changes in the resident's condition or preferences, which was not done in these cases.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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