Windsor Gardens Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 915 S. Crenshaw Blvd., Los Angeles, California 90019
- CMS Provider Number
- 056194
- Inspections on file
- 61
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Windsor Gardens Convalescent Hospital during CMS and state inspections, most recent first.
Three residents with varying levels of dependence and medical needs reported that staff did not respond promptly to their call lights and requests for assistance, particularly during the night shift. Residents described long waits for help, observed staff sleeping in the nursing station, and expressed feelings of irritation, anger, and disrespect. Staff interviews confirmed that sleeping in the nurses' station is against facility policy, and facility procedures require immediate response to resident requests.
A resident with diabetes had multiple blood sugar checks performed by nursing staff without a physician order, and the physician was not notified or documentation was lacking when the resident's blood sugar levels were repeatedly elevated. Facility policy required both a physician order for such procedures and documentation of physician notifications, but these were not followed.
A resident with severe cognitive impairment, impaired mobility, and multiple medical conditions was found on the floor after a fall, despite being care planned for fall risk with interventions such as a clutter-free environment and call light accessibility. Staff interviews indicated the resident was bedbound and fully dependent, but supervision was insufficient, and the last observation time was unclear, leading to the resident's transfer to an acute care hospital.
The facility did not follow the planned menu or provide appropriate dietary options for residents with specific needs, including serving boiled chicken instead of baked chicken to a resident who disliked fish, failing to provide vegan menu items to a vegan resident, and substituting peas for oven French fries for residents on a renal diet. Staff were unaware of some residents' dietary requirements, and menu substitutions were made without proper review.
Twelve residents on pureed diets were served carrots with a thin, soupy consistency instead of the required smooth, pudding-like texture. The cook acknowledged using too much liquid, and the dietary supervisor confirmed the food did not meet the facility's policy or recipe standards for pureed diets, which require a homogenous, cohesive texture to ensure safe swallowing.
Surveyors found that a can opener blade in the kitchen was worn, dented, stained, and had metal shavings and dried residue, which was confirmed by the Dietary Supervisor. The blade's condition did not meet facility policy or FDA Food Code requirements for cleanliness and repair, resulting in a deficiency in safe and sanitary food preparation practices.
The facility did not obtain informed consent before starting or increasing psychotropic medications for three residents with mental health diagnoses. In each case, either the required education about risks and benefits was not provided, or consent forms were incomplete or missing, despite facility policy and staff acknowledgment that consent was necessary.
A resident with dementia, chronic kidney disease, and limited mobility did not have their call light within reach while in bed, despite being dependent on staff for care. Staff confirmed the call light was inaccessible, and facility policy required it to be accessible at all times.
A resident with multiple diagnoses received a nicotine patch as ordered, but staff failed to document the removal of the patch after 24 hours on several occasions. The MAR showed administration dates, but there was no record of patch removal, and a nurse confirmed this documentation was missing, contrary to facility policy.
A resident's MDS assessment was completed without including active diagnoses of schizophrenia, depression, and bipolar disorder, despite these being documented in the medical record and supported by psychiatric notes and physician orders. The DON confirmed the assessment was inaccurate and did not match the resident's clinical information.
Two residents did not have their care plans updated after changes in their care needs: one resident with severe cognitive impairment refused to wear hearing aids, but the care plan was not revised to reflect this or to add alternative interventions; another resident was prescribed a nicotine patch, but the care plan did not include instructions for monitoring, removal, or documentation of the patch. Facility policy requires care plans to be reviewed and revised as resident needs change, but this was not done.
Two residents who required assistance with ADLs were found with long and unclean fingernails, despite care plans and facility policy requiring regular assessment, cleaning, and trimming. Staff acknowledged the oversight, and interviews confirmed that daily nail care was expected but not performed as required.
A resident with severe cognitive impairment and hearing loss was not assisted by staff in wearing hearing aids as required by her care plan, resulting in communication difficulties. Staff interviews and observations confirmed the hearing aids were not provided daily, despite facility policy and assessment indicating the need for such assistance.
A resident with severe cognitive impairment and multiple medical conditions, including an unstageable pressure ulcer, was found to have a low air loss (LAL) mattress set at 325 lbs instead of the physician-ordered 113 lbs. This discrepancy was confirmed by the DSD, who noted the setting did not match the resident's weight and placed the resident at risk for skin breakdown, contrary to facility policy and physician orders.
Staff did not notify the physician when a resident with an indwelling catheter showed signs of sediment in the urine, despite care plans and orders requiring such notification. Documentation review confirmed no record of physician notification, and both an LVN and the DON acknowledged this omission during interviews. This failure could have delayed appropriate treatment for a possible UTI.
A resident dependent on staff for care and receiving tube feeding for dysphagia was found with feeding formula leaking from the gastrostomy tube onto their skin and bedding. Staff failed to properly assess and secure the tube, with both CNA and LVN relying on the previous shift and not fully checking the resident. Facility policy required verification of tube placement and reporting of complications, but these steps were not followed, resulting in the resident not receiving prescribed nutrition and being exposed to risk of skin breakdown.
A resident with a history of cerebral infarction, venous thrombosis, and end stage renal failure on hemodialysis was prescribed aspirin and Eliquis for blood clot prevention. Despite being identified as high risk for bleeding, staff did not monitor or document signs and symptoms of bleeding or bruising as required by the care plan and facility policy. The DON confirmed this lapse in monitoring for the duration of the resident's anticoagulant therapy.
Two residents experienced medication administration errors when nurses failed to follow physician orders: one received a carbamazepine suspension that was not shaken prior to dosing, and another was given a multivitamin without minerals instead of the prescribed formulation with minerals. These incidents resulted in a medication error rate above the acceptable threshold.
Two residents experienced significant medication errors when a nurse failed to shake a carbamazepine suspension before administration and antihypertensive medications were given outside of prescribed blood pressure parameters. Staff interviews and record reviews confirmed that facility policies for safe medication administration were not followed in these cases.
A treatment nurse failed to change gloves between removing soiled dressings, cleaning wounds, and applying new dressings for a resident with multiple wounds, contrary to facility infection control policy. The nurse and facility leadership confirmed that gloves should be changed at each step to prevent cross-contamination, but this was not done during the observed wound care.
A facility failed to provide a resident's records upon request from their legal representative. The request was faxed to an incorrect number, and the Administrator, responsible for handling such requests, did not receive it. The facility's policy mandates providing access to records within 24 hours of a request, but this was not met, violating the resident's rights.
A resident did not receive prescribed skin treatments and glaucoma eye drops on multiple occasions, as the facility failed to document these in the TAR and MAR. The resident, who was confused and dependent on assistance, was admitted with conditions including a left above-knee amputation and glaucoma. The facility's policies require immediate documentation of administered treatments, which was not followed in this case.
A facility failed to verify a resident's DNR status upon admission, despite the resident having a DNR order from a hospital. The resident, with metabolic encephalopathy and dementia, was admitted without confirmation of their code status with the NOK or physician. Staff interviews revealed the resident was considered full code, contrary to the hospital's DNR order, highlighting a lapse in communication and documentation.
A resident with severe cognitive impairment and multiple health issues was not readmitted to the LTC facility after hospitalization, despite available beds. The facility's bed-hold policy was not implemented, leading to the resident remaining in the hospital. Interviews revealed a communication breakdown, as the Director of Nursing was unaware of the discharge readiness.
A resident's oxygen tubing was not changed weekly and was found on the floor, contrary to facility policy. The resident, who required oxygen for shortness of breath, had tubing dated over two weeks old. Both an LVN and the DON confirmed the deficiency, acknowledging the risk of infection due to the tubing's condition and placement.
A CNA failed to wear gloves when entering a COVID-19 isolation room and did not remove her face shield and N-95 mask upon exiting, contrary to the facility's infection control policies. The resident in the room had severe cognitive impairment and tested positive for COVID-19, requiring novel respiratory precautions. Interviews confirmed the importance of following PPE protocols to prevent infection spread.
The facility did not have a Registered Nurse (RN) available for at least 8 consecutive hours daily, as required, from July 1 to July 18, 2024. The only RN on staff was the Director of Nursing (DON), who also performed RN supervisory duties. The facility's policy allowed the DON to serve as a charge nurse only if the average daily occupancy was 60 or fewer residents, but the facility had an average daily census of 87. This deficiency risked delayed care and services for all 85 residents.
The facility failed to develop and implement comprehensive care plans for two residents. One resident did not have a timely care plan for an indwelling urinary catheter, and another lacked a care plan for self-administration of medications. These deficiencies were confirmed by LVNs and were not in compliance with the facility's policy.
A resident with spinal conditions and recent surgery did not receive a scheduled neurologist appointment due to inadequate transportation arrangements. The resident was unable to sit in a wheelchair due to pain, and gurney transport was not arranged. Lack of communication among staff contributed to the oversight.
A resident with an indwelling urinary catheter was at risk for UTIs due to improper placement of the catheter drainage bag above the bladder level, causing urine flow issues. The facility's policy required the bag to be below the bladder, which was not adhered to, as confirmed by an LVN and the DON.
A resident was found with medications at the bedside without a physician's order or a self-administration assessment. The resident, who required assistance for daily activities, had no comprehensive care plan for self-administering medications. Interviews and policy reviews confirmed the need for a physician's order and care plan, which were not in place, potentially leading to complications.
A resident with severe cognitive impairment and behavioral symptoms experienced a fracture of unknown origin, which was not reported to the State Survey Agency within the required two-hour timeframe. The resident expressed pain during a transfer, leading to an x-ray that revealed a fracture, and subsequent hip replacement surgery. The facility delayed reporting the incident to the Department of Public Health, contrary to its policy, potentially delaying investigation and risking further injury.
A resident with dementia and a history of wandering did not receive a comprehensive care plan or necessary supervision, leading to an injury. The facility failed to conduct quarterly wandering and fall risk assessments, and staff underestimated the resident's need for supervision. This resulted in the resident suffering a fracture and requiring hospitalization.
Nursing staff at the facility were found using personal vital signs equipment instead of the facility-provided and calibrated equipment, as observed with three LVNs. This practice was against the facility's policy, which requires the use of assigned equipment to ensure safety and accuracy. Interviews with the Medical Director, Facility Administrator, and Interim Director of Nursing confirmed the policy, highlighting the importance of using calibrated equipment.
Three LVNs were observed using personal vital signs equipment instead of the facility-provided and calibrated equipment, contrary to the facility's policies. The Medical Director, Facility Administrator, and Interim Director of Nursing confirmed that staff should use only facility equipment to ensure proper functionality and safety.
The facility staff failed to notify the physician of changes in condition for two residents. One resident refused multiple medications over several days without proper documentation or physician notification. Another resident complained of feeling weak, but the assigned LVN did not notify the physician or document the complaint. The IDON confirmed that these actions were against facility policy.
The facility failed to promptly resolve a grievance for a resident with intact cognitive skills who reported missing items totaling $87.02. Despite acknowledging the issue and promising reimbursement, the resident had not received the funds more than three weeks later. Staff interviews confirmed the delay was due to waiting for corporate funds, which was deemed unacceptable.
A resident with multiple diagnoses, including COPD and diabetes, repeatedly refused critical medications throughout April 2024. The facility staff failed to develop and implement a comprehensive care plan to address these refusals, as required by their policies. This oversight was confirmed by interviews with nursing staff and the Interim Director of Nursing.
A resident with multiple diagnoses did not receive their scheduled 9:00 a.m. medications until 10:35-10:38 a.m., outside the facility's policy of administering medications within one hour before or after the prescribed time. The delay was due to the nurse being busy in the morning.
The facility failed to develop and implement a policy for verifying informed consent for psychotropic medications and did not ensure regular IDT evaluations for residents on such medications. This was observed in five residents, where informed consent forms were incomplete or missing, and IDT evaluations were not conducted as required.
The facility failed to document residents' behavior episodes and clinical justifications for declining gradual dose reductions (GDR) for psychotropic medications. Additionally, there were no physician orders to monitor behaviors being treated with psychotropics for some residents, leading to potential unnecessary medications and/or medication errors.
The facility failed to provide adequate communication means for a non-verbal resident with cerebral infarction, aphasia, and hemiplegia. The resident did not have access to a communication board, requiring staff to guess the resident's needs, contrary to the facility's policy on accommodating individual needs and preferences.
A resident with a history of falls and requiring two-person assistance for transfers fell and sustained a severe eye injury when a CNA attempted to transfer the resident alone, contrary to the care plan and facility policy. The facility failed to conduct a fall risk assessment and did not follow its own fall management and safe patient handling procedures.
A resident with Parkinson's disease did not receive their prescribed Carbidopa/Levodopa medication on two occasions due to delays in re-ordering and delivery from the pharmacy. The resident's cognition was not intact, and they were dependent on staff for mobility and transfers. The facility's policy to re-order medications when there are five pills left was not followed, leading to the medication's unavailability.
Failure to Respond Timely to Resident Call Lights and Requests for Assistance
Penalty
Summary
The facility failed to meet the needs of three residents by not responding to call lights and requests for assistance in a timely manner. Resident 1, who was admitted with diabetes mellitus and generalized muscle weakness and was occasionally incontinent, reported calling for assistance during the night shift and not receiving help, observing staff sleeping in the nursing station, and feeling irritated by the lack of response. Resident 2, with diabetes mellitus, age-related debility, and total incontinence, stated he requested to be changed in the evening and again during the night shift, but was not assisted until early morning. He also observed a CNA sleeping in the nursing station and expressed anger and upset over the lack of care. Resident 3, with a history of cerebral infarction and difficulty walking but independent in ADLs, reported calling for assistance during the night shift and not being attended to for approximately two hours, leading to feelings of disrespect from staff. Interviews with staff confirmed that CNAs take turns on 30-minute breaks and are expected to cover each other's responsibilities, with explicit policies prohibiting sleeping in the nursing station. The DON and DSD both stated that while staff may rest during their breaks, sleeping in the nurses' station is not permitted. Facility policies reviewed require immediate response to call lights and prompt fulfillment of resident requests, typically within five minutes if possible. The observed staff behaviors and delayed responses to resident needs were inconsistent with these policies and contributed to the residents' negative experiences.
Failure to Obtain Physician Order and Notify Physician for Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to obtain a physician order prior to performing fingerstick blood sugar level (BSL) checks for a newly admitted resident with diabetes mellitus and generalized muscle weakness. The resident's care plan required that medications, treatments, and other services be administered in accordance with physician orders. Despite this, nursing staff performed multiple BSL checks at the resident's request without a physician order on several occasions. Interviews with nursing staff confirmed that they were aware a physician order was required but proceeded with the checks regardless. Additionally, the facility did not notify the physician when the resident's BSL results were repeatedly above 189 mg/dL, with some readings as high as 400 mg/dL. Although a nurse stated that the physician was notified about the elevated BSLs, there was no documentation to support this communication, as required by the facility's policy on charting and documentation. The policy also specified that physician orders must be written and maintained, and that all physician notifications should be documented, which was not done in this case.
Failure to Prevent Fall in Cognitively Impaired, Bedbound Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety of a resident with severe cognitive impairment, impaired mobility, and multiple medical diagnoses, including metabolic encephalopathy, chronic kidney disease, weakness, and Alzheimer's disease. The resident was assessed as being at high risk for falls, with a care plan in place that included maintaining a clutter-free environment, monitoring and assisting with toileting needs, and ensuring call lights were within reach. Despite these interventions, the resident was found on the floor next to the bed in the early morning hours and was subsequently transferred to a general acute care hospital for evaluation following the fall. Interviews with facility staff revealed that the resident was bedbound and required full assistance for mobility, with staff noting the resident's dependence and inability to turn or get up independently. The staff could not recall the last time the resident was observed in bed prior to the fall. The facility's policies required assessment for fall risk and implementation of appropriate interventions, but the incident demonstrated a failure to provide adequate supervision and accident hazard prevention, resulting in the resident's fall and hospital transfer.
Failure to Follow Menus and Provide Appropriate Dietary Options
Penalty
Summary
The facility failed to follow the planned menu and provide appropriate food options for residents with specific dietary needs and preferences. One resident who disliked fish was served boiled diced chicken instead of the baked chicken alternative listed on the menu. The cook prepared the boiled chicken due to a lack of available chicken breast or thigh, and the dietary supervisor confirmed there had been delays in food deliveries. The resident's meal ticket indicated baked chicken and oven French fries, but the resident received boiled diced chicken, mashed potatoes, and carrots instead. Another resident, who followed a vegan plant-based diet, did not receive the vegan options specified on the menu. Instead, the resident was served pureed carrots and mashed potatoes, with the mashed potatoes containing chicken bouillon powder. The cook and dietary staff were unaware of the resident's vegan status, and the vegan menu items such as veggie cutlets and non-dairy beverages were not prepared. The resident confirmed her long-term vegan status and stated she does not consume animal products. Additionally, six residents on a renal diet received peas instead of the oven French fries listed on the menu. The cooks stated they did not check the menu and believed potatoes were not allowed on the renal diet, so they substituted peas. Both the cook and dietary supervisor acknowledged that the menu should have been followed. Facility policies require that missing food groups be replaced with appropriate alternatives and that renal diets be individualized with input from a registered dietitian.
Improper Pureed Diet Texture Provided to Residents
Penalty
Summary
The facility failed to provide pureed food with the correct texture to 12 residents who required a pureed diet. During a lunch tray line observation, residents on pureed diets were served carrots that had a thin, soupy, liquid consistency rather than the required homogenous, cohesive, pudding-like texture. The cook responsible for preparing the carrots stated that she added liquid and blended the carrots until smooth, but acknowledged that the final product was too thin. The dietary supervisor confirmed that the carrots did not meet the required consistency and explained to the cook that less water should be used, and that pureed foods should have a pudding-like consistency. A review of the facility's recipe for pureed buttered carrots and the policy for Dysphagia Diets Puree IDDSI Level 4 indicated that pureed foods should be lump-free, hold their shape, and not have separated liquids, with a smooth, pudding-like consistency. The recipe also specified the use of a thickener and a spoon tilt test to ensure proper texture. The failure to follow these guidelines resulted in the serving of improperly prepared pureed carrots to residents requiring this specific diet texture.
Unsanitary and Damaged Can Opener Blade in Kitchen
Penalty
Summary
Surveyors observed that a can opener blade in the kitchen food preparation area was worn, dented, stained, and covered with dried brown residue and metal shavings. The blade was not smooth to the touch, and its condition was verified by the Dietary Supervisor during the inspection. The Dietary Supervisor acknowledged the presence of metal shavings and dents on the blade and was unable to state when the blade was last changed, noting that she was new to the position. A review of the facility's policy and procedure on sanitization indicated that all utensils and equipment are to be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Additionally, the 2022 U.S. Food and Drug Administration Food Code specifies that can opener blades must be kept sharp to minimize the creation of metal fragments and must be replaced if they become pitted or uncleanable. The facility failed to adhere to these standards, resulting in a deficiency related to safe and sanitary food preparation practices.
Failure to Obtain Informed Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent from residents or their responsible parties prior to initiating or increasing psychotropic medication therapy in multiple cases. For one resident with schizophrenia and bipolar disorder, there was no documentation that either the resident or a responsible party received education regarding the risks and benefits of divalproex before it was started. Similarly, another resident with schizoaffective disorder had her aripiprazole dose increased upon readmission from the hospital, but there was no evidence that informed consent was obtained for the higher dose. The DON confirmed that the increase in dosage was likely unintentional and that informed consent was not secured as required. Additionally, a third resident with encephalopathy, schizoaffective disorder, and PTSD received an intramuscular injection of aripiprazole without a completed or signed consent form. The resident's cognitive status was documented as intact, and facility protocol required consent for antipsychotic medications prior to administration. Both the RN and DON acknowledged that the consent process was not completed, and the resident was not made aware of the medication's risks and benefits as required by facility policy. Facility policies reviewed indicated that residents and/or their representatives must be educated about the risks, benefits, and alternatives to psychotropic medications, and have the right to decline such treatments. In these cases, the required process for obtaining and documenting informed consent was not followed, as confirmed by staff interviews and record reviews.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease, dementia, and contractures of the left hand did not have their call light within reach while in their room. The resident was dependent on staff for showering, dressing, and personal hygiene, and their ability to understand ranged from rarely to never understood. During an observation, the call light was found hanging from the rail toward the floor, making it inaccessible to the resident. Interviews with facility staff confirmed that the call light was not within reach and emphasized the importance of accessibility for communication and assistance. The facility's policy required that call lights be accessible to residents at all times. The failure to ensure the call light was within reach constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Document Nicotine Patch Removal
Penalty
Summary
The facility failed to document the removal of a nicotine patch for one resident who was admitted with diagnoses including encephalopathy, schizoaffective disorder, and PTSD. The resident's Minimum Data Set indicated intact cognition and a need for substantial assistance with activities of daily living. The care plan allowed the resident to smoke independently but did not mention the nicotine patch. Physician's orders specified the use of a 21 mg nicotine patch to be applied every 24 hours as needed. Review of the Medication Administration Record (MAR) showed that the nicotine patch was administered on several dates, but there was no documentation of when the patch was removed after 24 hours as required. During a concurrent review, a registered nurse confirmed that the removal of the patch should have been documented on the MAR and was unable to locate such documentation. The facility's policy required timely and comprehensive documentation of care provided, but this was not followed in the case of the nicotine patch removal for this resident.
Failure to Accurately Complete MDS Assessment for Active Psychiatric Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment Section I for a resident by omitting active diagnoses of schizophrenia, depression, and bipolar disorder, despite these conditions being documented in the resident's medical record. The resident's admission record, psychiatric notes, and physician orders all indicated a history and current treatment for these mental health conditions, including prescribed medications specifically for schizophrenia and bipolar disorder. However, the MDS assessment did not reflect any of these diagnoses. During an interview, the Director of Nursing acknowledged that the MDS assessment was inaccurate compared to the resident's clinical record, confirming that the psychiatric section failed to list the resident's actual diagnoses. The facility's policy requires that MDS assessments consistently reflect information found in progress notes, care plans, and resident interviews, which was not followed in this case.
Failure to Revise Care Plans for Changes in Resident Needs
Penalty
Summary
The facility failed to revise and update care plans for two residents following changes in their care needs. For one resident with severe cognitive impairment and a history of COPD, dementia, and heart failure, the care plan indicated the use of hearing aids and staff assistance to ensure they were in place daily. However, observations showed the resident was not wearing hearing aids and had difficulty hearing staff, and the DON confirmed the resident was refusing to wear them. Despite this, the care plan was not revised to reflect the resident's refusal or to include alternative interventions, contrary to facility policy requiring care plans to be updated as resident needs change. For another resident with diagnoses including encephalopathy, schizoaffective disorder, and PTSD, the care plan addressed independent smoking but did not include interventions related to a newly ordered nicotine patch. The physician's order specified the use of a nicotine patch, but the care plan lacked instructions for monitoring, removal, or documentation of the patch's disposal. The RN acknowledged that the care plan should have been updated to include these interventions. Facility policy requires comprehensive, person-centered care plans to be reviewed and revised as new information arises, which was not done in these cases.
Failure to Maintain Clean and Trimmed Fingernails for Dependent Residents
Penalty
Summary
The facility failed to provide proper care and assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. Both residents had documented deficits in self-care related to their medical conditions, including dementia, hypothyroidism, hypertension, major depressive disorder, and impaired mobility or balance. Care plans for both residents specified that fingernail length should be checked and nails should be trimmed and cleaned during bathing and as necessary. However, during observations, both residents were found to have long and unclean fingernails. Certified Nurse Assistants (CNAs) acknowledged that the residents' nails were long and dirty, and stated that nail care was performed every two weeks or as needed, but had not been done at the time of observation. Interviews with facility staff, including the Infection Preventionist and Director of Nursing, confirmed that daily assessment and maintenance of residents' fingernails were expected as part of ADL care. The facility's policy also required daily cleaning and regular trimming of nails to prevent skin problems and accidental injury. Despite these policies and care plan interventions, the observed failure to maintain clean and trimmed fingernails for the two dependent residents constituted a deficiency in providing care according to professional standards.
Failure to Assist Resident with Hearing Aid Use
Penalty
Summary
Facility staff failed to assist a resident with severe cognitive impairment and multiple diagnoses, including COPD, dementia, and heart failure, in wearing hearing aids as required by her care plan. Observations on two separate occasions showed the resident was not wearing her hearing aids and had difficulty hearing and communicating with staff. The resident's Minimum Data Set indicated a high level of hearing impairment and a need for hearing aids, with moderate assistance required for daily activities. Interviews with the Social Service Director and the Director of Nursing confirmed that the hearing aids were not in use and were stored in the medication cart. Both acknowledged that the hearing aids should be offered daily and that staff were responsible for assisting the resident in applying them. The facility's policy required staff to assist hearing-impaired residents with their devices and to evaluate their adaptive needs regularly, but these procedures were not followed for this resident.
Incorrect LAL Mattress Setting for Pressure Ulcer Care
Penalty
Summary
A resident with diagnoses including malignant neoplasm, diabetes mellitus, and parkinsonism was admitted to the facility and assessed as having severely impaired cognition and being dependent on staff for personal care. The resident was identified as having an unstageable pressure ulcer and was prescribed a low air loss (LAL) mattress with the control knob to be set at 113 lbs, according to physician orders. However, during observation, the LAL mattress was found to be set at 325 lbs, which did not align with the resident's weight or the physician's order. The discrepancy in the LAL mattress setting was confirmed during an interview with the Director of Staff Development, who acknowledged that the incorrect setting placed the resident at risk for skin breakdown. The facility's policy on skin integrity management required appropriate assessment and implementation of support surfaces as needed, but this was not followed in this instance. The failure to set the LAL mattress correctly constituted a deficiency in providing appropriate pressure ulcer care and prevention.
Failure to Notify Physician of Catheter Sediment in Resident with UTI Risk
Penalty
Summary
Facility staff failed to provide appropriate care and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who was dependent on staff for toileting and hygiene, had a care plan and physician orders requiring staff to monitor for and report signs and symptoms of possible UTI, including changes in urine character, foul smell, and sediment. Despite these directives, staff did not notify the resident's physician when cloudy sediment was observed in the catheter tubing. Progress notes reviewed over a three-month period showed no documentation of physician notification regarding the presence of sediment in the urine. During an observation, a nurse confirmed the presence of sediment in the resident's catheter tubing and acknowledged that the physician should have been notified. The facility's policy and procedure for preventing catheter-associated UTIs required documentation and reporting of UTI symptoms to the physician. The Director of Nursing also confirmed that there was no documentation of physician notification or specific symptoms of UTI, which was necessary for appropriate treatment. This lack of action had the potential to delay healing or worsen the resident's urinary tract infection.
Failure to Prevent and Address Gastrostomy Tube Feeding Leakage
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube (GT) did not receive appropriate care to prevent complications associated with tube feeding. The resident, who was dependent on staff for mobility and had diagnoses including major depressive disorder, protein-calorie malnutrition, and dysphagia, was observed with tube feeding leaking from the GT onto their skin and bed linen. Staff interviews revealed that the Certified Nurse Assistant (CNA) was unaware of the leakage and did not assess the resident's body, only checking the face for signs of life. The CNA also indicated that it was the night shift's responsibility to ensure the feeding tube was properly attached and functioning. The Licensed Vocational Nurse (LVN) confirmed the presence of leaking formula and acknowledged that the standard process was to check the tube site at the start of the shift, but admitted to relying on the previous shift and not fully checking the resident. The Director of Nursing (DON) stated that both CNAs and LVNs are required to make rounds at the beginning of their shifts to ensure residents' needs are met and to assess for any problems, including issues with gastrostomy tubes. Facility policy required verification of tube placement and prompt reporting of complications. Despite these policies, the resident's tube feeding was not securely connected, resulting in leakage and failure to deliver nutrition as ordered. This lapse in care placed the resident at risk for malnutrition and skin breakdown, as the feeding formula was not being properly administered and was instead soaking the resident and their bedding.
Failure to Monitor for Bleeding in Resident on Anticoagulants
Penalty
Summary
Facility staff failed to monitor for signs and symptoms of bleeding and bruising in a resident who was prescribed both aspirin and Eliquis for blood clot prevention. The resident had a history of cerebral infarction, venous thrombosis, end stage renal failure, and was receiving hemodialysis, all of which increased the risk of bleeding. Despite a care plan identifying the resident as high risk for bleeding and instructing staff to monitor for related symptoms, there was no documented monitoring for bleeding or bruising in the Medication Administration Record (MAR) during the specified period. The Director of Nursing confirmed that monitoring for bleeding and bruising was not performed or documented for the resident while on anticoagulant therapy, despite the resident's increased risk due to frequent dialysis port access. The facility's policy required staff and physicians to monitor for complications in individuals on anticoagulation therapy and to consult with a physician if signs of bleeding were observed, but this protocol was not followed for the resident in question.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors out of 26 observed opportunities, resulting in a 7.69% error rate. In one instance, a nurse prepared a dose of carbamazepine suspension for a resident with chronic pain without first shaking the bottle, despite the pharmacy label and physician's order specifying that the suspension must be shaken well prior to use. The nurse acknowledged during an interview that failing to shake the suspension could result in the resident receiving an incorrect dose of medication. In another instance, a nurse administered a regular multivitamin tablet without minerals to a resident whose physician's order specified a multivitamin with minerals. The nurse admitted to overlooking the correct formulation and stated that she usually checks the product label against the order but failed to do so in this case. Both errors were observed during medication administration and were confirmed through interviews with the involved nursing staff.
Failure to Prevent Significant Medication Errors During Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors in two separate incidents involving medication administration. In the first incident, a nurse was observed preparing a dose of carbamazepine suspension for a resident with chronic pain without first shaking the bottle, as required by the medication's instructions. The nurse acknowledged the error, explaining that suspensions must be shaken to ensure the correct dosage, and that failing to do so could result in the resident receiving too much or too little of the medication. The facility's policy required medications to be administered as prescribed, including following specific preparation instructions. In the second incident, the facility did not adhere to prescribed parameters for administering antihypertensive medications to a resident with a history of hypotension, muscle weakness, and diabetes. The resident's orders specified that certain blood pressure medications should be held if the systolic blood pressure was below 110 or the heart rate was below 60. However, medication administration records showed that these medications were given on multiple occasions when the resident's blood pressure was below the specified threshold. Nursing staff confirmed that medications should be held and the physician notified if parameters were not met, and that administering them outside of parameters was unsafe. Both incidents were confirmed through observation, record review, and staff interviews. The facility's policies required medications to be administered safely and in accordance with prescriber orders, but these requirements were not followed in the cases described, resulting in significant medication errors for the affected residents.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care for a resident. The treatment nurse was observed removing soiled dressings from multiple wounds on a resident's right foot, left heel, and right buttocks without changing gloves between steps such as removing the soiled dressing, cleaning the wound, and applying new dressings. The nurse did not change gloves after removing soiled dressings and before cleaning wounds, nor before applying clean dressings, despite facility policy and standard infection control procedures requiring glove changes at these points. The nurse acknowledged during interview that gloves should be changed after removing soiled dressings and before proceeding with wound cleaning and dressing application to prevent cross-contamination. The resident involved had significant medical conditions, including Alzheimer's disease, muscle wasting, atrophy, and lack of coordination, and was dependent on staff for activities of daily living. Physician orders for wound care specified the use of various topical treatments and dressings for arterial and pressure ulcers. Interviews with the infection preventionist and the director of nursing confirmed that the observed wound care did not follow facility policy or accepted infection control practices, which require hand hygiene and glove changes at specific points during wound care to prevent contamination.
Failure to Provide Resident Records Upon Request
Penalty
Summary
The facility failed to provide a copy of the records upon written request from a legal representative of a resident. The legal representative of the resident faxed a record request to the facility, but the request was sent to a number not accessible by the Administrator, who was responsible for handling medical record requests in the absence of the medical records director. The facility's Administrator stated that the legal representative did not obtain the correct fax number and did not ask to speak to the person responsible for handling medical records. The Director of Nursing confirmed that the resident was admitted to the facility for a few days before being transferred to a General Acute Care Hospital and did not return to the facility. The facility's policy and procedure require providing access to view all records to the resident or their legal representative as soon as possible and no later than 24 hours from receipt of a request, excluding weekends and facility holidays. However, the facility did not receive the record request, resulting in a violation of the resident's rights.
Failure to Administer and Document Medications and Treatments
Penalty
Summary
The facility failed to ensure that a resident received necessary skin treatments and medications as documented in their Treatment Administration Record (TAR) and Medication Administration Record (MAR). Specifically, the resident did not receive their prescribed skin treatment on two consecutive days, as the TAR was not signed to confirm the treatment was administered. Additionally, the resident did not receive their prescribed eye drops for glaucoma on two separate occasions, as the MAR was not signed to indicate administration. These omissions were confirmed during a review with the Director of Nursing (DON), who acknowledged the lack of documentation. The resident involved was admitted with multiple diagnoses, including being a left above-knee amputee, muscle weakness, and glaucoma. The Minimum Data Set (MDS) assessment indicated the resident was confused and dependent on assistance for daily activities. The facility's policies require that medications and treatments be documented immediately after administration, but this was not adhered to in the case of the resident's skin treatment and eye drops. The failure to document and administer these treatments could potentially affect the resident's skin healing and eye pressure management.
Failure to Verify Resident's DNR Status
Penalty
Summary
The facility failed to ensure that a resident's wishes for medical care and treatment were clarified with the resident and/or their representative. This deficiency involved a resident who had a do not resuscitate (DNR) order at a general acute hospital prior to being admitted to the facility. Upon admission, the facility did not verify the resident's code status with the family or the physician, leading to a lack of clarity regarding the resident's treatment preferences during emergencies. The resident, who had diagnoses including metabolic encephalopathy and dementia, was admitted to the facility with a DNR order from the hospital. However, the facility did not confirm this status with the resident's next of kin (NOK) or document the verification of the code status upon admission. Interviews with facility staff, including a licensed vocational nurse and the director of nursing, revealed that the resident was considered full code at the facility, despite the DNR order from the hospital. The facility's policy and procedure on nursing documentation and resident rights emphasize the importance of clear and accurate communication regarding a resident's condition and treatment preferences, which was not adhered to in this case.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating their bed-hold policy. The resident, who had been admitted with chronic obstructive pulmonary disease, encephalopathy, and respiratory failure, was transferred to a general acute care hospital for treatment. Despite being ready for discharge back to the facility, the resident was not readmitted due to the facility's claim of no available bed, even though the census indicated otherwise. Interviews with the facility's Admission Director and Director of Nursing confirmed that beds were available, and the resident should have been readmitted. The facility's policy requires that residents be allowed to return after hospitalization or therapeutic leave, regardless of payer source, and that they be informed of bed-hold policies in advance. The facility's failure to adhere to this policy resulted in the resident remaining at the hospital, potentially causing psychosocial harm. The Director of Nursing was unaware of the resident's readiness for discharge, indicating a communication breakdown within the facility.
Failure to Change Oxygen Tubing Weekly and Keep Off Floor
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the management of oxygen tubing for a resident who was on oxygen via nasal cannula. The deficiency was identified during an observation where the oxygen tubing for a resident was found to be dated 7/31/2024, indicating it had not been changed weekly as required by the facility's policy. Additionally, the nasal cannula end of the tubing was observed to be on the floor, which is against the facility's guidelines that require the tubing to be kept off the ground. The resident involved was admitted with conditions including sepsis, type 2 diabetes, and essential hypertension. The resident was cognitively intact and required varying levels of assistance for personal care. The physician's order specified oxygen administration at 2-3 liters per minute via nasal cannula for shortness of breath. During interviews, both an LVN and the DON confirmed the findings and acknowledged that the failure to change the tubing weekly and keep it off the floor could lead to an infection, such as pneumonia, due to potential contamination.
Infection Control Breach in Isolation Precaution Room
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, specifically in the case of a Certified Nurse Assistant (CNA 1) who did not wear gloves when entering a novel respiratory isolation precaution room for a resident diagnosed with COVID-19. The resident, admitted with conditions including hemiplegia, hemiparesis, and type 2 diabetes mellitus, tested positive for COVID-19 and was placed under novel respiratory precautions. Despite the clear signage and policy requirements for wearing gloves, CNA 1 entered the resident's room without gloves while delivering a lunch tray. Additionally, CNA 1 did not remove her face shield and N-95 mask upon exiting the isolation room, contrary to the facility's policy that mandates the removal and disposal of all personal protective equipment (PPE) before leaving such rooms. Interviews with the Infection Preventionist Nurse and the Director of Staff Development confirmed the importance of these protocols to prevent the spread of infection. The facility's policies clearly outlined the necessary PPE for COVID-19 precautions, which CNA 1 failed to follow, increasing the risk of infection transmission.
Failure to Staff RN for Required Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was available to work for at least 8 consecutive hours a day, as federally required, from July 1, 2024, to July 18, 2024. This deficiency was identified through observation, interviews, and record reviews, revealing that the facility had only one RN, who was also the Director of Nursing (DON). The facility's Licensed Nurses Schedule confirmed that the DON was the sole RN on staff during this period. The DON, who had recently started in the role, was responsible for both RN supervisory duties and DON responsibilities, including administering intravenous medications and handling admissions. The facility's policy and procedure for the Director of Nursing Services, reviewed in December 2023, stated that the DON is employed full-time and is responsible for recruiting and retaining sufficient nursing personnel to meet residents' needs. The policy also indicated that the DON may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. However, the facility had an average daily census of 87 residents, exceeding this threshold. This staffing deficiency placed all 85 residents at risk for delayed care, missed treatments, and potential delays in emergency care.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized and comprehensive care plans for two residents, leading to deficiencies in their care. Resident 1 was admitted with an indwelling urinary catheter, but the facility did not create a care plan for the catheter upon admission. The care plan was only initiated nearly a month later, which was not in compliance with the facility's policy that requires care plans to be developed within seven days of the resident's comprehensive assessment. This oversight was confirmed during an interview with a Licensed Vocational Nurse, who acknowledged the absence of a timely care plan for the catheter. Similarly, Resident 2, who was admitted with conditions including COPD, dysphagia, and type 2 diabetes, was approved to self-administer certain medications. However, the facility did not implement a care plan addressing the resident's self-administration of oral, nasal, and inhaler medications. The existing care plan only addressed non-compliance issues related to keeping medication at the bedside, but not the self-administration aspect. This deficiency was also confirmed by a Licensed Vocational Nurse, who noted the lack of a care plan for the resident's self-administration of medication.
Failure to Provide Necessary Neurologist Appointment
Penalty
Summary
The facility failed to ensure that a resident received necessary treatment and care in accordance with professional standards of practice. The resident, who was admitted with diagnoses including spinal stenosis, spinal fusion, and hypertension, had a physician's order to be seen by a neurologist for a surgery follow-up. However, the appointment was not fulfilled as the resident was unable to tolerate sitting in a wheelchair due to pain, and the necessary gurney transportation was not arranged in time. This resulted in the resident not being seen by the neurologist as scheduled. The deficiency was further compounded by a lack of communication and coordination among the facility's staff. The Social Services Director was not informed of the resident's need for gurney transportation, and there were no Interdisciplinary Team meeting notes conducted upon the resident's admission to discuss the resident's needs. The Director of Nursing acknowledged that the facility should have ensured proper transportation arrangements, especially for a follow-up appointment after surgery. The failure to provide the necessary care and services placed the resident at risk of complications from the recent surgery.
Improper Catheter Placement Leads to UTI Risk
Penalty
Summary
The facility staff failed to ensure appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including spinal stenosis, spinal fusion, and hypertension, required maximal assistance for activities of daily living and had intact cognitive skills. The resident's care plan aimed to minimize the risk of complications from the indwelling catheter, with interventions to secure the catheter to facilitate urine flow. During an observation, the resident's foley catheter drainage bag was found hanging above the level of the bladder, with urine not flowing properly into the bag due to a twisted catheter tubing. This placement was confirmed by an LVN, who acknowledged that the drainage bag should have been below the bladder to prevent backflow and potential UTIs. The facility's policy on catheter care also specified that the drainage bag should be positioned below the bladder level to ensure free urine flow.
Failure to Ensure Safe Medication Management for a Resident
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident by not ensuring that medications were not left unattended at the bedside. The resident was observed with a bottle of Tums and a lactulose oral solution on the bedside table, which were not prescribed by a physician nor was there an order allowing the resident to keep and self-administer these medications. This oversight was confirmed during an interview with a Licensed Vocational Nurse (LVN), who acknowledged that there was no physician's order for the resident to self-administer or store medications at the bedside. The resident, who was admitted with chronic obstructive pulmonary disease, dysphagia, and type two diabetes mellitus, was assessed to have intact cognition for daily decision-making but required maximal assistance for activities of daily living. Despite this, the facility did not complete a self-administration assessment for the medications found at the bedside, nor was there a comprehensive care plan developed and implemented for the resident's self-administration of oral, nasal, and inhaler medications. The existing care plan only addressed non-compliance with keeping medications at the bedside but did not cover the self-administration aspect. Interviews with the Director of Nursing (DON) and a review of the facility's policies confirmed that a physician's order and a care plan were necessary for residents wishing to self-administer medications. The facility's policy required the interdisciplinary team to assess the safety and appropriateness of self-administration, which was not documented in the resident's medical record or care plan. This lack of adherence to policy and procedure had the potential to result in unintended complications for the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Survey Agency (SSA) within the required two-hour timeframe for a resident who complained of pain in the right upper leg, which resulted in a fracture. The resident, who had a history of dementia, schizoaffective disorder, generalized anxiety disorder, and cognitive communication deficit, was readmitted to the facility earlier in the year. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and behavioral symptoms, requiring various levels of assistance for daily activities and was on multiple medications. On June 18, 2024, a Certified Nursing Assistant (CNA) reported to the Charge Nurse (CN) that the resident expressed pain during a transfer to a shower chair. An assessment showed mild pain without visible signs of injury, and acetaminophen was administered. An x-ray was ordered, and the results on June 19, 2024, revealed an acute subcapital fracture of the right femur. The resident was transferred to a general acute care hospital (GACH) for further evaluation, where a displaced and angulated right femoral neck fracture was confirmed, leading to a hip replacement surgery on June 20, 2024. The facility delayed reporting the injury to the Department of Public Health (DPH) until June 20, 2024, despite being aware of the fracture on June 19, 2024. Interviews with the Licensed Vocational Nurse (LVN), Director of Nursing (DON), and Administrator revealed a lack of timely communication and reporting, which was against the facility's policy requiring notification within two hours for serious bodily injuries. The delay in reporting potentially caused a delay in the investigation and could have led to further injury to the resident.
Failure to Provide Comprehensive Care for Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate care and services to a resident diagnosed with dementia, who had a history of wandering and was at risk for falls. The resident, who was readmitted to the facility with multiple diagnoses including dementia, schizoaffective disorder, and generalized anxiety disorder, did not have a comprehensive care plan addressing their dementia. The care plan lacked specific interventions for monitoring the resident's whereabouts or providing necessary supervision to prevent injury. The facility also failed to complete quarterly wandering and fall risk assessments for the resident. The last documented assessments were completed on 10/8/2023, despite the resident being at high risk for wandering and moderate risk for falls. The resident's Minimum Data Set indicated severely impaired cognition and behavioral symptoms, yet the care plan did not include adequate measures to address these risks. As a result, the resident experienced an acute subcapital fracture of the right femur, leading to hospitalization and surgery. Interviews with facility staff revealed a lack of awareness and understanding of the resident's need for supervision and the importance of a comprehensive care plan. Staff members described the resident as independent and not requiring much supervision, despite the resident's known wandering behavior and cognitive impairments. The Director of Nursing acknowledged the absence of a care plan for dementia and the failure to conduct necessary risk assessments, which could have contributed to the resident not receiving the care needed to prevent injury.
Nursing Staff Use Personal Equipment Against Facility Policy
Penalty
Summary
The facility failed to meet professional standards of practice by allowing nursing staff to use their own vital signs (VS) equipment instead of the equipment provided by the facility. This was observed during an interaction with three Licensed Vocational Nurses (LVNs) who were using personal blood pressure equipment and thermometers. LVN2 was observed using her own equipment for convenience, and both LVN1 and LVN4 expressed a preference for using their own VS equipment. This practice was contrary to the facility's policy, which mandates the use of facility-provided and calibrated equipment to ensure accuracy and safety. Interviews with the Medical Director, Facility Administrator, and Interim Director of Nursing confirmed that the facility's policy requires staff to use only the equipment provided by the facility. The Medical Director emphasized the importance of using calibrated equipment to ensure proper functioning. The facility's policies and procedures, as well as the job description for the Charge Nurse, clearly state that staff should use assigned equipment to promote safety and comply with established departmental policies. The failure to adhere to these policies had the potential to negatively impact the delivery of care services to all residents.
Improper Use of Personal Vital Signs Equipment by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff adhered to professional standards of practice by using the facility's provided vital signs (VS) equipment. Instead, three out of four nursing staff members, including two Licensed Vocational Nurses (LVN1 and LVN2) and another LVN (LVN4), were observed using their personal VS equipment. This practice was noted during observations and interviews conducted on June 6 and June 7, 2024. LVN2 and LVN4 both expressed a preference for using their own equipment for convenience, while LVN1 acknowledged that some staff members prefer to bring and use their own equipment. The facility's Medical Director, Facility Administrator, and Interim Director of Nursing all confirmed that nursing staff should not be using personal VS equipment, as the facility is responsible for providing and calibrating the equipment to ensure proper functionality. The facility's policies and procedures, as well as the job description for the Charge Nurse, emphasize the use of assigned equipment and compliance with established departmental policies to promote safety. The failure to adhere to these policies and procedures had the potential to negatively impact the delivery of care services to all residents.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility staff failed to ensure that the physician was notified concerning the change of conditions for two residents. Resident 3 had multiple episodes of refusing medications, including blood pressure medication, anti-blood clot medication, anti-allergy medication, and diabetic medication over a period of several days. Despite these refusals, the Licensed Vocational Nurse (LVN) did not complete any change of condition (COC) documentation or notify the physician, as required by the facility's policy. The Interim Director of Nursing (IDON) confirmed that the facility should have monitored the refusals and notified the physician, as well as updated the care plan accordingly. Resident 6 complained of feeling very weak and possibly having a seizure. The resident informed the assigned LVN, who acknowledged the complaint but did not notify the physician or document the change of condition in the medical chart. The IDON confirmed that the facility's policy requires notifying the physician and proper documentation when a resident complains of weakness. The failure to follow these procedures had the potential to delay necessary care and services for both residents.
Failure to Promptly Resolve Resident Grievance
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for Resident 4, who had concerns about missing items totaling $87.02. Despite the facility's acknowledgment on 3/25/2024 that the cost of the missing items would be reimbursed, Resident 4 had not received the reimbursement by 4/18/2024, more than three weeks later. Resident 4, who had intact cognitive skills and required supervision for activities of daily living, expressed frustration over the delay during an interview. Interviews with the Social Service Department Staff and the Interim Director of Nursing confirmed that the delay was due to waiting for funds from the corporate office, and both acknowledged that the wait time was unacceptable. The facility's policy on grievances and complaints, reviewed on 12/14/2023, indicated that grievance reports should be filed in a timely manner, which was not adhered to in this case.
Failure to Develop and Implement Comprehensive Care Plan for Medication Refusals
Penalty
Summary
The facility staff failed to develop and implement a comprehensive care plan that addressed a resident's refusal of medications. The resident, who was admitted with diagnoses including a periprosthetic fracture, COPD, and diabetes mellitus, had an intact cognition and required maximal assistance for activities of daily living. Despite multiple refusals of critical medications such as Amlodipine Besylate, Apixaban, Fexofenadine HCL, Januvia, and Losartan Potassium throughout April 2024, there were no care plans in place to address these refusals. This oversight was confirmed during interviews with the Licensed Vocational Nurse and the Interim Director of Nursing, who acknowledged that the refusals should have been documented, and a care plan should have been developed and implemented. The facility's policies and procedures, which were reviewed in December 2023, clearly state that a comprehensive, person-centered care plan must be developed and implemented for each resident, including documentation of refusals in the resident's clinical record. The failure to follow these policies resulted in a deficiency that had the potential to negatively impact the resident's health and safety, as well as the quality of care and services provided. The staff's inaction in notifying the MD, completing a change of condition documentation, and creating a care plan for the medication refusals were key factors leading to this deficiency.
Failure to Timely Administer Medications
Penalty
Summary
The facility failed to timely administer medications per its policy to a resident, identified as Resident 11. Resident 11, who has diagnoses including hemiplegia, hemiparesis, and diabetes mellitus, was readmitted to the facility and required maximal assistance for activities of daily living. On the date of the incident, Resident 11's scheduled 9:00 a.m. medications were administered between 10:35 and 10:38 a.m., which is outside the facility's policy of administering medications within one hour before or after the prescribed time. The medications included antihypertensives, anti-dementia medication, anti-blood clot medications, and a multivitamin supplement. During an observation and interview with LVN 2, it was noted that the medications were administered late because the nurse was busy in the morning. The Interim Director of Nursing confirmed that the facility's policy requires medications to be administered within one hour before or after the scheduled time. The facility's policy, reviewed on 12/14/2023, also indicated this requirement. This failure to adhere to the medication administration schedule had the potential to result in medication ineffectiveness and placed Resident 11 at risk for unsafe and improper medication use.
Inadequate Documentation and Evaluation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure there was a policy developed and implemented to verify whether residents had been provided informed consent or given refusal for the use of psychotropic medications. This deficiency was observed in the cases of five residents, where the facility had inconsistent procedures in documenting informed consent verification. For instance, Resident 1 had an order for Seroquel with a blank signature area for the physician on the informed consent form, and Resident 2 had no consent form for the prescribed sertraline. Similar issues were found with Residents 3, 4, and 5, where the informed consent forms were either incomplete or missing signatures from the physician who obtained the consent. The Director of Quality Assurance and the Administrator confirmed that the facility did not have a policy on informed consent for psychotropic medications. Additionally, the facility failed to ensure that the interdisciplinary team (IDT) met periodically to evaluate residents on psychotherapeutic medication therapy as per policy and guidance. This was evident in the cases of Residents 1 and 2. Resident 1, who was non-verbal and had no known family member or representative, had IDT notes that did not include an evaluation of the resident's psychotherapy. Similarly, Resident 2, who received dialysis and was a non-English speaker, had no IDT meeting notes evaluating their psychotropic medication use and behavior management. The IDT notes for Resident 2 only discussed weight loss, nutrition, and skin condition. These deficiencies indicate a lack of proper documentation and evaluation processes for residents on psychotropic medications, potentially leading to medication errors and unnecessary medications. The facility's failure to develop and implement a policy for informed consent and to conduct regular IDT evaluations for residents on psychotropic medications were significant lapses in ensuring the safety and well-being of the residents.
Failure to Document Behavioral Episodes and Clinical Justifications for Psychotropic Medications
Penalty
Summary
The facility failed to ensure there were descriptive documentations of residents' behavior episodes and significant specific behavior for one of five sampled residents. Specifically, Resident 1 had an order for Seroquel to treat schizoaffective disorder depressive type manifested by combativeness, but there were no nursing notes to describe the episodes of combativeness. Additionally, the director of social services mentioned hearing about Resident 1's combativeness but had not witnessed it. The psychiatric progress note for Resident 1 indicated that gradual dose reduction (GDR) was contraindicated, but it lacked clinical evidence to support this decision. Similar issues were found with Residents 4 and 5, where the psychiatric progress notes also lacked clinical evidence to support the decision to decline GDR for their psychotropic medications. Furthermore, there were no physician orders to monitor behaviors being treated with psychotropics for Residents 3, 4, and 5. The facility's policy and procedures on psychotropic medication use indicated that residents should not receive medications that are not clinically indicated to treat a specific condition and that psychotropic medication management includes adequate monitoring for efficacy and consequences. However, the facility failed to document clinical justifications for declining GDR and did not have orders to monitor behaviors for some residents. This lack of documentation and monitoring had the potential to lead to unnecessary medications and/or medication errors. The administrator acknowledged the lack of documented supportive evidence to decline GDR and the need for descriptive documentation related to residents' behavioral events to support quantitative behavioral data.
Failure to Provide Communication Means for Non-Verbal Resident
Penalty
Summary
The facility failed to provide adequate means of communication for a non-verbal resident who was admitted with diagnoses including cerebral infarction, aphasia, and hemiplegia. The resident, who did not have a conservatorship or known family members, relied on the interdisciplinary team and attending physician for decision-making. The resident could respond to simple questions using body language but did not have access to a communication board, which was supposed to help express needs and preferences. During an interview, the Licensed Vocational Nurse (LVN) acknowledged that the resident's responses required staff to guess what the resident wanted, and the communication board was not present with the resident during the observation. The Director of Social Services and the Director of Quality Assurance Nursing consultant confirmed that the resident did not have a communication board available at the bedside or attached to the wheelchair. The Administrator also stated that the use of communication boards could help non-verbal residents express their needs, preventing staff from having to guess and potentially aggravating the resident's behavior. The facility's policy on accommodating needs indicated that residents' individual needs and preferences, including adaptive devices, should be evaluated upon admission and reviewed on an ongoing basis, which was not adhered to in this case.
Failure to Provide Adequate Supervision and Assistance During Transfer
Penalty
Summary
The facility failed to provide the necessary assessments, care, and services to prevent falls for a resident. On 2/25/2024, a certified nurse assistant (CNA 1) attempted to transfer a resident from a wheelchair to a bed without the assistance of another staff member, contrary to the resident's care plan and facility policy. As a result, the resident fell and sustained a severe right eye injury, requiring emergent transfer to a general acute care hospital and subsequent transfer to a trauma center for specialized ophthalmology care. The resident had a history of dementia, Parkinson's disease, osteoarthritis, and a history of falls, and was assessed as needing a total lift and two staff members for transfers. Despite this, CNA 1 attempted the transfer alone, leading to the fall. The resident's care plan indicated the need for staff to anticipate and meet the resident's needs to prevent falls, but it did not specify the resident's particular needs or include the facility's fall protocol. Interviews with staff and the resident's family confirmed that the resident required two-person assistance for transfers due to poor balance and strength. The Director of Nursing acknowledged that the facility did not conduct a fall risk assessment for the resident and that the fall could have been avoided if two staff members had been present to assist with the transfer. The facility's policy and procedures for fall management and safe patient handling were not followed in this instance.
Failure to Administer Parkinson's Medication
Penalty
Summary
The facility failed to administer Carbidopa/Levodopa 25-100 mg four times a day for a resident with Parkinson's disease on 2/22/2024 and 2/23/2024. The resident, who was admitted on 2/2/2024, had multiple diagnoses including Parkinson's disease, unspecified dementia, and a history of falls. The resident's physician had ordered the medication to be given at specific times throughout the day. However, the Medication Administration Record (MAR) indicated that the 6:00 a.m. doses on the specified dates were not given, and nursing progress notes revealed that the medication was re-ordered and awaited delivery from the pharmacy. Interviews with family members and nursing staff confirmed the medication was not administered due to a delay in re-ordering and delivery from the pharmacy, despite the facility's policy to re-order medications when there are five pills left to ensure availability. The Director of Nursing (DON) acknowledged that the medication should have been ordered ahead of time to prevent such issues. The resident's Minimum Data Set (MDS) dated 2/9/2024 indicated that the resident's cognition was not intact and that they were dependent on facility staff for mobility and transfers. The failure to administer the medication as prescribed may have placed the resident at risk for falls, as the medication is crucial for managing Parkinson's symptoms such as tremors and muscle stiffness. Interviews with the Licensed Vocational Nurses (LVNs) and the DON highlighted a lapse in the facility's medication management process, which led to the unavailability of the medication at the required times.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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