Alamitos West Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Alamitos, California.
- Location
- 3902 Katella Avenue, Los Alamitos, California 90720
- CMS Provider Number
- 056169
- Inspections on file
- 28
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Alamitos West Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with Parkinson’s disease and bilateral ankle contractures was discharged to a board-and-care setting without the facility fully completing the required discharge planning process. Although a physician ordered that the resident could go to a board and care with PT evaluation and HH, and a written Notice of Proposed Transfer/Discharge documented that notice was given to the resident and representative and mailed to the Ombudsman, the medical record lacked documentation that the Ombudsman was actually notified as required. Facility policy called for Ombudsman notification 30 days prior to a facility-initiated discharge, but the DON acknowledged this did not occur, and no discharge care plan was developed for the resident.
A resident with documented decision-making capacity was left unattended outside while waiting for family transportation to a medical appointment. After accompanying the resident outside following lunch, a CNA left the resident alone when the resident repeatedly asked to be left, positioning herself just inside the facility door instead of remaining with the resident. The DON later stated the CNA was expected to stay with the resident until the family arrived, demonstrating a failure to provide adequate supervision to prevent accidents.
A resident receiving carbidopa-levodopa for Parkinson’s disease had two duplicate physician orders with different dates for the same dose and time recorded on the MAR. An LVN confirmed administering the medication and acknowledged that the duplicate orders should have been clarified with the physician but were not. The DON verified the inaccurate, duplicate orders in the medical record, resulting in an inaccurate MAR for the resident’s Parkinson’s medication.
A resident with Parkinson's disease and significant mobility limitations was not repositioned every two hours as ordered by the physician. Staff interviews and observations confirmed that the resident remained on his back for extended periods, with repositioning not performed according to the care plan. Instead, staff adjusted pillows or pulled the resident up in bed, contrary to the specific physician's order.
A resident's medical record was found to be incomplete and inaccurately maintained, with missing documentation by licensed nurses for several physician-ordered treatments and interventions, including oral hygiene, skin care, and use of assistive devices. Despite documentation indicating oral care was provided, both the resident and a CNA confirmed it was not done. The DON verified these deficiencies.
Facility staff did not follow infection control procedures by leaving a used glove on the sink and toilet tank and a soiled towel on the floor in a shower room, instead of disposing of them properly in designated containers, as confirmed by the Account Manager and DON.
Three shower rooms were found to be inadequately cleaned and disinfected, with a resident reporting the appearance of fecal matter in the showers. Observations revealed dark brown residue on shower heads and brown stains on the walls and shower head holders, which were acknowledged by facility management.
Staff did not follow Enhanced Barrier Precautions during wound care for a resident with a chronic wound. An LVN and a CNA performed high-contact care activities without donning gowns, despite posted signage and physician orders requiring both gown and gloves. The staff later acknowledged that gowns should have been worn, and facility leadership confirmed the lapse in infection control practice.
Three residents with significant care needs and fall risks were observed in bed with unlocked bed wheels. Staff, including a CNA and an LVN, confirmed the bed wheels were not locked, despite facility procedures requiring this safety measure. The residents involved had diagnoses such as dementia, hemiplegia, and immobility, and were dependent on staff for mobility and transfers.
A resident who was cognitively intact was observed repeatedly calling a CNA by name and was initially ignored, then addressed with a curt 'what' rather than a respectful response. The resident reported feeling dissatisfied and disrespected by the interaction. Staff interviews confirmed that such a response was not in line with facility policy on resident dignity.
A resident did not receive whole milk with meals as specified on their meal ticket, despite being cognitively intact and having this preference documented. Staff confirmed the omission during both breakfast and lunch, and the DSS verified that all items on the meal ticket should have been served. The issue was acknowledged by facility leadership after being brought to their attention.
A resident refused bowel management medications for three days without the physician being notified, contrary to facility policy. The resident later experienced severe pain and was transferred to the hospital, where a CT scan revealed diverticulitis with an abscess and an associated ileus or possible small bowel obstruction.
The facility failed to update elopement risk assessments for two residents with dementia, leading to inadequate monitoring and intervention. One resident exhibited increased wandering behavior, prompting the use of a Wander Guard without a reassessment. Another resident, who attempted to elope, was not assessed quarterly as required, missing critical evaluations of their elopement risk.
A facility failed to respect a resident's right to self-determination by not adhering to the requested medication schedule after the resident's return from a hospital stay. Despite previous arrangements to spread out medication administration times, the facility administered medications at an earlier time without documented justification, contrary to the resident and family's request.
A resident with moderate cognitive impairment did not receive timely care for an indwelling urinary catheter, which was inserted due to urinary retention. The facility failed to provide necessary daily catheter care until five days after insertion, despite policy requirements for continual assessment and proper handling. This lapse was confirmed by interviews with the resident, a family member, and an LVN, and acknowledged by the DON, posing a risk for catheter-associated urinary tract infections.
A resident with moderate cognitive impairment was administered docusate sodium despite having loose bowel movements, contrary to physician orders. The medication was given on multiple occasions without proper communication between staff about the resident's bowel condition, leading to unnecessary medication administration.
A resident with moderate cognitive impairment requested a bath, which was not provided on the requested day due to staffing issues. The resident expressed frustration, and facility records confirmed the bath was not documented as given. Interviews with staff and family verified the oversight.
A resident with moderate cognitive impairment experienced mild weakness and a flushed face, but the facility failed to update the care plan to address this change in condition. This oversight was confirmed by interviews with an LVN and an RN, and acknowledged by the DON.
A resident with moderate cognitive impairment received an extra capsule of psyllium on multiple occasions due to a pharmacy error. The physician's order was for one capsule twice a day, but the pharmacy delivered a bubble pack with two capsules, leading to the administration of an extra dose. The DON confirmed the error during a review.
The facility failed to ensure accurate documentation of bladder elimination for three residents with indwelling urinary catheters. CNAs inaccurately recorded these residents as incontinent, despite the presence of catheters, potentially affecting their care needs. The inaccuracies were confirmed by the DON during a review.
The facility failed to notify a physician when a resident had no bowel movements for over three days, despite having a bowel management protocol. Additionally, another resident did not receive dynamic splints as ordered, with multiple instances of non-compliance documented. These deficiencies were confirmed through interviews and record reviews.
A resident in an LTC facility was not provided with the correct toothbrush for oral hygiene, using a denture brush instead. This occurred because a CNA failed to provide the regular toothbrush, which the resident preferred and was supposed to use. Interviews with an LVN and the DON confirmed the intended use of the brushes, highlighting a failure to accommodate the resident's needs.
The facility failed to maintain sanitary conditions in the kitchen, including improper use of hair restraints by staff, inadequate labeling and dating of food items, and unsanitary kitchen equipment. Observations revealed food debris in the microwave, corroded pans, and wet plates and domes. Cutting boards were also heavily marred, and a scoop was improperly stored in a food bin, potentially risking foodborne illnesses among residents.
The facility failed to maintain infection control practices, lacking documentation for Legionella risk assessment and testing protocols. CNAs did not follow Enhanced Barrier Precautions for a resident with a Foley catheter, and personal items were improperly stored in the clean laundry area. Visitors did not adhere to contact isolation precautions, and a CNA did not change gowns between assisting two residents.
The facility failed to obtain or provide information on advance directives for several residents, leading to incomplete or missing documentation. Residents with the capacity to make decisions were not offered information on formulating advance directives, and some residents' directives were incomplete or not verified. This deficiency was identified through interviews and medical record reviews.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their individual care needs. A resident with severe cognitive impairment experienced a fall without a care plan being developed. Another resident on antidepressant medication and a third resident on antibiotics for an infected wound also lacked appropriate care plans. These deficiencies were confirmed by staff and acknowledged by the DON and Administrator.
The facility failed to provide adequate respiratory care for multiple residents, as evidenced by undated and unlabeled oxygen equipment, lack of proper storage, and missing care plans. Staff confirmed these deficiencies, indicating a systemic issue in equipment management and documentation.
A facility failed to adjust medication administration for a resident undergoing hemodialysis, resulting in missed doses of colchicine and magnesium on dialysis days. The facility's policy required medication administration within a specific timeframe, but there was no physician's order to hold or reschedule medications, nor was the physician notified of the resident's absence during scheduled medication times. The DON confirmed the lack of documentation and adjustment.
A facility failed to provide necessary medications to a resident due to unavailability, as observed during a medication administration session. An LVN was unable to administer a Calcium Vitamin D tablet and an Acidophilus Probiotic oral tablet, both ordered by the resident's physician. The facility's policy requires contacting the pharmacy if medications are unavailable, but this was not done. The Administrator and DON acknowledged the deficiency.
A facility failed to act on a pharmacy consultant's recommendation to reduce a resident's venlafaxine dosage and did not identify duplicate therapy for acetaminophen. The resident's physician did not respond to the pharmacist's suggestion for a gradual dose reduction, and duplicate orders for acetaminophen were not clarified. These issues were confirmed by the DON and LVN.
A resident's medication regimen was not properly monitored, leading to duplicate therapy for acetaminophen and lack of monitoring for side effects of Keflex and hydrocodone-acetaminophen. An LVN confirmed the oversight, and the facility's Administrator and DON acknowledged the deficiencies.
The facility failed to monitor two residents for side effects and behaviors related to psychotropic medications. One resident was not monitored for sertraline and quetiapine use, while another lacked documentation for extending doxepin use beyond 14 days and was not monitored for side effects. These deficiencies were confirmed by facility staff.
A long-term care facility experienced a medication error rate of 18.52% during a medication pass observation. Errors included incorrect mixing of a laxative, failure to instruct a resident to rinse after using an inhaler, administering the wrong B complex supplement, not administering vitamin B6 due to expiration, and giving the wrong potassium supplement. These errors involved three LVNs and three residents, highlighting a failure to adhere to prescribed medication orders and facility policies.
The facility failed to ensure proper storage, labeling, and disposal of medications, leading to several deficiencies. A resident's eye solution was left unattended, and medication rooms had temperature control issues. Medication carts contained unlabeled and expired medications, and oral medications were stored with externally used ones. These lapses were confirmed by staff, indicating a failure to adhere to proper protocols.
The facility did not follow prescribed pureed recipes for 12 residents, potentially affecting their nutritional intake. Observations and interviews revealed deviations from the recipes for chicken ala king, steamed broccoli, and brown rice, including the use of milk, butter, and rice hot cereal instead of specified ingredients. The Dietary Services Supervisor confirmed these discrepancies, indicating a failure to meet the nutritional needs of residents on a pureed diet.
The facility did not follow its policy on the use and storage of food brought by family and visitors. Staff interviews revealed that the facility lacked a refrigerator for storing outside food, leading to instructions for immediate consumption and no storage of unconsumed food. This failure had the potential to cause foodborne illnesses among residents.
A facility failed to ensure a resident receiving hospice services attained their highest well-being by not communicating with the hospice agency about missing aide visits. The resident had orders for hospice aide visits twice weekly, but several visits were missed without coordination or follow-up. Interviews with staff confirmed the lack of communication and coordination, and the designated hospice coordinator did not have a clinical background or meet the resident.
The facility failed to monitor antibiotic use for two residents who did not meet McGeer's criteria for infection. Antibiotics were prescribed without symptoms, and there was no documentation of physician notification. The IP and DON confirmed these findings.
A facility failed to ensure a resident received the influenza vaccine and did not properly document the refusal process. The resident's representative was not provided with information about the risks and benefits of the vaccine, and the necessary consent or declination form was incomplete. The facility's IP confirmed the lack of follow-up, and the DON acknowledged the deficiency.
The facility failed to maintain essential kitchen equipment, including a dish machine and digital thermometers, in safe operating condition. The dish machine was not sanitizing properly, and digital thermometers were not calibrated, potentially risking foodborne illnesses for residents.
The facility failed to accommodate residents' needs by not ensuring call lights and controls were within reach. A resident waited 30 minutes for toilet assistance, resulting in wetting her diaper. Other residents had call lights, bed controls, and remotes out of reach, impacting their ability to request help or perform daily activities. Staff confirmed these deficiencies, acknowledging the need for accessibility.
A resident was served cooked carrots despite having a documented dislike for them, as observed during a dining session. The resident, who is cognitively intact, expressed dissatisfaction, and both the LVN and DSS confirmed the oversight. The facility's diet spreadsheet included carrots, and the resident's medical records specified a diet excluding cooked carrots, highlighting a failure to adhere to dietary instructions.
A facility failed to ensure accurate medical record documentation for a resident, leading to conflicting information about the resident's decision-making capacity. The H&P examination showed both that the resident had and did not have the capacity to make decisions, while a surrogate decision-maker was listed. Despite this, the resident signed a consent form for treatment. The DON confirmed the findings and acknowledged the need for physician clarification.
The facility failed to dispose of trash in a sanitary manner, with three out of four dumpsters not properly covered, risking pest infestation. The green food waste dumpster was overflowing, preventing the lid from closing, and an untied garbage bag was open with food waste dripping to the ground, attracting flies. The blue recycling dumpster was fully open, and one gray trash dumpster had a lid not fully closed. These issues were confirmed by the Maintenance Director.
Failure to Complete Required Discharge Planning and Ombudsman Notification
Penalty
Summary
The facility failed to complete the discharge planning process for one of three sampled residents by not providing required notifications and not developing a discharge care plan. Facility policy titled “Admission, Transfer and Discharge” (revised 4/2025) requires that residents not be transferred or discharged unless specific criteria are met and that written notice of transfer or discharge, including reasons and appeal rights, be provided to the resident and representative, with a copy sent to the State Long-Term Care Ombudsman at least 30 days in advance except in limited circumstances. The policy also requires that, when a transfer or discharge is necessary because the resident’s needs cannot be met, the physician document the basis for transfer and the specific needs and services involved. Resident 1, who had Parkinson’s disease and contractures of both ankles, was admitted to the facility on an unspecified date and later had a physician order dated 1/30/26 stating it was acceptable for the resident to go to a board and care if acceptable to the family and resident, and that the resident may go with PT evaluation and home health. A Notice of Proposed Transfer/Discharge for this resident, dated 2/2/26, documented that the notice was provided to the resident and the resident representative on that date, that the notice was mailed to the Long-Term Care Ombudsman on that date, and that the reason for discharge was that the resident’s health had improved sufficiently so that facility services were no longer required. The notice also indicated that notice was given as soon as practicable. However, review of Resident 1’s medical record did not show documented evidence that the Ombudsman was notified of the resident’s discharge as required by facility policy, and the DON confirmed during interview that the notice of transfer/discharge should have been provided to the Ombudsman 30 days in advance. Additionally, review of Resident 1’s care plans showed no care plan developed for a discharge plan, and the DON verified that a discharge plan care plan was not developed for this resident. These inactions constituted a failure to ensure the discharge planning process was thoroughly completed for Resident 1.
Resident Left Unattended Outside While Awaiting Transportation
Penalty
Summary
The facility failed to ensure an area was free from accident hazards and that adequate supervision was provided when a resident was left unattended outside while waiting for transportation to a medical appointment. The resident, who had decision-making capacity per a history and physical dated 10/18/25, was scheduled to be picked up by family for a doctor's appointment. On the day of the incident, after the resident’s lunch, CNA 4 accompanied the resident outside the facility to wait for the family. During this time, the resident repeatedly told CNA 4 to leave him. CNA 4 reported that she left the resident alone outside to give him space, remaining just inside the door rather than staying with him. The DON later confirmed that CNA 4 was expected to remain with the resident until the family arrived, indicating that the resident had been left unattended in violation of supervision expectations. This sequence of events, as identified through complaint intake, medical record review, and staff interviews, formed the basis of the deficiency for failure to provide necessary care and services to ensure adequate supervision and prevent accidents for one of four sampled residents.
Duplicate Parkinson’s Medication Orders Not Clarified on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for a resident receiving carbidopa-levodopa for Parkinson’s disease. The facility’s policy on Medication Administration requires that all current drugs and dosage schedules be accurately recorded on the MAR and that licensed or otherwise authorized staff prepare, administer, and record medications. For this resident, the Order Summary Report showed a physician’s order dated 1/14/26 for carbidopa-levodopa 25-100 mg, two tablets by mouth daily. However, review of the January 2026 MAR revealed two active physician orders for the same medication and dose, one dated 11/25/25 and another dated 1/14/26, both scheduled for administration at 0900. During an interview and concurrent record review, an LVN confirmed that she administered carbidopa-levodopa 25-100 mg, two tablets at 0900, and verified that there were duplicate orders with different dates on the MAR. She stated that she should have clarified these duplicate orders with the resident’s physician but had not done so. In a separate interview and concurrent record review, the DON also verified the presence of the duplicate orders and the inaccuracy in the medical record. The report states that this failure had the potential for the resident’s care needs not being met because the medical information was inaccurate.
Failure to Follow Physician's Repositioning Order for Dependent Resident
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained or maintained their highest practical physical well-being. Specifically, the facility did not follow a physician's order to reposition the resident every two hours on the left side and every two hours on the right side while in bed. The resident, who had diagnoses including Parkinson's disease, right ankle contracture, and mobility abnormalities, was dependent or required substantial assistance for bed mobility and transfers. Observations on multiple occasions showed the resident lying on his back with the head of the bed elevated, and interviews with CNAs revealed that repositioning was not performed as ordered. Instead, staff reported only pulling the resident up in bed or adjusting pillows under his arms, rather than turning his body as specified in the physician's order. The facility's policies required that all physician orders be specific and complete, and that staff provide interventions according to individualized care plans and professional standards. Despite these policies, staff interviews indicated that repositioning was done only when the resident requested it or according to his preference to remain on his back, rather than following the prescribed schedule. The DON acknowledged that the order should have been discontinued if it was not being followed, but at the time of the survey, the order remained in place and was not being implemented as written.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as evidenced by missing documentation on the Treatment Administration Record (TAR) for multiple physician-ordered treatments and interventions. Specifically, there were no entries from licensed nurses for several ordered tasks, including application of fluocinonide cream, transferring the resident to a wheelchair, floating the heels, oral hygiene after meals, use of a foot brace, monitoring an ingrown toenail, and use of a PRAFO device. When questioned, a licensed nurse confirmed that the documentation was missing and could not verify whether the tasks had been completed as ordered. Additionally, there was inaccurate documentation regarding the provision of oral hygiene. The resident reported not receiving oral care, and a CNA confirmed during an interview that oral care supplies had not been set up and that she had not provided oral care, despite having documented that it was done. The DON verified these findings, indicating that the resident's clinical record did not provide a concise and accurate account of the care and treatments provided, as required by facility policy.
Failure to Follow Infection Control Practices in Shower Room
Penalty
Summary
The facility failed to implement appropriate infection control practices as required by its Infection Prevention and Control Program. During an observation in a shower room, a used glove was found on the sink and on top of the toilet tank, and the Account Manager confirmed that the glove should have been properly disposed of. In a separate observation in the same shower room, a soiled towel with visible stains was found on the floor, and the Account Manager acknowledged that the towel should have been placed in the dirty linen barrel. The Director of Nursing (DON) was informed of these findings and stated that the cleaning process for shower rooms should ensure they are free of used gloves and washcloths.
Failure to Clean and Disinfect Shower Rooms
Penalty
Summary
The facility failed to ensure that three shower rooms were properly cleaned and disinfected, specifically neglecting to clean the shower heads. During an interview, a resident reported that the showers appeared to have fecal matter present. Observations confirmed the presence of dark brown residue on the lower half of the shower heads and brown stains on the walls and shower head holders in the shower stalls. The Account Manager acknowledged that the shower heads had a constant leak and required replacement, and both the Administrator and DON confirmed the discoloration and residue observed during the inspection. Medical record review indicated that the resident who reported the issue had been admitted to the facility prior to the observation, but no additional medical history or condition at the time of the deficiency was provided.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement infection control practices as outlined in their own policies and procedures for a resident requiring Enhanced Barrier Precautions (EBP) during wound care. During an observed wound care treatment, an LVN and a CNA did not don gowns as required, despite an EBP sign posted outside the resident's room and a physician's order specifying the use of gown and gloves for direct care. The LVN prepared wound care supplies and the CNA assisted in turning the resident, both wearing gloves but not gowns. The LVN proceeded with the wound care treatment without a gown, stating that a gown was not necessary if the wound was not draining. However, the facility's policy and the EBP sign indicated that gowns and gloves were required for high-contact care activities, including wound care, regardless of wound drainage status. The resident involved was non-verbal, lacked decision-making capacity, and had a chronic wound in the sacrococcyx area. Medical records confirmed the need for EBP, and staff interviews later acknowledged that proper PPE, including gowns, should have been used during the wound care procedure. The Infection Preventionist and Director of Nursing both confirmed that the observed practice did not align with facility policy and recognized the potential for infection transmission when proper PPE is not utilized.
Failure to Lock Bed Wheels for Dependent Residents
Penalty
Summary
The facility failed to maintain a safe environment for three nonsampled residents by not ensuring that bed wheels were locked while the residents were in bed. Observations confirmed that Residents A, B, and C were each found lying in beds with unlocked wheels. Staff members, including a CNA and an LVN, verified during interviews that the bed wheels were indeed unlocked at the time of observation. Medical record reviews for these residents indicated that all three had significant care needs, including dependence on staff for bed mobility, transfers, and activities of daily living, as well as documented risks for falls. Resident A had a diagnosis of unspecified dementia with psychotic disturbance and was care planned for self-care deficits and fall risk. Resident B had diagnoses including obesity, difficulty walking, hemiplegia, and hemiparesis, and used a trapeze bar for mobility; this resident also had a recent assisted fall and was care planned for fall risk and substantial assistance with mobility. Resident C had dementia, bowel incontinence related to immobility, and was dependent on staff for transfers and hygiene, with a care plan noting fall risk. Staff interviews confirmed that the facility's process for resident safety included locking bed wheels, but this was not followed for these residents.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
A deficiency was identified when a cognitively intact resident, as indicated by a BIMS score of 15, was not treated with dignity and respect by a CNA. The resident was observed sitting in his wheelchair at his doorway, repeatedly calling the CNA by name. The CNA initially ignored the resident and, when she did respond, replied with a curt 'what' rather than addressing the resident respectfully. The resident expressed dissatisfaction with the interaction, stating he had been waiting for 30 minutes and felt as though he was working for the CNA. Interviews with other staff, including another CNA, an RN, and the DON, confirmed that responding to residents with 'what' is not considered respectful or acceptable according to facility policy. The facility's policy on promoting and maintaining resident dignity requires staff to speak respectfully to residents. The incident was acknowledged by facility leadership after being brought to their attention.
Failure to Follow Resident Food Preferences
Penalty
Summary
The facility failed to follow a resident's documented food preferences as outlined in their policies and procedures. During a meal observation, it was noted that a cognitively intact resident did not receive whole milk with their lunch, despite it being listed on their meal ticket. A CNA confirmed that the whole milk was missing and stated that she also had to retrieve whole milk for the resident at breakfast. The Dietary Services Supervisor (DSS) verified that all items on the meal ticket, including whole milk, should have been served. The Administrator and Director of Nursing (DON) were made aware of these findings and acknowledged the issue. The deficiency was identified through observation, interviews, and review of facility documentation, which showed that the resident's nutritional preferences were not consistently honored as required by facility policy.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician of a change in a resident's condition, specifically regarding the refusal of bowel management medications over a three-day period. The resident, who had been refusing stool softeners and other bowel management medications from January 1 to January 3, did not have a bowel movement during this time. Despite the facility's policy requiring notification of a physician when there is a change in a resident's condition, there was no documented evidence that the physician was informed of the resident's medication refusal. On January 4, the resident finally had a bowel movement, but later complained of severe pain and requested to go to the hospital. The resident was subsequently transferred to the hospital, where a CT scan revealed diverticulitis with an abscess and an associated ileus or possible small bowel obstruction. The Director of Nursing acknowledged that the physician should have been notified of the resident's refusal to take bowel management medications.
Failure to Update Elopement Risk Assessments
Penalty
Summary
The facility failed to ensure the necessary care and services to prevent elopement for two residents. Resident 2, who was admitted with dementia and a low risk for elopement, exhibited increased wandering behaviors shortly after admission. Despite these changes, the facility did not update Resident 2's elopement risk assessment when a Wander Guard was placed on the resident's wrist. The Director of Nursing (DON) confirmed that a new elopement risk evaluation should have been completed following the change in Resident 2's behavior. Resident 4, also diagnosed with dementia, was not assessed for elopement risk quarterly as required by the facility's policy. Although Resident 4 had an elopement attempt and was seen outside the facility, the elopement risk assessments were not completed at the necessary intervals. The DON verified that the assessments were only completed upon admission and after an elopement attempt, missing several required quarterly assessments. This oversight failed to capture changes in Resident 4's elopement risk and the need for interventions.
Failure to Honor Resident's Medication Schedule Request
Penalty
Summary
The facility failed to respect a resident's right to self-determination by not administering medications according to the resident and family member's request. Resident 1, who was initially admitted to the facility, had their medication administration times altered without documented justification after returning from a hospital stay. The facility's policy on resident rights emphasizes supporting residents' choices, including medication schedules. However, upon Resident 1's return from the hospital, the administration times for cholecalciferol and cyanocobalamin were changed from 1300 hours to 0900 hours, contrary to the previously agreed schedule. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN 3) revealed that the medication schedule was initially adjusted to spread out administration times per the resident and family's request. However, upon readmission, the facility failed to resume the agreed-upon schedule. Family Member 1 attempted to discuss the medication schedule with the facility before Resident 1's readmission but was unable to do so. Consequently, the medications were administered at 0900 hours, including additional medications, without adhering to the previously established schedule, leading to a failure in honoring the resident's rights.
Failure to Provide Timely Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a potential risk of catheter-associated urinary tract infections. The resident, who had moderate cognitive impairment, had an indwelling urinary catheter inserted due to urinary retention. However, the facility did not provide the necessary daily catheter care until five days after the insertion. This lapse in care was confirmed through interviews with the resident, a family member, and a Licensed Vocational Nurse (LVN), who acknowledged that catheter care was not ordered or rendered until several days after the catheter was inserted. The facility's policy and procedure for urinary catheters required continual assessment and proper handling of catheters, including keeping the urine collection bag below the bladder level and ensuring the catheter tubing was unobstructed. Despite these guidelines, the resident's catheter site was not checked or cleaned, and a bruise was observed by a family member during a urologist appointment. The Director of Nursing (DON) confirmed that catheter care should have been ordered upon insertion and that nurses were expected to assess the catheter site for signs of infection. The failure to adhere to these standards posed a risk for the resident to develop catheter-associated urinary tract infections.
Failure to Withhold Medication Despite Loose Bowel Movements
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a resident was administered docusate sodium, a stool softener, despite having loose bowel movements or diarrhea, which was against the physician's order to hold the medication under such conditions. The resident had a history of fluctuating capacity to understand and make decisions, with a BIMS score indicating moderate cognitive impairment. The physician's order clearly stated to administer the medication twice daily unless the resident experienced loose bowel movements. The medication administration records showed that the resident received the medication on multiple occasions when they had loose stools, as documented in the bowel elimination records. An LVN confirmed administering the medication without being informed of the resident's bowel condition, and the DON verified the discrepancy between the medication administration and the resident's bowel movement records. This oversight in communication and adherence to physician orders led to the administration of unnecessary medication to the resident.
Failure to Accommodate Resident's Bathing Request
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident who requested a bath on a specific date. The resident, who had a moderate cognitive impairment with a BIMS score of 12, expressed frustration when his request for a bath was not fulfilled. The resident had returned from the hospital the day before and refused a scheduled shower, opting instead to request a bath the following day. However, the bath was not provided until the day after the request, as the CNA assigned to the resident was working a double shift and needed to take a break. Interviews with the resident, family member, and facility staff, including the DSD and LVN, confirmed that the bath was not documented as given on the requested date. The DSD and DON verified that the facility's records did not show a bath being provided on the requested date, and the LVN could not recall if the bath was given or who was responsible for it. This oversight led to the resident feeling frustrated, which could negatively impact their physical and emotional well-being.
Failure to Update Care Plan for Change in Condition
Penalty
Summary
The facility failed to develop a comprehensive care plan to address a change in condition for one of the sampled residents. On 11/11/24, the resident exhibited mild weakness and a flushed face, but the care plan did not reflect this change in condition. The resident's medical history included fluctuating capacity to understand and make decisions, with a BIMS score indicating moderate cognitive impairment. Despite these observations, the care plan was not updated to address the resident's new symptoms, as confirmed by interviews with LVN 2 and RN 1. The Director of Nursing was informed and acknowledged the findings.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to ensure the accurate administration of medications for a resident, specifically regarding the administration of psyllium, a soluble fiber used as a bulk-forming laxative. The physician's order required the administration of one capsule by mouth twice a day. However, due to a pharmacy error, the resident received an extra capsule on multiple occasions. This discrepancy was noted in the resident's progress notes, which indicated that the pharmacy delivered a wrong medication bubble pack containing two psyllium capsules. The resident, who had a fluctuating capacity to understand and make decisions and a BIMS score indicating moderate cognitive impairment, received an extra capsule of psyllium on four separate days. The Director of Nursing (DON) confirmed this error during an interview and medical record review. The failure to administer the medication as ordered by the physician had the potential to negatively affect the resident's well-being.
Inaccurate Documentation of Bladder Elimination for Residents with Catheters
Penalty
Summary
The facility failed to ensure the accuracy of medical records for three residents who had indwelling urinary catheters. The Certified Nursing Assistants (CNAs) inaccurately documented these residents as incontinent in the Task-Bladder Elimination records, despite the presence of the catheters. This discrepancy was identified through interviews, medical record reviews, and facility policy and procedure reviews. The inaccurate documentation had the potential to impact the residents' care needs due to the incorrect medical information. Resident 1, who had fluctuating capacity to understand and make decisions, was documented as incontinent on two occasions while having an indwelling urinary catheter. Resident 2, who had the capacity to understand and make decisions, was documented as incontinent on multiple occasions over a span of several weeks, despite having a catheter. Similarly, Resident 3, who also had an indwelling urinary catheter, was inaccurately documented as incontinent on numerous occasions. The Director of Nursing (DON) confirmed the inaccuracies in the documentation during an interview and concurrent medical record review.
Failure to Notify Physician and Apply Splints as Ordered
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. For Resident 1, the facility did not notify the physician when the resident had no bowel movements for more than three days, despite having a bowel management protocol in place. The resident was on a bowel management medication regimen, but the lack of bowel movement from 9/29/24 to 10/3/24 was not communicated to the physician, which was against the facility's policy. This oversight was confirmed by both the LVN and the DON during interviews. For Resident 2, the facility did not adhere to the physician's orders regarding the application of dynamic splints. The resident, who had diagnoses including Parkinson's Disease and contractures, was ordered to have dynamic splints applied three times a day. However, the splint tracking log and progress notes revealed multiple instances where the splints were not applied as ordered. Interviews with the PT and LVN confirmed that the splints were crucial for the resident's functional improvement, yet there was no documentation of refusals or education provided to the resident about the benefits of the splints. These failures in following physician orders and facility protocols had the potential to negatively impact the residents' well-being. The facility's policies on constipation management and the use of assistive devices were not followed, leading to a lack of necessary care for the residents involved.
Failure to Provide Correct Oral Hygiene Tools
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident 2's oral hygiene needs, as observed during a survey. Resident 2, who was admitted and readmitted to the facility on unspecified dates, was found using an incorrect dental tool for brushing their teeth. During an observation and interview, it was noted that Resident 2 used a short handle brush with bristles on both sides, typically used for cleaning dentures, instead of a regular toothbrush. This occurred because CNA 2 did not provide the regular toothbrush, which Resident 2 preferred and was supposed to use for brushing their teeth. Further interviews with LVN 4 and the DON confirmed that the short handle brush was intended for denture cleaning, while the regular toothbrush was meant for Resident 2's teeth. LVN 4 acknowledged Resident 2's preference for the regular toothbrush, and the DON verified the intended use of both brushes. This oversight in providing the correct toothbrush potentially impacted Resident 2's well-being, as the facility's policy requires accommodations to meet individual needs and preferences.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to sanitary requirements in the kitchen, as observed during a survey. Dietary and non-dietary staff were found not wearing hair restraints, which is a violation of the Food Code of 2022. This was confirmed during observations and interviews with staff members, including a Dining Assistant and the Dietary Services Supervisor (DSS). The DSS acknowledged that kitchen staff should wear hair restraints for any exposed hair, beard, and body hairs. Additionally, the facility did not ensure proper labeling and dating of food items in the kitchen. During an initial tour, several food containers were found without labels or dates, including an opened container of Montreal chicken seasoning and clear containers of red and brown powders. This was verified by a cook present during the observation. Furthermore, kitchen equipment and utensils were not maintained in a sanitary condition. The microwave had food debris and rust, and a corroded pan was found among other pots and pans. Plates ready for use were also observed with food debris. The facility also failed to maintain sanitary conditions for cutting boards and air-drying of utensils. Cutting boards were heavily marred and discolored, making them difficult to clean and sanitize. Plates and insulated domes were observed wet, indicating they were not air-dried properly. Lastly, a scoop was improperly stored inside a bin containing oatmeal, contrary to the facility's policy on food storage. These deficiencies had the potential to cause foodborne illnesses among the residents consuming food prepared in the kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several deficiencies observed during the survey. The facility did not have documentation of a Legionella risk assessment, control measures, or testing protocols, which are essential to prevent the growth and spread of Legionella and other opportunistic pathogens in the water system. The Maintenance Supervisor confirmed the absence of these critical documents and acknowledged the lack of records for using chlorine tablets in decorative water fountains. Additionally, CNAs 11 and 12 did not adhere to Enhanced Barrier Precautions (EBP) when providing care to Resident 34, who had a Foley catheter and was under EBP. They failed to wear gowns and perform hand hygiene before donning gloves, which are necessary steps to prevent the transmission of multidrug-resistant organisms. The Director of Nursing (DON) confirmed that repositioning a resident is considered high-contact care, requiring full PPE, including gowns. The facility also failed to ensure that employee personal items were not stored in the clean laundry area, as observed with personal items placed on a table where linens were being folded. Furthermore, visitors in Resident 109's room did not follow contact isolation precautions, as they were not wearing PPE despite the resident being on contact isolation for ESBL in urine. Lastly, CNA 14 did not change gowns between assisting two residents, which is a breach of standard precautions to prevent cross-contamination.
Failure to Obtain and Document Advance Directives
Penalty
Summary
The facility failed to ensure that copies of advance directives were obtained or that information on how to formulate an advance directive was provided for eight of the 24 sampled residents. This deficiency was identified through interviews, medical record reviews, and facility policy and procedure reviews. The facility's policy requires informing and providing information to all new residents upon admission regarding their rights to accept or refuse medical treatment and to formulate an advance directive. However, the facility did not adhere to this policy for several residents. For Resident 34, there was no documented evidence that the resident was offered information on how to formulate an advance directive, despite having the capacity to understand and make decisions. Similarly, Resident 81's medical record showed no attempt to obtain a copy of the resident's advance directive, even though the resident had one. Resident 566, who had cognitive and psychiatric impairments, also lacked documentation of an attempt to obtain an advance directive. Other residents, such as Resident 59, had incomplete advance directives that were not verified for completeness before being uploaded into the electronic health record. Resident 75 was not provided with written information regarding advance directives, and Resident 89's POA was for financial authority rather than healthcare, with no attempt made to obtain an advance directive for healthcare. Additionally, Residents 109 and 414 had no documented evidence of attempts to obtain their advance directives, despite having the capacity to understand and make decisions.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which resulted in deficiencies in addressing their individual care needs. Resident 20, who had severe cognitive impairment, experienced a fall on 9/15/24, but no care plan was developed to address this incident. During an observation and interview, it was confirmed by LVN 1 and RN 1 that there was no care plan in place for the fall, despite the presence of bilateral floor mats in the resident's room. Similarly, Resident 42, who lacked the capacity to make decisions, was prescribed sertraline for depression, but the facility did not create a care plan to manage the use of this antidepressant medication. This was verified by LVN 3 and acknowledged by the DON. Additionally, Resident 81, who had intact cognition, was prescribed Keflex for an infected wound, yet no care plan was developed to address the use of this antibiotic. LVN 13 confirmed the absence of a care plan, and both the Administrator and DON acknowledged these findings.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as evidenced by the lack of proper labeling, dating, and storage of respiratory equipment. For Resident 814, the oxygen nasal cannula tubing, humidifier, and Yankauer were not dated or labeled, and were not stored in a set-up bag when not in use. Additionally, there was no care plan developed for the resident's oxygen use and monitoring, nor was there a physician's order for oral suction at the bedside. This oversight was confirmed by LVN 3 and RN 1, who acknowledged the absence of necessary documentation and care plans. Similarly, Resident 76's oxygen tubing, humidifier, and storage bags for the nebulizer and suction devices were not dated or labeled, and there was no set-up bag for the oxygen tubing. LVN 17 verified these findings and stated that the respiratory devices and storage bags should be dated, labeled, and changed weekly. Resident 564 also had a storage bag for the nebulizer that was not dated or labeled, as confirmed by LVN 2, who emphasized the importance of changing respiratory supplies weekly for infection control. Other residents, including Residents 10, 42, 87, 75, 89, 414, 417, and 418, were found to have similar deficiencies in the management of their respiratory equipment. The nasal cannulas, humidifiers, and set-up bags were either undated, unlabeled, or not changed weekly as required. These findings were verified by various staff members, including LVNs and the Central Supply Clerk, who confirmed the facility's policy for changing and labeling respiratory equipment. The DON acknowledged these deficiencies, highlighting a systemic issue in the facility's respiratory care practices.
Failure to Adjust Medication Administration for Dialysis Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident requiring hemodialysis, specifically in the administration of medications. Resident 108, who was admitted to the facility and had physician's orders for hemodialysis on specific days, did not have their medications adjusted or rescheduled on dialysis days. The medications, including colchicine and magnesium, were not administered or rescheduled on multiple occasions when the resident was absent from the facility for dialysis. The facility's policy and procedure for medication administration required medications to be administered within 60 minutes of the scheduled time unless specified otherwise by the prescriber. However, there was no physician's order to hold or reschedule the medications on dialysis days, and the facility did not document any notification to the physician about the resident's absence during medication times. The Director of Nursing confirmed the lack of documentation and the failure to adjust medication times for the resident on dialysis days.
Failure to Provide Required Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of a resident, as observed during a medication administration session. A Licensed Vocational Nurse (LVN) was unable to administer a Calcium Vitamin D tablet to a resident because it was not available and had not been replaced. The facility's policy and procedure for medication administration, revised in November 2021, requires that if a medication with a current, active order cannot be located, the pharmacy should be contacted. However, this procedure was not followed, leading to a failure in medication administration. Further investigation revealed that the resident also did not receive an Acidophilus Probiotic oral tablet, which was ordered by the resident's physician. The LVN acknowledged that both the Calcium Vitamin D and Acidophilus Probiotic tablets were unavailable during the medication administration. The LVN admitted that he should have informed the physician about the unavailability of the medications. The facility's Administrator and Director of Nursing (DON) were informed of these findings and acknowledged the deficiency.
Failure to Act on Pharmacy Recommendations and Identify Duplicate Therapy
Penalty
Summary
The facility failed to ensure that the pharmacy consultant's recommendations were acted upon for a resident reviewed for unnecessary medications. Specifically, the consultant pharmacist recommended a gradual dose reduction of venlafaxine, an antidepressant, for a resident who had been on the same dose since September 2023. However, the physician did not respond to this recommendation, and the resident's dosage was not adjusted. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the physician did not act on the pharmacist's suggestion. Additionally, the facility did not ensure that the consultant pharmacist identified a duplicate therapy issue involving acetaminophen. The resident had two separate orders for acetaminophen, one as a generic and the other as the brand name Tylenol, both for mild pain. This duplication was not addressed, and the orders were not clarified with the resident's physician. The Licensed Vocational Nurse (LVN) confirmed the duplication and stated that it should have been clarified. The Administrator and DON were informed of these findings and acknowledged the issues.
Failure to Monitor Resident's Medication Regimen
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, leading to several deficiencies. The resident was prescribed duplicate therapy for acetaminophen, with two separate orders for Tylenol and acetaminophen, both intended for mild pain relief. This duplication was acknowledged by an LVN during an interview, who stated that the orders should have been clarified with the resident's physician. Additionally, the resident was not monitored for side effects of Keflex, an antibiotic prescribed for an infected wound, nor for the side effects of hydrocodone-acetaminophen, a controlled pain medication. The LVN confirmed the lack of monitoring for potential side effects such as headache, dizziness, nausea, vomiting, constipation, and drowsiness. The medical record review and interviews revealed that the facility's policies and procedures were not followed, as there was no adequate monitoring for the side effects of the medications administered to the resident. The resident, who had intact cognition, was receiving Keflex for a skin tear and hydrocodone-acetaminophen for moderate to severe pain. Despite the absence of observed side effects or allergic reactions, the lack of monitoring for these medications was a significant oversight. The facility's Administrator and DON were informed of these findings and acknowledged the deficiencies.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 566, the facility did not monitor side effects and behaviors related to the use of sertraline, an antidepressant, and quetiapine, an antipsychotic. Despite the resident's cognitive and psychiatric impairments, there was no documented evidence of monitoring for these medications. During an interview, RN 3 confirmed the lack of monitoring and emphasized the importance of tracking side effects to adjust medication dosages appropriately. For Resident 75, the facility did not document the physician's rationale for extending the use of doxepin, an antidepressant, beyond the 14-day period. Additionally, there was no evidence of monitoring for behavior manifestations and side effects related to doxepin from the evening shift on 9/4/24 to 9/27/24. LVN 13 was unable to provide documentation of monitoring, and the DON confirmed that the licensed staff failed to continue monitoring after the physician extended the order. These deficiencies were acknowledged by the facility's Administrator and DON, who verified the findings during interviews. The lack of monitoring and documentation for psychotropic medications had the potential to negatively impact the residents' well-being, as stated in the facility's policy and procedure for the use of psychotropic drugs.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a cumulative error rate of 18.52% during a medication pass observation. This was observed across three licensed nurses who administered medications to three nonsampled residents. The errors included incorrect mixing of a laxative, failure to instruct a resident to rinse their mouth after using an inhaler, administering the wrong type of B complex supplement, failing to administer a prescribed vitamin due to expiration, and administering the wrong potassium supplement. One of the errors involved LVN 8, who added 90 ml of water to a laxative powder for a resident, contrary to the instructions on the medication container, which specified mixing with four or eight ounces of beverage. Another error by LVN 9 involved not instructing a resident to rinse their mouth after using an inhaler, as required by the physician's order. Additionally, LVN 9 administered a B complex supplement that did not contain biotin, as was ordered by the physician. Further errors were observed with LVN 3, who did not administer vitamin B6 to a resident because the medication had expired. LVN 3 also administered potassium chloride instead of the prescribed potassium citrate. These actions were contrary to the facility's policies and procedures, which emphasize the importance of administering medications as prescribed and ensuring familiarity with the medications being administered.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, which was observed through various deficiencies. Resident 51's Artificial Tears ophthalmic solution was left unattended on the bedside table by LVN 8, who acknowledged the oversight. This lapse in procedure could lead to unauthorized access to medications. Additionally, Medication Room A had multiple instances of out-of-range room temperatures above 77 degrees Fahrenheit, which were not reported to the Maintenance Director as required. RN 3 and the DON confirmed these findings, indicating a failure to maintain proper environmental controls for medication storage. Medication Room B lacked a temperature log, which RN 3 and the DON acknowledged. This absence of documentation suggests a failure to monitor and ensure appropriate storage conditions for medications. Furthermore, Medication Cart F contained topical prescription medications that were not labeled with a specific resident's name, as verified by LVN 11. This lack of labeling could lead to medication errors and unauthorized use. Medication Cart C had oral medications stored with externally used medications, and Resident 1's Refresh lubricant eye solution lacked an open date label. LVN 3 confirmed these findings, indicating a failure to adhere to proper medication storage protocols. Additionally, Medication Cart B contained an expired bottle of Humulin R and had oral medications stored with suppositories, as verified by LVN 9. These deficiencies highlight the facility's failure to ensure the safe and effective administration of medications, as outlined in their policies and procedures.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to adhere to the prescribed pureed recipes for 12 residents who were on a pureed diet, potentially compromising their nutritional needs. The deficiency was identified through observations, interviews, and document reviews, revealing that the pureed recipes for chicken ala king, steamed broccoli, and brown rice were not followed as specified. The facility's policy and procedure for pureed foods outlined specific instructions for preparing these meals, including the use of food thickeners and specific liquids to achieve the desired consistency. However, during the preparation, deviations from these instructions were observed, such as the addition of milk and butter to the pureed chicken ala king and steamed broccoli, and the use of rice hot cereal instead of brown rice for the pureed brown rice. Interviews with the dietary staff and the Dietary Services Supervisor (DSS) confirmed these discrepancies. The DSS verified that the recipes did not include the use of milk or butter for the chicken ala king and broccoli, nor the substitution of rice hot cereal for brown rice. Additionally, the preparation of the pureed brown rice involved the use of hot water instead of the specified 2% milk. These deviations from the established recipes indicate a failure to provide meals that meet the nutritional requirements of residents on a pureed diet, as outlined in the facility's policies.
Failure to Follow Policy on Outside Food Storage
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the use and storage of food brought to residents by family and visitors. The policy, which was reviewed on 8/10/23, allows residents to have food brought in by family or visitors, provided it is handled safely. This includes labeling food not in original containers with a use-by date, refrigerating labeled items, and consuming food within four days. However, interviews with staff, including RNs, LVNs, the DON, and the DSS, revealed that the facility did not have a refrigerator designated for storing food from outside sources. Consequently, visitors were instructed to consume the food immediately, and any unconsumed food was not allowed to be stored at the facility. The staff interviews indicated a lack of awareness and implementation of the facility's policy on safe food handling of outside food. Staff members, including RN 3, LVN 13, and LVN 14, confirmed that visitors were encouraged not to bring excess food and were informed that the facility could not store unconsumed food. The DON and DSS also verified that visitors were not allowed to leave any unconsumed food due to the absence of a refrigerator for such items. This failure to follow the established policy and procedures had the potential to cause foodborne illnesses among the medically vulnerable resident population.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident receiving hospice services attained and maintained their highest practicable well-being. Specifically, the facility did not communicate with the hospice agency regarding missing hospice aide visitations for a resident, which could potentially delay hospice care. The facility's policies and procedures, as well as their contract with the hospice provider, outlined the responsibilities for coordinating care and maintaining communication with hospice representatives, but these were not followed. The medical record review revealed that the resident was admitted to hospice services with orders for hospice aide visits twice per week. However, documentation showed that several scheduled hospice aide visits were missed over multiple weeks, and there was no evidence that the facility coordinated with the hospice agency to address these missing visits. Interviews with facility staff, including a registered nurse, the social services department, the director of nursing, and the infection preventionist, confirmed the lack of communication and coordination regarding the missed hospice aide visits. The designated hospice coordinator, who was responsible for coordinating care with the hospice agency, did not have a clinical background and had not met the resident. The facility conducted weekly interdisciplinary team meetings, but the missing hospice aide visits were not discussed. The infection preventionist, who was also a designated hospice coordinator, acknowledged that they would need to contact the hospice agency if visits were missing but admitted that no follow-up had been conducted regarding the missed visits for the resident.
Failure to Monitor Antibiotic Use According to McGeer's Criteria
Penalty
Summary
The facility failed to monitor and address the use of antibiotics for two residents, as their conditions did not meet the McGeer's criteria for infection. Resident 40 was prescribed Keflex despite having no urinary symptoms and not meeting the criteria for infection. The medical records lacked documentation of physician notification regarding the inappropriate use of antibiotics. Similarly, Resident 64 was prescribed cefpodoxime without meeting the infection criteria, and there was no evidence of physician notification in the medical records. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed these findings. The IP acknowledged that the facility's antibiotic stewardship program required physician notification if a resident did not meet the infection criteria, but was unable to provide documentation of such notifications for Residents 40 and 64. The DON was informed of these findings and acknowledged the deficiency.
Failure to Ensure Informed Consent for Influenza Vaccination
Penalty
Summary
The facility failed to ensure that a resident received the influenza vaccine and did not adequately document the refusal process. Specifically, the facility did not provide the resident's representative with the necessary information about the risks and benefits of the influenza vaccination when the vaccine was refused. The facility's policy requires that individuals or their legal representatives sign a consent or declination form, which should be filed in the individual's medical record. However, for the resident in question, the documentation was incomplete, lacking the signature of the resident's representative, the time of contact, and confirmation that the risks and benefits were discussed. The medical record review revealed that the resident's representative was contacted multiple times regarding the flu vaccine, but there was no evidence that the representative was informed about the risks and benefits of the vaccination. The facility's Infection Preventionist (IP) confirmed these findings and acknowledged the lack of follow-up with the resident's representative. Additionally, the Director of Nursing (DON) was informed and acknowledged the deficiency, which highlights a failure in the facility's process to ensure informed decision-making regarding vaccinations.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the dish machine and digital thermometers. During an observation and interview, it was found that the dish machine was not functioning properly as the chlorine test strip only read 10 ppm, which is below the required level for proper sanitization. Dining Assistant 3 admitted to not documenting the chlorine test results due to a missing log and did not report the inadequate chlorine level. The facility's documentation showed that the temperature and chlorine levels were not recorded for certain periods, confirming the dish machine was not working as intended. Additionally, the facility did not ensure that digital thermometers used in the kitchen were calibrated. Interviews with staff revealed a misunderstanding regarding the necessity of calibrating digital thermometers, as they believed calibration was unnecessary for digital devices. However, the facility's policy and the manufacturer's manual both indicated that regular calibration is required to ensure accurate temperature readings. The DSS acknowledged the need for calibration of the digital thermometers. These deficiencies in maintaining kitchen equipment could potentially lead to foodborne illnesses among the residents, as 116 out of 121 residents received food prepared in the facility's kitchen. The lack of proper documentation and failure to adhere to established procedures for equipment maintenance and calibration were significant factors contributing to these deficiencies.
Failure to Ensure Accessibility of Call Lights and Controls
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents, as observed during a survey. One resident, who was cognitively intact and capable of making decisions, reported waiting for 30 minutes for assistance to use the toilet, resulting in her wetting her diaper. This incident occurred despite the resident's preference to use the toilet, highlighting a delay in staff response to call lights, which is against the facility's policy. Multiple residents were found with their call lights out of reach, preventing them from requesting assistance when needed. For instance, one resident was observed with the call light on the floor, another with it clipped to a curtain, and another with it inside a bedside drawer. These observations were confirmed by staff members, who acknowledged that the call lights should be within reach and accessible to residents at all times. Additional deficiencies included a resident unable to reach the bed control to adjust the bed position, another unable to reach the headlight cord, and a resident unable to reach the TV remote control. These inactions by the facility staff potentially impacted the residents' ability to perform daily activities and maintain their psychosocial well-being. The Director of Nursing acknowledged these findings, confirming the facility's failure to ensure that necessary controls and devices were within reach of the residents.
Failure to Follow Resident's Dietary Preferences
Penalty
Summary
The facility failed to adhere to a resident's food preferences, specifically for Resident 418, who was served cooked carrots despite having a documented dislike for them. During a dining observation, Resident 418, who is cognitively intact, expressed dissatisfaction with being served carrots, which he had previously indicated he did not like. The facility's diet spreadsheet for the specified menu cycle included baby carrots for lunch, and this was confirmed by both the LVN and the DSS during interviews. A review of Resident 418's meal ticket and medical records showed a physician's order specifying a regular renal focus diet with no cooked carrots, among other restrictions. Despite these documented preferences and orders, the resident was still served the disliked food item, indicating a lapse in following dietary instructions.
Inaccurate Medical Record Documentation for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one resident, identified as Resident 564. Upon review of the resident's medical records, it was found that there was a discrepancy in the documentation regarding the resident's decision-making capacity. The History and Physical (H&P) examination dated 9/12/24 indicated conflicting information about the resident's ability to understand and make decisions, stating both that the resident did and did not have the capacity. Additionally, a surrogate decision-maker was listed. Despite this, the Consent For Treatment form, also dated 9/12/24, was signed by the resident, indicating consent to be admitted and treated at the facility. There was no documented evidence that the physician had been consulted to clarify the resident's decision-making capacity. During an interview and concurrent medical record review with the Director of Nursing (DON) on 9/27/24, the DON confirmed the findings and acknowledged that the physician should have been consulted to clarify the resident's decision-making capabilities. The DON stated that the physician would need to reevaluate the resident to address this issue.
Improper Trash Disposal and Pest Risk
Penalty
Summary
The facility failed to ensure that trash was disposed of in a sanitary manner, as observed during a survey. Three out of four dumpsters were not properly covered, which had the potential to harbor pests. Specifically, the green food waste dumpster was overflowing with trash, preventing the lid from closing, and an untied black garbage bag was open with food waste dripping to the ground, attracting flies. The blue recycling dumpster was fully open, and one gray trash dumpster had a lid that was not fully closed. These observations were verified by the Maintenance Director. The facility's policy and procedure for garbage and trash disposal, dated 2023, required that all food waste be placed in sealed, leak-proof, non-absorbent containers and disposed of as necessary to prevent nuisance or unsightliness. It also required that garbage and trash cans be inspected daily to ensure no debris was on the ground or surrounding area and that lids were closed. Additionally, the trash collection area was to be kept clean to prevent it from becoming a feeding ground for vermin and rodents.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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