Alhambra Hospital Med Ctr Dp/snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Alhambra, California.
- Location
- 100 S Raymond Ave, Alhambra, California 91801
- CMS Provider Number
- 555850
- Inspections on file
- 19
- Latest survey
- July 3, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Alhambra Hospital Med Ctr Dp/snf during CMS and state inspections, most recent first.
Two residents with g-tube feedings were observed to have their feeding tube tips left uncapped and uncovered when not in use, despite manufacturer guidelines requiring the connector cap to be replaced. Both residents had complex medical conditions and were dependent on staff for care. Facility staff, including the DON and an LVN, confirmed that the g-tube tips should be capped to prevent contamination, but this practice was not included in the facility's policy and procedure.
Staff failed to follow infection prevention and control practices, including not sanitizing pulse oximeters between residents, not wearing required PPE during G-tube care, and not changing gloves or sanitizing surfaces during tracheostomy care. These actions involved residents with complex medical needs, such as ventilator dependence and indwelling devices, and were confirmed by staff interviews and policy reviews.
A resident with severe cognitive impairment and multiple medical conditions was found to have a room sink with stripped Formica and exposed rough wood, creating an unsanitary environment. Facility staff, including the DON, Maintenance Assistant, and an LVN, confirmed the condition and acknowledged it did not meet the facility's standards for a safe and comfortable environment.
A resident with a stage 4 pressure ulcer was found to have their low air loss mattress set at an incorrect firmness level for their weight, contrary to care plan instructions and manufacturer guidelines. Nursing staff and the DON confirmed the mattress was not set properly, which could impact wound healing.
A resident with a midline catheter did not have swab caps covering the two lumen injection ports as required by facility policy and care plan. Staff confirmed that the ports should have been capped to prevent infection, and observations showed the ports were left uncovered despite established protocols.
A resident with a G-tube did not receive the full prescribed doses of glycopyrrolate and Vitamin C when an LVN failed to properly mix and dissolve the medications in water before administration, leaving visible residue in the medication cups. The DON confirmed this was not in accordance with facility policy, resulting in incomplete medication delivery.
A nurse failed to fully administer glycopyrrolate and Vitamin C to a resident with a G-tube by not properly dissolving the medications, resulting in visible residue left in the cups and an overall medication error rate above 5%. Both the nurse and DON confirmed the medications were not fully given as required by facility policy.
Surveyors identified deficiencies in food handling and equipment sanitation, including unsealed food containers, a soiled soy sauce container, and a chipped, rusted can opener. These issues were confirmed by the RD and KS, who acknowledged that the practices did not meet facility policies for food storage and cleanliness.
The facility failed to use dignity bags for the catheter drainage bags of two residents, compromising their dignity and privacy. One resident, who was comatose, had an exposed catheter bag in their private room. Another resident, with impaired cognitive skills, had an exposed catheter bag visible to visitors and from the hallway. The DON acknowledged that dignity bags should be used to respect residents' privacy, indicating a lapse in policy adherence.
The facility failed to document advance directives for several residents, including those with chronic conditions and dependencies, potentially violating their rights to have their healthcare preferences respected. Interviews and record reviews confirmed the absence of advance directive forms in both paper and electronic records, despite facility policy requirements.
The facility failed to properly implement gastrostomy tube feeding practices for two residents. One resident's feeding solution was not labeled correctly, risking delayed feedings and incorrect amounts. Another resident's water bag flush was not labeled, risking improper replacement timing. Observations and interviews revealed non-compliance with facility policies requiring proper labeling to ensure adherence to physician orders.
The facility failed to provide necessary respiratory care services for three residents, leading to potential infection risks. A resident's nasal cannula tubing was not changed weekly, and two residents had suction tubing touching the floor, which could lead to respiratory infections. The DON acknowledged the lack of a policy for changing nasal cannula tubing weekly, and the facility's policy indicated that all tubing should not touch the floor.
The facility failed to follow proper food handling practices, including labeling food items with open and use-by dates, discarding expired items, and maintaining proper drainage. Observations revealed unlabeled food items, improper storage of salsa, and a drainpipe not meeting the required gap. Trash was also found in the kitchen floor drain, contrary to facility policies.
The facility failed to educate, offer, and document COVID-19 vaccinations for three residents, including those with severe health conditions. Despite the availability of updated vaccines, there was no record of consent, refusal, or administration for these residents, nor evidence that their responsible parties were informed. This oversight violated the facility's policy and placed residents at risk.
A resident with significant medical conditions, including anoxic encephalopathy and chronic respiratory failure, was found to have the call light placed on the side of the body they could not move. The resident's MDS indicated dependency on assistance and impairment in both upper and lower extremities. RN 1 and the DON confirmed the call light should be on the resident's strong side to ensure it was within reach, as per facility policy.
Two residents' confidentiality was breached when LVNs left computer monitors displaying medication lists visible to passersby. One LVN left a monitor on for over an hour, while another did so twice for shorter periods. Both acknowledged the importance of securing monitors to protect resident privacy, as required by facility policy and HIPAA rules.
A facility failed to update a resident's care plan to include a low air loss mattress (LAL) for pressure ulcer prevention, despite a physician's order. The resident, with multiple health issues and severe cognitive impairment, was dependent on assistance for daily activities. The Director of Nursing confirmed the oversight, noting that care plans are reviewed every shift and should be updated immediately with any changes.
A resident in an LTC facility did not receive the correct dosage of Mylicon due to an error by an LVN, who administered only 0.6 ml instead of the prescribed 2 ml. Additionally, the LVN left the medication unattended on a cart in the hallway, violating the facility's policy requiring medications to be securely stored. The Pharmacy Director and DON confirmed the importance of adhering to these policies to ensure safety.
A resident with a seizure disorder did not have their Keppra level checked as recommended by a pharmacist and approved by a physician. The facility failed to enter the order into the electronic health record, and the charge nurse did not follow up, leading to a deficiency in medication monitoring.
A resident's inhaler was improperly stored at the bedside instead of in a locked compartment, contrary to facility policy. The resident was in a persistent vegetative state and dependent on staff for care. Additionally, medication carts were found unclean, with expired and unnecessary items, violating the facility's policies on medication storage and infection control.
The facility failed to offer and document influenza vaccinations for two residents, both in a persistent vegetative state and with significant medical conditions, during and after the influenza season. Despite the facility's policy to offer vaccinations annually and throughout the season, the residents were not provided with the opportunity to receive the vaccine, nor was there documentation of consent or declination. The Director of Nursing and Infection Control Director acknowledged the oversight, highlighting a lapse in following the facility's infection control policy.
Failure to Cap G-Tube Feeding Tips When Not in Use
Penalty
Summary
The facility failed to ensure that the purple cone tip of the gastrostomy tube (g-tube) feeding apparatus was capped when not connected to the resident for two sampled residents. For both residents, observations revealed that the g-tube feeding tips were left uncapped and uncovered in their rooms. Record reviews indicated that both residents had orders for continuous tube feeding and care plans specifying the prevention of tube feeding-related infections. The manufacturer's guidelines for the feeding equipment directed that the connector cap should be replaced when not in use. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the g-tube tips should be capped to prevent contamination, as outlined in the manufacturer's instructions, although this requirement was not included in the facility's policy and procedure. Both residents involved had significant medical conditions, including respiratory failure, ventilator dependence, dementia, hypertension, and dysphagia, and were dependent on staff for personal care and nutrition via g-tube. The failure to cap the g-tube tips was observed directly and acknowledged by facility staff as inconsistent with manufacturer guidelines.
Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
Facility staff failed to follow standard infection prevention and control practices for four sampled residents, as observed through direct care activities and confirmed by staff interviews and record reviews. For two residents requiring pulse oximetry monitoring, the respiratory therapist did not sanitize the pulse oximeter and sensor before and after each use, despite handling the device between residents and storing it in a shirt pocket. Both the infection prevention director and the director of nursing confirmed that the facility's policy required sanitizing the device before and after use, and that failure to do so could transmit infectious organisms between residents. In another instance, a registered nurse did not don a gown while administering medications and checking the gastrostomy tube of a resident with an indwelling device, despite the facility's policy requiring enhanced standard precautions, including gown use, for such procedures. The nurse acknowledged the omission and stated that PPE is necessary to prevent contamination and infection from bodily fluids. The infection prevention director and director of nursing both confirmed that a gown should have been worn to prevent cross-contamination. Additionally, during tracheostomy care for another resident, a registered nurse failed to change gloves and perform hand hygiene between tasks, placed used dressings and an inner cannula on the resident's bedside table alongside clean supplies, and did not sanitize the table after disposing of the used items. The nurse admitted to not following the facility's policy for glove changes and proper disposal of used supplies. The infection prevention director and director of nursing confirmed that these actions were inconsistent with facility policies and could result in contamination of the environment and equipment.
Unsanitary Sink Condition in Resident Room Due to Damaged Surface
Penalty
Summary
A deficiency was identified when a resident's room was found to have a sink with the Formica surface stripped off, leaving exposed rough wood. Observations confirmed the unsanitary condition, and interviews with facility staff, including the Director of Nursing (DON), Maintenance Assistant, and a Licensed Vocational Nurse (LVN), acknowledged the presence of chipped and water-damaged wood. The exposed wood was noted to be a potential site for mold growth and was considered unacceptable by staff due to the risk of infection and possible harm to both residents and staff. The resident involved had a history of acute chronic hypoxic respiratory failure, hypertension, and seizures, and was assessed as severely impaired in cognitive skills and dependent on staff for daily living activities. The facility's own policy and procedure for management of the environment of care emphasized the importance of maintaining a safe, comfortable, and appropriately furnished environment, which staff admitted was not met in this instance.
Failure to Set Low Air Loss Mattress Correctly for Pressure Ulcer Management
Penalty
Summary
The facility failed to follow its policy and procedure on pressure ulcer prevention and wound management for one resident by not ensuring that the low air loss (LAL) mattress was set according to the resident's weight. The resident, who had a stage 4 sacral/coccyx pressure ulcer and was dependent on care for activities of daily living, was observed with the LAL mattress set at a firmness level appropriate for a much heavier individual (setting 4 for 175 lbs), while the resident's actual weight was 123 lbs, which required a lower setting (2 to 3). This discrepancy was confirmed through interviews with nursing staff, who acknowledged that the mattress was not set correctly and that this could impact the effectiveness of the pressure injury management. Record reviews showed that the resident's care plan and facility policy specifically required the use of the LAL mattress per manufacturer guidelines, including setting the firmness based on the resident's weight. Staff interviews and documentation confirmed that these guidelines were not followed, and the care plan intervention to educate staff on proper mattress settings was not implemented. The Director of Nursing also acknowledged that the failure to follow the care plan and manufacturer’s instructions could negatively affect the resident’s wound healing.
Failure to Cover Midline Catheter Injection Ports with Swab Caps
Penalty
Summary
A deficiency was identified when a resident with a midline catheter featuring two lumen injection ports did not have a swab cap covering the ports when not in use, as required by facility policy. The resident, who had diagnoses including anemia, seizure disorder, and quadriplegia, was severely cognitively impaired and dependent on staff for all activities of daily living. The resident's care plan and active orders specified that injection ports should be covered with swab caps and changed daily or as needed after use, in accordance with infection prevention protocols. During observations, it was noted that the midline catheter's injection ports were left uncapped. Interviews with nursing staff and the DON confirmed that the ports should have been covered with swab caps to prevent infection, and that this was the facility's established practice. The facility's policy also indicated that injection caps should be changed whenever removed. The failure to follow these protocols was directly observed and acknowledged by staff.
Incomplete Administration of G-Tube Medications Due to Improper Mixing
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to ensure the complete administration of two prescribed medications, glycopyrrolate and ascorbic acid (Vitamin C), to a resident with a G-tube. The LVN prepared the medications by adding water to the medication cups but did not stir or ensure the medications were fully dissolved before administration. After administering the medications via the resident's G-tube, a white pasty residue was observed remaining in the cups, indicating that not all of the medication had been delivered to the resident. The resident involved had a history of respiratory failure, a tracheostomy, and was dependent on a G-tube for feeding due to swallowing difficulties. The resident was assessed as having severely impaired cognitive skills and required maximal assistance with daily activities. Physician orders were in place for the administration of glycopyrrolate and Vitamin C via the feeding tube, with specific dosages and frequencies. During interviews, the LVN acknowledged that the medications were not completely dissolved and that the resident did not receive the full prescribed doses. The Director of Nursing (DON) confirmed that facility policy required medications to be mixed and fully dissolved before administration, and that no residue should remain in the medication cups. The failure to follow these procedures resulted in the resident not receiving the entire dose of the prescribed medications.
Medication Error Rate Exceeds Acceptable Threshold Due to Incomplete Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 7.41 percent during a medication pass observation. Specifically, two medication errors were identified out of 27 opportunities, involving the incomplete administration of glycopyrrolate and ascorbic acid (Vitamin C) to a resident. The errors occurred when the nurse did not ensure the medications were fully dissolved and administered, leaving a white pasty residue in the medication cups after administration via the resident's G-tube. The resident involved had significant medical needs, including respiratory failure, a tracheostomy, and a G-tube for feeding, and was assessed as having severely impaired cognitive skills and high dependence on staff for daily activities. Physician orders required the administration of glycopyrrolate and Vitamin C via the feeding tube, but the nurse failed to properly mix and dissolve the medications before administration, resulting in the resident not receiving the full prescribed doses. Both the nurse and the Director of Nursing confirmed during interviews that the medications were not fully administered as required, and that facility policy mandates medications be properly mixed and fully delivered with no visible residue left in the cups. The failure to follow these procedures led to the resident not receiving the complete doses of their prescribed medications.
Improper Food Handling and Equipment Sanitation
Penalty
Summary
Surveyors observed multiple failures in food handling practices within the facility's kitchen. Specifically, a box of Kosher salt was found unsealed, a container of soy sauce had drippings on it, and a container of Japanese curry powder was not properly sealed. Additionally, the can opener in use was chipped and rusted. These observations were confirmed during interviews with the Registered Dietitian (RD), who acknowledged that food containers should be properly sealed and free of drippings to prevent contamination, and that the can opener's condition was unacceptable due to the risk of contamination. Further review of the facility's policies and procedures with the Kitchen Supervisor (KS) revealed that the facility's guidelines require food items to be stored appropriately, covered, and labeled, and that all work areas and equipment must be kept clean and in good repair. The KS confirmed that the observed practices did not align with these policies, as food items were not properly sealed or stored, and equipment was not maintained in a sanitary condition.
Failure to Use Dignity Bags for Catheter Drainage
Penalty
Summary
The facility failed to provide dignity bags for the urinary catheter drainage bags of two residents, compromising their dignity and privacy. Resident 14, who was comatose and dependent on assistance for daily activities, was observed with an exposed Foley catheter drainage bag in their private room. The Director of Nursing (DON) acknowledged that dignity bags should be used even in private rooms if the catheter bag is visible to visitors, indicating a lapse in adhering to the facility's policy on patient dignity and privacy. Similarly, Resident 126, who had severely impaired cognitive skills and was dependent on assistance, was observed with an exposed Foley catheter bag while having visitors in their private room. The catheter bag was also visible from the hallway. A registered nurse stated that the dignity bag was not used to allow easy monitoring of the urine, but the DON later confirmed that the catheter bag should not be visible to visitors, highlighting a failure to respect the resident's privacy and dignity as per the facility's policy.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to reflect discussions and documentation of advance directives for six out of eight sampled residents. This deficiency was identified through interviews and record reviews, revealing that the facility did not provide or document the provision of advance directive information to residents or their representatives. This oversight potentially violated the residents' rights to be fully informed about their options to formulate advance directives, which are crucial for ensuring that their healthcare preferences are respected. Resident 3, who was admitted with chronic respiratory failure, a chronic vegetative state, and anoxic encephalopathy, had no advance directive documented in their medical records from March 2023 to June 2024. Similarly, Resident 16, who was comatose and dependent on a ventilator, also lacked documentation of advance directive information in their records. Resident 21, with moderate cognitive impairment and ventilator dependence, had no advance directive on file, and there was no evidence that such information was provided to the resident or their representative. The deficiency extended to Residents 22, 23, and 19, all of whom had significant medical conditions and dependencies, yet lacked documented advance directives in their medical records. Interviews with the Director of Nursing (DON) confirmed the absence of advance directive forms in both paper and electronic records for these residents. The facility's policy required that advance directives be offered and documented, but this was not adhered to, leading to the potential bypassing of residents' healthcare preferences.
Deficiencies in Gastrostomy Tube Feeding Practices
Penalty
Summary
The facility failed to implement proper gastrostomy tube (GT) feeding practices for two residents, leading to deficiencies in their care. For Resident 21, the facility did not properly label the opened gastrostomy feeding solution bottle at the bedside. This oversight had the potential to result in delayed feedings and incorrect total feeding amounts received by the resident. Resident 21 was admitted with multiple diagnoses, including chronic respiratory failure, ventilator dependency, and quadriplegia, and was dependent on a feeding tube for nutrition. Observations revealed that the feeding solution was set up prior to the allowed time, and the label on the Jevity formula was dated and timed incorrectly, which could lead to confusion about when the feeding should be administered. For Resident 19, the facility failed to ensure that the GT water bag flush was labeled completely, including the total number of hours as per the physician's order. This deficiency posed a risk of the water flush bag not being replaced on time, potentially leading to complications. Resident 19, who was also dependent on a ventilator and had a history of anoxic encephalopathy and ischemic stroke, required careful management of their feeding and hydration needs. During an observation, it was noted that the water bag was not labeled, and the only information present was the rate of 50 cc per hour written directly on the bag. Interviews with nursing staff and the Director of Nursing (DON) highlighted the importance of proper labeling to ensure adherence to physician orders and prevent errors. The facility's policies and procedures required that feeding solutions and water bags be labeled with the date and time to ensure they were changed and administered correctly. However, these practices were not followed, leading to the deficiencies observed during the survey.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for three residents, leading to potential risks of respiratory infections. Resident 21's nasal cannula tubing was not changed weekly as required, and there was no date label on the tubing to indicate when it was last changed. The Director of Nursing (DON) acknowledged that the facility lacked a policy for changing nasal cannula tubing weekly, which could prevent infections. The Respiratory Therapist stated that nasal cannula tubing should be changed every three days or as needed, but this was not consistently documented or followed. For Resident 19, the suction tubing connected to the ventilator was observed touching the floor, which was identified as a potential source of respiratory infection due to contamination from the dirty floor. Licensed Vocational Nurse 2 (LVN 2) confirmed that the suction tubing should not be in contact with the floor and needed to be changed immediately to prevent infection. Similarly, Resident 1's suction tubing was also found lying on the floor, posing a similar infection risk. The DON reiterated that medical equipment should not touch the floor due to infection control concerns. The facility's policy on respiratory services indicated that all tubing should not be in contact with the floor, highlighting a failure to adhere to established infection control procedures.
Deficiencies in Food Handling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. Several food items in the kitchen, including vinegar, turmeric, cinnamon sticks, black pepper, and cooking wine, were found without labels indicating the open date and use-by date. The Registered Dietician (RD) confirmed that these items should have been labeled and that the cinnamon sticks were expired and should have been discarded. Additionally, a container of salsa was improperly stored with labeling supplies, and the RD stated it needed to be discarded due to improper storage. The facility's policy requires all food items to be labeled with the open date and expiration date, which was not followed in these instances. Further observations revealed issues with the facility's drainage system and food storage. The Engineer Supervisor (ES) noted that the drainpipe did not meet the required one-inch gap from the drain, which is a guideline specified in the facility's safety policies. In the walk-in freezer, several food items, including waffles, chicken patties, green beans, and bacon bits, were found without labels indicating the item name, open date, and use-by date. The Lead confirmed that these items should have been labeled and discarded if the expiration date was not known. Additionally, trash and debris were found in the kitchen floor drain, which the RD stated should have been clear to allow proper drainage.
Failure to Educate, Offer, and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to provide education, offer, and document COVID-19 vaccinations for three of five sampled residents, placing them at risk for possible infection. Resident 15, who was admitted to the facility with chronic respiratory failure and other serious conditions, had not received an updated COVID-19 vaccination since 2021. There was no documentation of consent, refusal, or administration of the updated vaccine, nor any indication that the resident's responsible party was informed or offered the vaccine. Similarly, Resident 22, who was dependent on a ventilator and had other significant health issues, had not received an updated COVID-19 vaccination since 2021. The records lacked any documentation of consent, refusal, or administration of the updated vaccine, and there was no evidence that the resident's responsible party was educated or offered the vaccine. The Director of Nursing confirmed these omissions during an interview. Resident 23, who was also in a persistent vegetative state and had multiple health conditions, had no record of receiving any COVID-19 vaccination. The facility's policy required that all residents be offered the vaccine and that any declinations be documented, but this was not followed. The Infection Control Director acknowledged that the updated vaccine was available and should have been offered to eligible residents, but this was not done for the sampled residents.
Call Light Accessibility Deficiency for a Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the residents, identified as Resident 19, as per the facility's policy and procedure. Resident 19 was admitted with significant medical conditions, including anoxic encephalopathy, chronic respiratory failure, and was ventilator-dependent. The resident's Minimum Data Set (MDS) indicated intact cognitive skills but showed dependency on assistance for various activities and impairment in both upper and lower extremities. During an observation, it was noted that the call light was placed next to the resident's left arm, which he could not move, as confirmed by the resident and Registered Nurse 1 (RN 1). RN 1 acknowledged that Resident 19 could only use his right hand and stated that the call light should be placed near the resident's right hand to ensure it was within reach. The Director of Nursing (DON) also confirmed that the call light should be on the resident's strong side to allow them to call for assistance. The facility's policy on the Patient Call Light System emphasized the importance of having the call light within reach to address patient needs promptly. This oversight had the potential to prevent Resident 19 from calling for assistance, thus not meeting the resident's needs and preferences.
Confidentiality Breach of Residents' Medical Records
Penalty
Summary
The facility failed to protect the confidentiality of personal and medical records for two residents, violating their rights to privacy. For Resident 1, the deficiency occurred when a Licensed Vocational Nurse (LVN 2) left a computer monitor on in the hallway outside the resident's room, displaying the resident's medication list. This occurred from 4:47 PM to 5:51 PM, during which time the LVN entered the resident's room without securing the monitor. The LVN acknowledged forgetting to turn off the monitor, which is necessary to comply with HIPAA privacy and security rules. Similarly, for Resident 14, another LVN (LVN 1) left a computer monitor on by the resident's door, displaying the medication list visible to passersby. This happened twice, once from 5:25 PM to 5:29 PM and again for four minutes while the LVN checked the resident's gastrostomy tube and administered medication. The LVN admitted to not turning off the monitor, recognizing the importance of doing so for resident privacy. The facility's policy requires maintaining the confidentiality and security of Protected Health Information (PHI) in any form, which was not adhered to in these instances.
Failure to Revise Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to revise the comprehensive care plan for the prevention of pressure ulcers for one of the residents, identified as Resident 126. The resident was admitted to the facility with several active diagnoses, including cerebral vascular accident, chronic respiratory failure, and hypertension, and was noted to have severely impaired cognitive skills. The Minimum Data Set (MDS) indicated that Resident 126 was dependent on assistance for various activities of daily living. Despite these needs, the care plan dated 6/17/2024 did not include interventions for the use of a low air loss mattress (LAL), which was ordered by the physician on 6/25/2024 for pressure injury management. During an interview with the Director of Nursing (DON), it was confirmed that the LAL should have been included in the care plan as part of the pressure injury intervention. The DON acknowledged that the care plan is reviewed every shift and should be revised immediately if there are any changes, a responsibility typically handled by the charge nurses. The facility's policy on pressure injury prevention and management, revised in 6/2019, mandates that appropriate care should be planned and documented in the patient's care plan, which was not adhered to in this case.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, identified as Resident 21, by not ensuring the correct dosage of Mylicon was administered according to the physician's order. During a medication pass observation, a Licensed Vocational Nurse (LVN 3) was observed preparing and administering only 0.6 ml (40 mg) of Mylicon instead of the prescribed 2 ml (80 mg) via the resident's gastrostomy tube. This error was acknowledged by LVN 3, who admitted that the resident would not receive the intended relief from abdominal gas with the incorrect dosage. Additionally, the facility did not ensure the safe storage of medications during administration. LVN 3 left the Mylicon medication unattended on top of the medication cart in the hallway while administering other medications to Resident 21 in their room. This practice was against the facility's policy, which requires medications to be stored and locked to prevent unauthorized access and potential safety risks. The Pharmacy Director and Director of Nursing confirmed that medications should not be left unattended and must be stored securely to prevent loss, theft, or misuse. The facility's policies on medication administration and storage were not adhered to, leading to potential safety concerns for residents and visitors in the unit.
Failure to Follow Pharmacist's Recommendation for Medication Monitoring
Penalty
Summary
The facility failed to act upon a pharmacist's recommendation, which was approved by the physician, during the Medication Regimen Review (MRR) for a resident. The pharmacist recommended checking the Keppra level for a resident who was on Keppra medication for a seizure disorder. The physician agreed to this recommendation, but the necessary blood test was not performed, which could lead to adverse consequences due to potential incorrect dosage of the medication. The resident in question was admitted with chronic respiratory failure, status post tracheostomy, and a seizure disorder. The resident was comatose and in a persistent vegetative state, dependent on staff for all activities of daily living. The resident's last Keppra level was checked in January 2024, and the pharmacist recommended another check in May 2024, which was not carried out. The facility's policy required licensed personnel to recap all current orders at the monthly team conference and resolve any discrepancies, but this was not done. Interviews with the pharmacist, pharmacy director, and director of nursing revealed that the order for the Keppra level check was not entered into the electronic health record, and the charge nurse did not follow up on the physician's order. The director of nursing acknowledged that the Keppra level should have been ordered immediately after the MRR meeting, but this did not occur, resulting in the deficiency.
Medication Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to store a resident's respiratory inhaler in accordance with its policy, which required medications to be stored in locked compartments. The inhaler was observed in a clear bag hanging on the wall at the head of the resident's bed. The resident, who was in a persistent vegetative state and dependent on staff for all activities, had an order for Albuterol inhaler to be administered every six hours. Despite this, the inhaler was not stored in the medication room as per the standard practice, and there was no order to keep it at the bedside. The Pharmacy Director confirmed that inhalers should be stored in the medication room, especially since the residents were not alert to administer the inhalers themselves. Additionally, the facility's medication carts were found to be unclean and contained expired and unnecessary items. Observations revealed dust, adhesives, and discoloration on the carts, as well as expired medical supplies and non-medical items like pens and rubber bands in the drawers. The Director of Nursing and a pharmacist acknowledged the need for regular cleaning of the medication carts and the removal of expired items to prevent contamination and infection. The facility's policies required medications to be stored in lockable cabinets and for all expired items to be removed from inventory. However, these policies were not followed, leading to the potential for unauthorized access to medications and the risk of infection due to unclean equipment. The staff admitted to not cleaning the medication carts regularly due to being busy, which contributed to the deficiencies observed.
Failure to Offer and Document Influenza Vaccination
Penalty
Summary
The facility failed to provide education, offer, and document influenza immunization for two residents, placing them at higher risk of complications from the influenza disease. Resident 22, who was admitted to the facility in May 2024, had a history of respiratory failure with ventilator dependence, Type 2 Diabetes Mellitus, seizure disorder, and cerebrovascular accident. The resident was comatose and in a persistent vegetative state, fully dependent on assistance for daily activities. Despite these conditions, there was no record of influenza vaccination being offered or administered to Resident 22 since their last vaccination in September 2021. The Director of Nursing (DON) confirmed that the influenza vaccination was not offered to Resident 22 due to their admission being after the typical influenza season, and there was no documentation of consent or declination. Similarly, Resident 23, who was readmitted during the influenza season in March 2024, also did not have any record of being offered or receiving the influenza vaccination. Resident 23 had diagnoses of respiratory failure with ventilator support, cerebrovascular accident, and atrial fibrillation, and was also comatose and in a persistent vegetative state. The DON acknowledged that there was no documentation of the influenza vaccination being offered or declined for Resident 23, despite the resident being readmitted during the influenza season. Interviews with the Infection Control Director (ICD) and the DON revealed that the facility's policy was to offer the influenza vaccination annually and throughout the influenza season. However, the policy was not followed for Residents 22 and 23. The ICD emphasized the importance of offering the influenza vaccination to all residents, regardless of the season, to protect them from complications. The facility's policy indicated that newly admitted residents should be assessed for prior receipt of the influenza vaccine and offered the vaccination if not previously administered, but this was not documented for the two residents in question.
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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