Alta View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 831 S Lake Street, Los Angeles, California 90057
- CMS Provider Number
- 056078
- Inspections on file
- 86
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Alta View Post Acute during CMS and state inspections, most recent first.
A resident with HTN, HLD, epilepsy, and impaired mobility, who had capacity to make medical decisions, was discharged to a board and care with orders for a follow-up MD appointment, home health PT/OT, RN safety visits, and DME (wheelchair). The record lacked a documented post-discharge plan, and the DON confirmed there was no documentation verifying that home health services were arranged or that the follow-up appointment was communicated to the board and care, contrary to the facility’s transfer/discharge policy requiring nursing to prepare a post-discharge plan for each resident.
A resident with complex medical needs was not promptly readmitted after hospitalization, despite available beds, due to the facility's lack of a bariatric mattress and delayed communication between staff and the hospital. Facility policy required readmission upon bed availability, but the resident's return was delayed as staff cited equipment shortages and were not fully aware of the resident's readiness for discharge.
Surveyors found undated peanut butter and jellied sandwiches and expired deli turkey slices stored in the kitchen refrigerator. The Dietary Manager confirmed the lack of required labeling and failure to discard expired food, and the Registered Dietitian stated that proper labeling is necessary to prevent serving expired food to residents.
Kitchen freezers used to store food items were repeatedly observed with internal temperatures above the required 0 degrees F, with readings of 10 to 12 degrees F noted during multiple checks. The Dietary Manager and Registered Dietitian confirmed that these temperatures did not meet facility policy and could result in food spoilage if not corrected.
The facility did not inform residents about Medicaid/Medicare coverage or their potential financial liability for non-covered services, failing to provide the required notifications.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was administered PRN Lorazepam for anxiety episodes without staff first attempting nonpharmacological interventions, as required by facility policy. This practice continued for over a month, and staff interviews confirmed that nonpharmacological approaches should have been used prior to medication administration.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with a history of malnutrition, dysphagia, and diabetes experienced significant unplanned weight loss after readmission. The facility did not follow the RD's recommendations for dietary changes, failed to notify the physician, and did not convene the IDT to address the weight loss. The Dietary Manager also did not obtain an updated weight, resulting in missed recognition of the resident's decline and lack of timely intervention.
The facility did not establish or maintain an infection prevention and control program, resulting in a deficiency related to infection control practices.
Three residents were not offered COVID-19 vaccine education or the opportunity to consent for vaccination upon admission, despite facility policy requiring this process. One resident with severe cognitive impairment and two residents with chronic medical conditions were not screened or provided information about the vaccine, and this was confirmed by both the IP and DON during interviews.
A resident with severe cognitive impairment and physical limitations was found unable to access their call light, which was left hanging out of reach after care. The resident, dependent on staff for most activities, was observed searching for the call light to request assistance. Facility staff confirmed that call lights are required to be within reach, and acknowledged lapses in this practice.
A resident with multiple comorbidities, including malnutrition and dysphagia, experienced a significant weight loss over 14 days. Despite facility policy requiring physician notification and interdisciplinary review for such changes, staff did not inform the MD or reassess the resident, as confirmed by record review and staff interviews.
A resident who was fully dependent on staff for activities of daily living and had a gastrostomy tube was found to have a thick, dried, brown-colored pasty substance on the right side bed rail in their room. A CNA acknowledged the unclean condition during an observation and interview, and the DON emphasized the importance of cleanliness for resident health. The facility's infection prevention policy requires staff training on maintaining a clean environment.
A resident was not assessed completely and in a timely manner upon admission and at the required 12-month interval, resulting in noncompliance with mandated assessment protocols.
A resident with multiple medical conditions, including malnutrition and dysphagia, experienced a significant weight loss that was documented in both the nutrition assessment and care plan. However, the MDS assessment was inaccurately coded to show no weight loss due to a misinterpretation by the MDS coordinator, despite facility policy requiring accurate certification of assessments.
A resident with malnutrition, dysphagia, and recent significant weight loss did not have a comprehensive care plan developed to address their nutritional needs. Despite facility policy requiring immediate multidisciplinary intervention for notable weight changes, the necessary care planning and notifications were not completed.
The facility did not provide pharmaceutical services to meet the needs of each resident and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident admitted with multiple medical conditions and prescribed several antibiotics did not have their antibiotic use properly documented or reviewed by the Infection Preventionist, as required by the facility's Antibiotic Stewardship Program. Staff interviews and record reviews confirmed that the necessary Infection Surveillance Outcome form was not completed for the resident's antibiotic therapy.
A resident with COPD, skin cancer, and recent scalp surgery, who was cognitively intact, consented to receive the PVC 20 vaccine but did not receive it within the facility's required timeframe. Review of records showed the vaccine was not ordered or administered for 25 days after consent, despite facility policy requiring administration within 72 hours.
A Restorative Nursing Assistant did not receive the required 12 hours of in-service training, including only 1 hour of dementia care and 9 hours of abuse prevention education, as confirmed by staff interviews and record review. The employee file lacked documentation of mandatory training, and the facility's policy requiring initial orientation and annual in-service education was not followed.
A facility failed to develop a care plan for a resident's Central Venous Catheter (CVC), despite the resident's complex medical needs, including COPD, diabetes, dementia, and pressure ulcers. The resident was dependent on staff for daily activities and had severely impaired cognition. The absence of a care plan for the CVC was confirmed by the DON, highlighting a failure to adhere to the facility's policy requiring care plans to incorporate goals and objectives for resident independence.
A facility failed to document care for a resident with a Central Venous Catheter (CVC), missing entries for monitoring and maintenance tasks in December. The resident had multiple health issues, including COPD and dementia, and required comprehensive care. The Director of Nursing acknowledged the documentation gaps, suggesting a possible issue with the order entry system. Facility policies stress the importance of care plans, but the lack of documentation left the completion of care unverified.
A resident experienced a significant weight loss, dropping from 126 to 118 pounds within a month. The facility failed to notify the resident's physician and NOK in a timely manner, as required by their policy. Despite the care plan's directive, the physician was informed four days after the weight loss was noted, and there was no evidence of NOK notification. Staff interviews revealed communication discrepancies, with incorrect information entered regarding family notification.
A resident with dementia and chronic kidney disease had a physician's order for a urine sample collection due to complaints of pain upon urination. The facility failed to collect the sample and did not document the failure or notify the physician, resulting in an inaccurate medical record.
The facility failed to maintain safe food storage and preparation practices, including inadequate dishware sanitization, unclean ice machines, and improper monitoring of thaw dates for juice and deli meats. These deficiencies could lead to cross-contamination and foodborne illness among residents.
A facility failed to accurately code the MDS for a resident regarding the Restorative Nursing Program. The resident, with conditions like neuralgia and a right-hand contracture, had a care plan involving a cock-up splint and passive range of motion exercises. Despite receiving these services, the MDS did not reflect them, as confirmed by staff interviews and record reviews.
A resident with multiple health issues, including aspiration pneumonia, did not receive chest physiotherapy on two occasions as ordered by a physician. The facility's failure to document the treatment on these dates suggests it was not performed, which could compromise the resident's respiratory status. The facility's policies require thorough documentation of all treatments, which was not adhered to in this case.
A facility failed to accurately account for a dose of lorazepam for a resident. An LVN administered the medication but did not document it in the Controlled Drug Record, leading to a discrepancy between the record and the medication card. This oversight increased the risk of medication diversion and incorrect dosage administration.
A resident experienced a delay in receiving dental services for dentures, despite having a physician order and a request noted in their nutritional assessment. The resident, with intact cognition and able to communicate needs, only saw a dental hygienist who could not address denture-related questions. The Social Services Director was unaware of the resident's request, and the Director of Nursing was unsure of the reason for the delay, which increased the resident's risk for weight loss.
Failure to Develop and Document Post-Discharge Plan for Resident Transferred to Board and Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its policy and procedure titled "Transfer or Discharge, Preparing a Resident for" for one of three sampled residents. The resident was admitted with diagnoses including HTN, HLD, epilepsy, and difficulty in walking, and the History and Physical documented that the resident had the capacity to understand and make their own medical decisions. The Order Summary Report showed a discharge-related order entered for a follow-up appointment with a doctor and a later order authorizing discharge to a board and care with home health services for PT, OT, RN safety visits, and DME in the form of a wheelchair. During an interview with concurrent record review, the DON confirmed that there was no post-discharge plan documented in the resident’s record, despite the facility’s policy requiring that a post-discharge plan be developed for each resident prior to transfer or discharge and assigning nursing services responsibility for preparing that plan. The DON acknowledged that, based on the documentation, there was no way to know if home health services were arranged or if the follow-up doctor’s appointment was communicated to the board and care. This lack of documented post-discharge planning and coordination constituted the cited failure to ensure the transfer/discharge met the resident’s needs and preferences and that the resident was prepared for a safe transfer/discharge.
Failure to Timely Readmit Resident Following Hospitalization
Penalty
Summary
The facility failed to allow a resident to return following a hospitalization, despite available beds, resulting in a delay of the resident's readmission. The resident, who had significant medical needs including hemiplegia, morbid obesity, type 2 diabetes, and functional quadriplegia, was transferred to a general acute care hospital and was ready for discharge back to the facility. Hospital discharge planners attempted to coordinate the resident's return, but facility staff repeatedly communicated that there were no available beds or mattresses, even though census records indicated open female beds during the relevant period. Interviews with facility staff revealed inconsistencies in communication and awareness regarding the resident's readiness for readmission. The admissions director stated that the first contact from the hospital was received several days after the hospital began attempting to arrange the resident's return, and cited a lack of a mattress as the reason for the delay, despite available beds. The director of social services and assistant director of nursing both indicated that the resident had a history of frequent hospitalizations and readmissions without prior issues, and acknowledged that the resident had the right to return to the facility after hospitalization. Facility policy required that Medicaid residents whose hospitalization exceeded the bed hold period be readmitted upon the first availability of a bed, provided certain criteria were met. Despite this policy, the resident's return was delayed due to the facility's failure to provide a necessary bariatric mattress and lack of timely communication between facility departments and with the hospital. This resulted in the resident not being readmitted as soon as a bed was available, contrary to facility policy and regulatory requirements.
Expired and Undated Food Items Found in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure expired and undated food items were not stored in the kitchen, affecting 76 of 84 residents who received food from the kitchen. During a kitchen tour with the Dietary Manager, undated prepared peanut butter and jellied sandwiches and expired deli turkey slices labeled with a past use-by date were found stored in one of the refrigerators. The Dietary Manager acknowledged that the sandwiches should have been labeled with preparation and use-by dates and that the expired turkey should have been discarded. The Registered Dietitian confirmed that food must be labeled to prevent serving expired items to residents. Review of the facility's policy indicated that all refrigerated or frozen foods must be labeled with a use-by date and either used or discarded by that date.
Failure to Maintain Freezer Temperatures at Required Levels
Penalty
Summary
The facility failed to maintain kitchen freezer #1 and freezer #2 at the required temperature of 0 degrees Fahrenheit or below while storing various food items, including hashbrowns, whipped topping, french fries, assorted vegetables, and sweet potato fries. Observations on multiple occasions showed that freezer #1, located outside the storeroom, had internal thermometer readings of 12 degrees F and 10 degrees F, while freezer #2, located inside the storeroom, also showed temperatures above the required range at times. The Dietary Manager (DM) explained that staff had been moving items to accommodate new food deliveries and had been opening the freezers for breakfast preparation, which contributed to the elevated temperatures. Interviews with the DM and the Registered Dietitian (RD) confirmed that the freezers should be maintained at 0 degrees F or below, as per facility policy revised in November 2024. Both acknowledged that failure to maintain proper freezer temperatures could result in food spoilage, which, if served, could negatively impact residents' health. The facility's monitoring logs indicated that temperatures are checked in the morning and afternoon to prevent food from entering the danger zone, but the observed temperatures did not meet the required standards during the survey.
Failure to Notify Residents of Coverage and Financial Liability
Penalty
Summary
The facility failed to provide residents with notice regarding Medicaid and Medicare coverage, as well as information about potential financial liability for services that are not covered. This deficiency occurred due to the facility's inaction in informing residents about their rights and responsibilities related to payment for care and services, as required by federal regulations. There is no mention of specific residents or medical conditions in the report, and the deficiency is based solely on the lack of required notification.
Failure to Provide Nonpharmacological Interventions Before PRN Psychotropic Medication Administration
Penalty
Summary
Facility staff failed to provide nonpharmacological interventions prior to administering Lorazepam PRN for anxiety to a resident with multiple psychiatric diagnoses, including anxiety, depression, psychosis, delusional disorders, and auditory hallucinations. The resident, who had severely impaired cognition and was dependent on staff for most activities of daily living, was prescribed Lorazepam via gastrostomy tube as needed for episodes of crying. Review of the Medication Administration Record and Order Summary Report showed that for 37 days, staff did not attempt or document nonpharmacological interventions before giving the medication. Interviews with the RN Supervisor and the Director of Nursing confirmed that nonpharmacological interventions should have been provided prior to administering psychotropic medications, as outlined in the facility's policy and procedure. The policy indicated that such approaches are to be used to minimize medication use, permit the lowest possible dose, and allow for discontinuation when possible. The failure to implement these interventions was not explained by staff, and the omission was acknowledged by facility leadership.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming.
Failure to Implement Timely Nutritional Interventions for Resident with Significant Weight Loss
Penalty
Summary
A resident with a history of protein-calorie malnutrition, dysphagia, pneumonitis due to inhalation, and diabetes mellitus experienced significant unplanned weight loss after readmission to the facility. The facility failed to follow the Registered Dietitian's (RD) interventions, including obtaining a dental evaluation, implementing a revised nutritional plan of care, and notifying the attending physician about the resident's significant weight loss. The RD's recommendations for a change in diet, double protein with meals, and daily multivitamins were not communicated or implemented. Additionally, the Dietary Manager did not obtain the resident's most current weight upon readmission, instead copying the previous admission weight, which led to missing the significant weight loss of 7.2 pounds in 14 days. The interdisciplinary team (IDT) did not convene to address, monitor, or intervene regarding the resident's undesirable weight loss as required by the facility's policy on unplanned weight loss. The resident was not accurately reassessed by the Dietary Manager, and the plan of care was not revised despite the documented weight loss. These actions and inactions resulted in the resident not receiving timely and appropriate nutritional interventions, as outlined in the facility's clinical protocol.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a structured program designed to minimize the risk of infection transmission among residents and staff. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Offer and Document COVID-19 Vaccination for New Admissions
Penalty
Summary
The facility failed to offer COVID-19 vaccines to three residents upon admission, as required by their policy and procedure. For each resident, record reviews and interviews revealed that they were not provided with education about the COVID-19 vaccine, nor were they screened or consented for vaccination at the time of admission. Specifically, one resident with severe cognitive impairment had not been screened or consented for the vaccine, despite having received a previous dose in 2022. Another resident, who was cognitively intact and able to make her own decisions, had no record of ever receiving the COVID-19 vaccine and was not offered information or the vaccine upon admission. The third resident, who was alert and oriented, had received a previous dose in 2023 but was also not screened or offered the vaccine or education upon admission. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the responsibility for screening, consenting, and administering the COVID-19 vaccine to residents upon admission lies with the IP. Both the IP and DON acknowledged that the three residents should have been screened and consented for the COVID-19 vaccine at the time of their admission, in accordance with the facility's policy. The facility's policy states that all residents are to be offered the COVID-19 vaccine unless medically contraindicated or already fully vaccinated, and that education regarding the vaccine's benefits, risks, and side effects must be provided.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Staff failed to ensure that a resident's call light was within reach, as required by the resident's care plan and the facility's policy. The resident, who had a history of cerebral infarction resulting in severely impaired cognition and right-sided weakness, was dependent on staff for most activities of daily living, including toileting, hygiene, and mobility. During an observation, the resident was seen searching for the call light, which was found hanging against the wall and out of reach. The resident stated that they use the call light to call for help from staff. Interviews with facility staff, including the Assistant Director of Staff Development and the Director of Nursing, confirmed that the call light should always be accessible to residents, especially those with significant physical and cognitive impairments. The staff acknowledged that sometimes call lights are not placed within reach after care is provided. Review of the facility's policy also indicated that staff are required to ensure call lights are accessible from the bed, toilet, shower, and floor. This failure to provide reasonable accommodation for the resident's needs constituted a deficiency.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify and consult with a resident's physician regarding a significant change in the resident's physical status, specifically a weight loss of 7.2 pounds over 14 days. The resident, who had diagnoses including unspecified protein-calorie malnutrition, dysphagia, pneumonitis due to inhalation, and diabetes mellitus, was moderately cognitively impaired and required substantial to maximal assistance with activities of daily living. The weight loss was documented in the resident's records, but there was no evidence that the physician was informed of this significant change. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the weight loss met the facility's criteria for a significant change, which should have triggered physician notification and an interdisciplinary review. The facility's policy required staff intervention and care plan revision for such changes, but documentation and staff statements indicated that the physician was not made aware, and the resident was not reassessed in response to the weight loss.
Unclean Bed Rail Found in Resident's Room
Penalty
Summary
A deficiency was identified when a resident's environment was found to be unclean during a survey. Specifically, a thick, dried, brown-colored pasty substance was observed on the top and inner side surfaces of the right side bed rail in the resident's bedroom. This observation was made during a concurrent interview and inspection with a CNA, who acknowledged the bed rail was dirty and indicated an intention to clean it. The resident involved was dependent on staff for all activities of daily living and had a gastrostomy tube, as well as a history of delayed childhood milestones. The facility's policy on infection prevention and control, dated April 2025, states that all personnel are trained on infection prevention and control procedures upon hire and periodically thereafter. The DON confirmed the importance of maintaining a clean environment for residents' health and well-being. The failure to maintain cleanliness in the resident's immediate environment constituted a breach of the facility's obligation to provide a safe, clean, and comfortable living space.
Failure to Complete Timely Resident Assessment
Penalty
Summary
A deficiency was identified when the facility failed to assess a resident completely and in a timely manner upon admission and at required intervals, specifically at least every 12 months. The report notes that the necessary comprehensive assessment was not conducted as mandated, which constitutes noncompliance with assessment requirements.
Inaccurate MDS Coding for Resident Weight Loss
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was accurately coded to reflect a significant weight loss. The resident, who had diagnoses including unspecified protein-calorie malnutrition, dysphagia, and pneumonitis due to inhalation, experienced a weight loss of 7.2 pounds, equating to a 5.9 percent decrease over 14 days. This weight loss was documented in the resident's nutrition assessment and care plan. However, the MDS assessment incorrectly indicated that there was no weight loss in the last one to six months. The MDS coordinator, responsible for completing the assessment, misinterpreted the calculation method after consulting with the facility's MDS consultant, leading to the inaccurate entry. The Director of Nursing confirmed that the MDS was coded incorrectly. The facility's policy requires that any healthcare professional completing the MDS must certify the accuracy of the assessment, but this was not adhered to in this instance, resulting in incorrect data being transmitted to CMS.
Failure to Develop Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who experienced significant weight loss shortly after admission. The resident, who had diagnoses including unspecified-calorie malnutrition, dysphagia, and pneumonitis due to inhalation of food and vomit, lost 7.2 pounds (5.9 percent of body weight) within 14 days. The Minimum Data Set indicated the resident had moderately impaired cognition, and the nutrition assessment by the Registered Dietitian confirmed the recent weight loss. Despite these findings, there was no evidence that a care plan addressing the resident's nutritional needs and weight loss was developed. Facility policy required that any weight change of 5 percent or more since the last assessment should prompt immediate written notification to the dietitian and physician, and involve a multidisciplinary team including nursing staff, the dietitian, the consultant pharmacist, and the resident or their legal surrogate. However, the records and interviews indicated that this process was not followed for the resident in question, resulting in a lack of timely and coordinated care planning to address the resident's nutritional status.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper labeling and storage protocols for medications and biologicals within the facility. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Complete Antibiotic Surveillance Documentation
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship for one of three sampled residents by not completing an Infection Surveillance Outcome form for a resident who was prescribed multiple antibiotics. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, skin cancer, and recent scalp surgery, and was cognitively intact and able to make decisions. Upon review, it was found that the resident was receiving Vancomycin and Meropenem for a brain abscess, as well as Erythromycin ointment and Bacitracin Zinc ointment for other conditions. However, the Infection Preventionist did not review or document the use of Vancomycin and Meropenem on the required surveillance form. Interviews with facility staff confirmed that the Infection Preventionist was responsible for completing the Infection Surveillance Outcome form for all residents on antibiotics, and that this process was not followed for the resident in question. The facility's policy required that all antibiotic usage and outcomes be documented and reviewed as part of the Antibiotic Stewardship Program, but this was not done for the antibiotics prescribed to the resident. This lapse was identified through interviews and record reviews conducted by surveyors.
Failure to Administer Pneumococcal Vaccine After Resident Consent
Penalty
Summary
A resident with diagnoses including chronic obstructive pulmonary disease (COPD), skin cancer, and recent scalp surgery was admitted to the facility and was found to be cognitively intact and able to make her own medical decisions. The resident provided written consent to receive the pneumococcal vaccine (PVC 20) on 7/26/2025. However, a review of the immunization record and medication administration record (MAR) for July and August 2025 showed that the vaccine was not administered, resulting in a delay of 25 days since the resident's request and consent. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that facility policy requires the PVC 20 vaccine to be ordered and administered within 72 hours of obtaining resident consent. In this case, the IP did not place the order for the vaccine, and the resident did not receive the immunization as required by facility policy. The facility's policy and procedure on pneumococcal vaccination states that all residents will be offered the vaccine unless medically contraindicated, already given, or refused, but this protocol was not followed for the resident in question.
Insufficient In-Service Training for Restorative Nursing Assistant
Penalty
Summary
The facility failed to ensure that a Restorative Nursing Assistant (RNA) received the required 12 hours of in-service training, including education in dementia care and abuse prevention. During an interview and record review with the Interim Director of Staff Development (IDSD), it was found that the RNA did not receive any training prior to working on the floor. The employee file lacked documentation of the mandatory in-service training, and the in-service binder showed only 1 hour of dementia training and 9 hours of abuse prevention training for the relevant period, both of which were insufficient according to facility policy. The facility's policy requires all staff to participate in initial orientation and annual in-service training, with specific requirements for dementia and abuse prevention education. The IDSD confirmed that the RNA's training was incomplete and acknowledged that the lack of adequate training could impact the ability to care for elderly residents, particularly those with dementia or at risk of abuse. The deficiency was identified through review of training records and staff interviews, which confirmed the absence of required documentation and insufficient training hours.
Failure to Develop Care Plan for Resident's Central Venous Catheter
Penalty
Summary
The facility failed to develop a care plan for a resident's Central Venous Catheter (CVC), which is crucial for administering fluids, blood, and medications. This oversight was identified during a review of the resident's records, which showed that the resident was readmitted with multiple diagnoses, including chronic obstructive pulmonary disease, diabetes mellitus, dementia, muscle weakness, and pressure ulcers. The resident was noted to have severely impaired cognition and was dependent on staff for various activities of daily living. Despite these complex medical needs, there was no care plan in place for the CVC, as confirmed by the Director of Nursing during an interview and record review. The facility's policy and procedures, reviewed in November 2024, require that care plans incorporate goals and objectives to achieve the resident's highest level of independence. These goals and objectives should be derived from the resident's comprehensive assessment. However, the absence of a care plan for the CVC indicates a failure to adhere to these policies, potentially affecting the delivery of care and services to the resident.
Failure to Document Central Venous Catheter Care
Penalty
Summary
The facility failed to ensure proper documentation of care for a resident with a Central Venous Catheter (CVC). The resident, who was readmitted with multiple diagnoses including COPD, diabetes mellitus, dementia, muscle weakness, and pressure ulcers, had an intravenous central line on the left upper chest. The facility's IV Administration Record (IVAR) for December 2024 showed missing entries for monitoring the central line site for signs of infection and infiltration from 12/21/24 to 12/31/24, and for measuring the external catheter length and changing the transparent dressing on 12/25/24. During an interview, the Director of Nursing (DON) confirmed the absence of documentation for the central line care on the specified dates. The DON speculated that the registered nurses might have performed the care but failed to document it due to a possible issue with the order entry system, which may not have displayed the tasks. The facility's policy and procedures emphasize the importance of care plans incorporating goals and objectives for residents' highest level of independence, but the lack of documentation made it impossible to verify if the care was completed as required.
Failure to Notify Physician and NOK of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and the next of kin (NOK) of a significant change in condition for a resident who experienced a notable weight loss. The resident, admitted with diagnoses including dementia and chronic kidney disease, had a weight of 126 pounds on October 8, 2024, which decreased to 118 pounds by November 4, 2024, indicating a significant weight loss of eight pounds in one month. Despite the care plan's directive to inform the physician about significant weight changes, the facility did not notify the resident's physician or NOK in a timely manner. The facility's policy requires prompt notification of the resident, their attending physician, and their representative of any significant changes in condition. However, documentation showed that the physician was only informed on November 8, 2024, and there was no evidence that the NOK was notified. Interviews with staff revealed discrepancies in the communication process, with one licensed vocational nurse admitting to entering incorrect information regarding family notification. The facility's policy emphasizes timely communication, which was not adhered to in this case.
Failure to Document Urine Sample Collection
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident who had a physician's order to collect a urine sample for urinalysis, culture, and sensitivity. The order was given after the resident's next of kin notified the facility of the resident's complaint of pain upon urination. Despite the physician's order, the urine sample was not collected, and there was no documentation in the resident's medical record indicating the failure to collect the sample or the notification of the resident's primary physician. The resident, who was admitted with diagnoses including dementia and chronic kidney disease, was cognitively impaired and required assistance with various activities of daily living. The facility's policy and procedure on charting and documentation required that all services provided, changes in the resident's condition, and notifications to family or physicians be documented in the medical record. However, the director of nursing confirmed that the urine sample was not collected due to difficulty in obtaining it, and the medical record director verified that the laboratory had no record of receiving the sample. This resulted in an inaccurate representation of the resident's medical record.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, leading to potential health risks for residents. During an observation, it was found that dishware was not sanitized with an adequate amount of chlorine sanitizer, as the concentration was below the recommended level of 50 parts per million (ppm). Dietary staff did not notice the low levels of chlorine in the container and continued washing dishes, which could lead to cross-contamination and foodborne illness. The facility's policy required immediate corrective action if sanitizer concentrations were too low, but this was not adhered to during the incident. Additionally, the ice machine in the kitchen was not maintained in a clean manner, with grey and black residue found in the ice storage bin. The Dietary Supervisor confirmed the presence of residue and acknowledged the importance of keeping the ice machine clean to prevent cross-contamination. The Registered Dietitian and Director of Maintenance also confirmed that the ice machine should be free from buildup to prevent contamination, but the machine had not been cleaned as frequently as required by the facility's policy. Furthermore, the facility did not monitor the thaw dates of individual juice cartons and deli meats, leading to potential consumption of expired products. Juice cartons were stored without thaw dates, and a package of ham was labeled with dates exceeding the facility's policy for food storage. The Dietary Supervisor admitted that staff did not label the deli meat correctly, which could result in spoilage and health risks for residents. The facility's policy required proper dating and rotation of food items to ensure safety, but this was not followed in these instances.
Inaccurate MDS Coding for Restorative Nursing Program
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, specifically in the section relating to the Restorative Nursing Program. This deficiency was identified for one resident who was admitted with conditions including neuralgia, neuritis, muscle weakness, and a right-hand contracture. The resident's care plan included the use of a cock-up splint and passive range of motion exercises, which were not accurately reflected in the MDS. The resident's care plan, developed in July 2023, indicated the need for an exercise program due to limitations in range of motion and a right-hand contracture. The plan included goals to increase endurance and regain strength, with interventions such as applying a cock-up splint and providing passive range of motion exercises. However, the Quarterly MDS did not indicate that the resident received restorative nursing services, despite records showing that the resident received these services for 18 days in July 2024. Interviews with staff, including the Restorative Nurse Aide and the MDS Coordinator, confirmed that the MDS was completed incorrectly. The MDS Coordinator acknowledged that the MDS did not reflect the resident's receipt of RNA services or the use of a splint. The Director of Nursing also stated that the MDS should accurately reflect the care the resident is receiving, and incorrect coding could lead to an inaccurate assessment of care.
Failure to Administer and Document Chest Physiotherapy
Penalty
Summary
The facility failed to provide chest physiotherapy to a resident, identified as Resident 42, on two specific dates, despite a physician's order. Resident 42 was admitted with multiple diagnoses, including Parkinson's disease, aspiration pneumonia, dysphagia, a Stage IV pressure ulcer, and Alzheimer's disease. The resident's care plan, developed in July 2024, aimed to reduce the frequency of acute exacerbations through various interventions, including adherence to prescribed regimens and regular respiratory assessments. However, the facility did not document the administration of chest physiotherapy on 8/10/2024 and 8/12/2024, as required by the physician's order dated 8/9/2024. The physician's order specified that Resident 42 was to receive chest wall manipulation five times a day for 30 days to aid lung function due to aspiration pneumonia. While the respiratory therapy daily note on 8/9/2024 indicated that the treatment was administered and well-tolerated, there was no documentation for the specified dates in question. Interviews with the registered nurse and the Director of Nursing confirmed that the absence of documentation implied the treatment was not performed, which could potentially compromise the resident's respiratory status. The facility's policy and procedure for respiratory therapy care and documentation required thorough and accurate records of all services provided, including the type and duration of therapy and the resident's response. The policy also mandated that all services, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. The lack of documentation for the chest physiotherapy on the specified dates indicates a failure to adhere to these policies, resulting in a deficiency in the care provided to Resident 42.
Failure to Accurately Account for Controlled Medication
Penalty
Summary
The facility failed to accurately account for a dose of lorazepam, a controlled medication, for a resident. During an observation and interview with an LVN, it was discovered that there was a discrepancy between the Controlled Drug Record and the medication card. The Controlled Drug Record indicated there were 16 doses left, but the medication card contained only 15 doses. The LVN admitted to administering the missing dose to the resident but failed to document it in the Controlled Drug Record at the time of administration. The facility's policy on Controlled Substances requires that an individual resident controlled substance record be maintained, which includes the time of administration and the signature of the nurse administering the medication. The LVN acknowledged the requirement to sign off on controlled medications immediately after administration to prevent potential over-administration. This oversight increased the risk of medication diversion and the possibility of the resident receiving an incorrect dosage, which could lead to serious health complications.
Delay in Dental Services for Dentures
Penalty
Summary
The facility failed to follow up on requested dental services for dentures for a resident, resulting in a delay in evaluation and increased risk for weight loss and muscle mass loss. The resident, who was initially admitted with diagnoses including anxiety, dorsalgia, and COPD, had intact cognition and was able to communicate needs. The resident's Minimum Data Set indicated obvious broken natural teeth, and a nutritional assessment noted a request for dentures. A physician order for a dental consult for dentures was made, but the resident only saw a dental hygienist who could not address denture-related questions. The Social Services Director, responsible for coordinating appointments, was unaware of the resident's request for dentures or any related issues. The resident had a scheduled dental appointment, but the Director of Nursing was unsure why there was a delay in the dental examination. The facility's policy stated that residents have the right to select dentists and that social services should assist with appointments and transportation. Despite this, the resident experienced a delay in receiving necessary dental care.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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