Alvarado Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 1154 S.alvarado St, Los Angeles, California 90006
- CMS Provider Number
- 056157
- Inspections on file
- 39
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 31 (1 serious)
Citation history
Health deficiencies cited at Alvarado Care Center during CMS and state inspections, most recent first.
A resident with HIV did not receive the prescribed medication Biktarvy for six consecutive days due to lack of supply, with incomplete documentation for the missed doses. The resident expressed concern about the missed medication and related health issues, while an LVN confirmed the medication was unavailable and that proper protocol was not followed. The DON acknowledged the facility's failure to ensure medication availability and proper documentation.
A resident with HIV did not receive the prescribed medication Biktarvy for six consecutive days due to lack of supply, with incomplete documentation and follow-up by nursing staff. The resident expressed concern about missed doses and experienced symptoms, while staff interviews confirmed lapses in medication management and adherence to facility policy.
A resident with multiple health conditions and high fall risk was admitted without a comprehensive care plan addressing fall prevention. Despite facility policy and assessment findings, no individualized fall risk interventions were documented, as confirmed by the DON during record review.
A resident with multiple health conditions and impaired cognition experienced two falls. Although documentation indicated the care plan was updated, review showed the care plan was not revised until days after the incidents, contrary to facility policy requiring timely updates and new interventions after falls.
A resident with multiple health conditions, including diabetes and dysphagia, repeatedly refused meals over several days. Despite care plan requirements and facility policy mandating notification of the physician and RD after such refusals, there was no documentation that these notifications occurred, resulting in the resident not receiving timely nutritional interventions.
A resident with multiple health conditions and impaired cognition had fall risk assessments that failed to indicate their correct fall risk status and inaccurately documented their fall history. The assessments did not specify whether the resident was at low or high risk for falls, and one assessment incorrectly stated there was no history of falls, despite evidence to the contrary. These documentation errors resulted in an incomplete and inaccurate medical record.
A resident with multiple medical conditions, including cognitive impairment and a history of falls, sustained a right femur fracture after a witnessed fall. The facility did not report this major accident to the State Agency, as required by regulations, due to an outdated policy and staff misunderstanding of reporting requirements.
A resident with dementia and impaired decision-making capacity was scheduled for an MRI without the POA being notified, despite facility policy requiring representative involvement in care decisions. Both the LVN and DON confirmed the POA should have been informed, and the POA stated she always accompanies the resident to appointments due to the resident's inability to self-advocate.
A resident with a sacrococcyx pressure injury was found lying on a chux placed on a low air loss (LAL) mattress, contrary to physician orders, manufacturer instructions, and facility policy. Staff interviews confirmed that the chux should not have been used with the LAL mattress, as it could interfere with the mattress's function and the resident's comfort and healing.
A resident with dementia, hypertension, and depression did not have multiple prescribed medications properly documented as administered, with several doses not signed for on the MAR and no reasons recorded for missed doses. The DON confirmed that the MAR should be signed immediately after administration, and the facility's policy requires this documentation. This failure resulted in uncertainty about whether medications were given and did not meet the resident's needs.
The facility failed to create individualized care plans for three residents, leading to potential delays in care. A resident with pressure ulcers lacked a care plan for ulcer management, another resident on Lexapro did not have a timely care plan for medication use, and a third resident refusing tube feedings had no care plan to address this issue. These deficiencies were confirmed by facility staff.
The facility failed to monitor behaviors and side effects of antipsychotic medications for two residents, leading to potential risks of unnecessary medication and adverse effects. One resident was prescribed Risperdal for bipolar disorder without monitoring for behaviors or side effects. Another resident, with multiple diagnoses, was prescribed Risperidone and Valproic acid, but there was no documentation of monitoring for side effects or behavioral episodes. The facility's policy required daily monitoring, which was not followed, as confirmed by nursing staff and the DON.
The facility failed to ensure proper food storage practices in the kitchen, with unlabeled and undated frozen food items found in the freezer, and personal items improperly stored in the dry food storage area. These actions were against the facility's policies, which require all food to be labeled and dated and personal belongings to be kept in designated areas.
The facility did not follow its policy for labeling and storing food brought in by visitors, as several items in the residents' refrigerator were found without labels indicating the resident's name or the date of arrival. This oversight was confirmed by an RN and the DON, who emphasized the importance of labeling to ensure dietary compatibility and prevent spoilage.
A facility failed to comprehensively assess a resident's oral health upon admission, leading to an oversight of missing upper teeth. Despite the resident's intact cognition and need for assistance with daily activities, the MDS did not report any denture issues. The oversight was confirmed during an interview, and the DON acknowledged potential health deterioration due to the inaccurate assessment.
A facility failed to conduct a quarterly Braden scale assessment for a resident at high risk for pressure ulcers. The resident, with a stage 3 pressure ulcer, was last assessed in August, missing the required assessment in November. Interviews with the RN and DON confirmed the lapse, which could lead to a worsening of the resident's condition due to unidentified necessary interventions.
A facility failed to transmit a resident's MDS assessment to CMS within the required timeframe, as confirmed by the facility's VP of Clinical Services and MDS Resource. The resident, with diagnoses including dementia and diabetes, had severely impaired cognitive skills and was dependent on staff for daily activities. The MDS was submitted and accepted beyond the 14-day requirement, contrary to the facility's policy.
A resident at risk for pressure ulcers had their Low Air Loss Mattress (LALM) set incorrectly at 120 pounds instead of their actual weight of 99 pounds. Despite a physician order discontinuing the LALM, it remained in use, potentially causing discomfort and hindering skin condition improvement. The facility's policy on pressure ulcer prevention was not followed, as confirmed by staff interviews and record reviews.
A resident with multiple diagnoses and a history of falls did not have their fall care plan revised after certain falls, and their fall risk was inaccurately assessed as low. This led to a lack of appropriate interventions to prevent further falls. Facility staff confirmed these deficiencies, acknowledging that care plans were not revised post-fall and fall risk assessments were incorrect.
A facility failed to store latanoprost eye drops, used for treating glaucoma, in the refrigerator as required by the manufacturer. An unopened bottle was found at room temperature in a medication cart. The LVN and DON acknowledged the error, noting that improper storage could reduce the medication's effectiveness.
A facility failed to follow its infection control policy when an LVN did not perform hand hygiene between administering eye drops to a resident's eyes, risking cross-contamination. The resident had chronic conditions and required assistance with daily activities. Interviews revealed a lack of awareness of the policy among staff.
Two residents did not receive prescribed ROM exercises on specific dates, as the facility failed to ensure restorative nursing assistants performed the exercises. Additionally, care plans addressing the residents' restorative needs were not created, contrary to facility policy. This oversight involved residents with conditions requiring consistent ROM exercises, such as a fracture and Huntington's disease.
A resident with severe cognitive impairment alleged that someone entered their room and placed a hand over their mouth. Despite the incident being reported and the resident's inability to provide details, the facility failed to create a care plan addressing the allegations. The resident required substantial assistance with daily activities and had multiple diagnoses, including cerebrovascular disease and anxiety disorder. The facility's policies mandated care plan updates for changes in condition, but this was not followed.
A resident with severe cognitive impairment and multiple diagnoses reported an incident where someone allegedly entered her room and placed a hand over her mouth. The social service designee filed a grievance report but failed to document further services provided, contrary to facility policy requiring documentation of psychosocial evaluations upon a change of condition.
A resident with severe cognitive impairment alleged that someone entered their room and placed a hand over their mouth. The incident was inaccurately documented by a registered nurse supervisor as a physical assault by a staff member, contrary to the facility's policy on maintaining clear and accurate medical records.
A resident with a history of aggressive behavior hit another resident, causing harm, due to inadequate care planning and monitoring. Despite known behavioral issues, the facility failed to update the care plan and prevent the altercation, resulting in the victim being transferred to a hospital for evaluation.
A facility failed to develop a care plan for a resident prescribed psychotropic medications, including Paxil, Seroquel, and Risperdal, despite the resident's diagnoses of psychosis, schizoaffective disorder, and depression. Interviews confirmed the absence of a care plan, which is required to ensure appropriate care and monitoring of potential side effects.
A facility failed to obtain informed consent for a resident's increased dosage of Fluvoxamine Maleate, a medication for depression. The resident initially consented to 50 mg, but the dosage was increased to 100 mg without a new consent, contrary to the facility's policy. This was confirmed by the RN Supervisor and Administrator, highlighting a lapse in following the required procedure for medication changes.
A resident with dementia and major depressive disorder made significant financial withdrawals without the knowledge of her Durable Power of Attorney (POA), despite her medical condition indicating a lack of decision-making capacity. Facility staff believed the resident could make her own decisions, leading to a violation of the resident's rights and placing her at risk.
Two residents experienced disturbances due to a roommate playing loud music and TV late at night, disrupting their sleep. Despite complaints to staff, no care plan was developed to address the noise issue, violating the facility's policy for a homelike environment.
The facility failed to implement a comprehensive care plan for three residents, leading to sleep disturbances for two residents due to their roommate's nighttime noise. Despite multiple complaints and staff awareness, no care plan was developed to address the situation.
A resident with nicotine dependence, COPD, and other health issues was not properly assessed for smoking safety, leading to potential fire hazards. The facility's policy required a safe smoking assessment and care plan, which were not implemented, despite the resident's family and physician advising against smoking.
Failure to Provide and Administer HIV Medication as Ordered
Penalty
Summary
The facility failed to ensure that a necessary medication, Biktarvy, used to treat HIV, was available and administered as ordered by the physician for a resident over six consecutive days. The resident was admitted with a diagnosis of HIV and had an active physician order for daily administration of Biktarvy. Review of the Medication Administration Record (MAR) showed that the medication was not administered on six specific dates, with incomplete documentation regarding the reason for omission on most of those days. Nursing progress notes only documented that the pharmacy had been contacted for a refill on the first day of omission, with no further explanation for the subsequent missed doses. During interviews, the resident expressed concern about not receiving the medication, reporting that staff informed him it was not in stock and expressing worry about the impact on his health. The resident also reported experiencing diarrhea and concern about infection, as well as uncertainty about when he would see his physician for a prescription refill. An LVN confirmed that the medication was not administered due to lack of supply and stated that the facility protocol would be to notify the physician and arrange for an appointment to ensure continued access to the medication. The LVN also noted that the turnaround time for obtaining the medication from the pharmacy is typically one to two days, emphasizing the importance of timely refills to prevent treatment interruption. The Director of Nursing verified the omission of the medication and acknowledged that the omissions should have been documented and explained by licensed nurses. The DON stated that it was the facility's responsibility to ensure medications are available for each resident and confirmed that the facility failed to have Biktarvy available for the resident on the dates in question. Review of the facility's pharmacy services policy indicated that staff should be educated on pharmacy services, and that drug regimens and medication distribution errors should be reviewed and updated regularly.
Failure to Provide and Administer Prescribed HIV Medication
Penalty
Summary
The facility failed to ensure that a necessary medication, Biktarvy, prescribed for the treatment of HIV, was available and administered as ordered for a resident. The resident was admitted with a diagnosis of HIV and had a physician's order for daily administration of Biktarvy. Despite this, the resident did not receive the medication for six consecutive days, as documented in the Medication Administration Record (MAR), with the reason for omission noted only on the first day and no further documentation for the subsequent days. Review of the resident's medical chart and nursing progress notes revealed that the medication was not administered due to a lack of supply, and the nurse had contacted the pharmacy regarding a refill. However, there was no documentation explaining the omissions for the remaining days, nor evidence of ongoing assessment or follow-up as required by facility policy. The resident expressed concern about missing doses and reported symptoms of diarrhea, as well as anxiety about the interruption in treatment. Interviews with facility staff confirmed that the medication was not available due to issues with insurance coverage and the need for a physician appointment to obtain a refill. The Director of Nursing verified the omissions and acknowledged that the medication should have been administered as ordered, and that omissions should have been properly documented and communicated. Facility policy required immediate assessment and documentation of any medication omissions, which was not followed in this case.
Failure to Develop Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the fall risk for a resident who was assessed as high risk for falls upon admission. Despite the resident's complex medical history, including diabetes, dysphagia, lack of coordination, and an above-knee amputation, there was no documented care plan targeting fall prevention. The Minimum Data Set assessment indicated the resident had moderately impaired cognition and required varying levels of assistance with activities of daily living, further underscoring the need for individualized fall prevention strategies. During a review of the resident's records and an interview with the DON, it was confirmed that the fall risk assessment identified the resident as high risk, but no corresponding care plan was found in the medical record. Facility policy requires that admission assessments be used to create an initial baseline care plan, and that fall risk assessments inform individualized plans of care. The absence of a fall risk care plan for this resident constituted a failure to meet these requirements.
Failure to Timely Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update and revise the care plan for a resident following two separate falls. The resident, who was admitted with diagnoses including diabetes, dysphagia, lack of coordination, and an above-knee amputation, was assessed as having moderately impaired cognition and required significant assistance with activities of daily living. The resident experienced falls on two occasions, once in the smoking patio and once beside the bed, as documented in the Change of Condition and Post Fall Assessment records. Although the post-fall documentation indicated that the care plan was updated, review of the actual care plan and interviews with the registered nurse supervisor revealed that the care plan was not created or revised until several days after the falls occurred. Facility policy required that the care plan be reviewed and revised after a fall, with new interventions implemented as appropriate. However, the care plan addressing falls was not initiated or updated in a timely manner following the resident's incidents. This resulted in a failure to develop and implement new interventions to prevent future falls, as required by the facility's Fall Management Program policy.
Failure to Intervene After Resident Meal Refusals
Penalty
Summary
The facility failed to ensure that a resident received adequate nutrition by not providing appropriate interventions when the resident refused multiple meals. The resident, who had diagnoses including diabetes, dysphagia, lack of coordination, and an above-knee amputation, was admitted with a care plan that identified a risk for nutritional problems and required a mechanical soft, carbohydrate-controlled, no added salt diet. The care plan specified that the resident should maintain adequate nutritional status by consuming at least 75% of three meals daily, and included interventions for the registered dietitian to evaluate and make dietary recommendations as needed. Despite these care plan requirements, documentation showed that the resident refused to eat dinner on one day and refused all meals on two other days. There was no evidence that the physician or registered dietitian were notified of these refusals, as required by facility policy. The DON confirmed during interview and record review that there was no documentation of such notifications, and acknowledged that the physician and RD should have been informed immediately to provide recommendations. Facility policy required notification of the physician and responsible party in cases of resident refusal of care or services, but this was not followed.
Inaccurate Fall Risk Assessments and Incomplete Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding fall risk assessments. The fall risk assessments dated 8/18/25 and 8/30/25 did not indicate whether the resident was at low or high risk for falls. Additionally, one of the fall risk assessments inaccurately documented that the resident had no history of falls, despite the resident having a previous fall history. These inaccuracies were confirmed during a review of the records with the registered nurse supervisor, who acknowledged that the assessments did not properly reflect the resident's fall risk status or history. The resident involved had multiple diagnoses, including diabetes, dysphagia, lack of coordination, and an above-knee amputation of the right leg. The Minimum Data Set assessment indicated the resident had moderately impaired cognition and required significant assistance with activities of daily living. The facility's policy required nursing documentation to be concise, clear, pertinent, and accurate, but the fall risk assessments did not meet these standards, resulting in an incomplete and inaccurate medical record for the resident.
Failure to Report Major Accidental Fall with Injury
Penalty
Summary
The facility failed to ensure its policy for Unusual Occurrence Reporting included major accidents and did not follow state and federal regulations to report a major accidental fall with injury. A resident with a history of unsteadiness, repeated falls, Parkinson's disease, osteoarthritis, and cognitive impairment experienced a witnessed fall while attempting to use a walker, resulting in a right femur fracture. The resident was transferred to the hospital for treatment and later readmitted to the facility. Despite the severity of the injury, the incident was not reported to the State Agency as required. Review of the facility's policy revealed it did not specify major accidents as reportable events, and both the DON and Administrator stated they did not consider the incident reportable because the fall was witnessed and the cause was known. However, state regulations require reporting of major accidents, regardless of whether the cause is known. The facility's outdated policy and misunderstanding of reporting requirements led to the failure to report the incident in accordance with applicable laws.
Failure to Notify POA of Resident's MRI Appointment
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) about a scheduled MRI appointment, despite the resident having diagnoses including dementia, hypertension, and depression, and being assessed as lacking capacity to make decisions. The resident was dependent on staff for most activities of daily living and had moderately impaired cognitive function, as documented in the Minimum Data Set. The physician had ordered an MRI to evaluate confusion, and the appointment was scheduled accordingly. Interviews revealed that the POA was not informed of the MRI appointment, even though she routinely accompanied the resident to medical appointments due to the resident's inability to advocate for herself. Both the LVN who arranged the appointment and the Director of Nursing acknowledged that the POA should have been notified, in accordance with the facility's policy on resident rights, which includes involving representatives in care decisions and ensuring residents and their representatives are fully informed and able to participate in treatment decisions.
Improper Use of Low Air Loss Mattress for Pressure Injury Care
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was used according to professional standards of practice for a resident with a sacrococcyx pressure injury. During observation, the resident was found lying on a blue reusable pad (chux) placed on top of the LAL mattress. The resident's care plan included interventions to follow facility protocols for pressure injury treatment, and a physician's order specified the use of the LAL mattress with daily monitoring for proper setting, functioning, and placement. The LAL mattress operator's manual instructed that only a cotton sheet should be used to cover the mattress to avoid direct contact and improve comfort. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that the chux should not have been used with the LAL mattress, as it could interfere with the mattress's function and potentially affect the resident's comfort and healing. The facility's policy required that all residents receive care and services in accordance with evidence-based and accepted professional clinical standards. The use of the chux on the LAL mattress was inconsistent with these standards and the manufacturer's instructions.
Failure to Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician and that medication administration was properly documented for a resident with multiple diagnoses, including dementia, hypertension, and depression. Review of the Medication Administration Record (MAR) revealed that several prescribed medications, such as ascorbic acid, famotidine, ferrous sulfate, folic acid, lisinopril, multiple vitamins, zinc sulfate, docusate sodium, and prostat oral liquid, were not signed as given on multiple occasions. The MAR lacked documentation indicating whether these medications were administered or, if not, the reasons for omission. The facility's policy requires that the licensed nurse chart the drug, time administered, and initial their name with each medication administration, which was not followed in these instances. During an interview, the DON confirmed that the MAR should be signed immediately after medication administration and agreed that unsigned entries indicate the medications were not given. The resident involved was noted to have moderately impaired cognitive function and required significant assistance with daily activities, making accurate medication administration and documentation particularly important. The failure to document medication administration as required resulted in the facility being unable to determine if the medications were given, as well as failing to prevent potential medication errors, duplication, or delays in care.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized person-centered care plans for three residents, leading to potential delays and inadequacies in care delivery. Resident 25, admitted with a displaced fracture, difficulty walking, and anemia, was at risk for pressure ulcers. Despite having a stage 3 pressure ulcer on the right knee, the resident's care plan lacked goals and interventions for pressure ulcer management, as confirmed by RN 2. This oversight could lead to the worsening of the resident's condition. Resident 28, diagnosed with major depressive disorder, bipolar disorder, and paranoid schizophrenia, was prescribed Lexapro for depression. However, a care plan addressing the use of Lexapro was not initiated until several months after admission. The Director of Nursing acknowledged that a care plan should have been developed upon the medication's prescription to ensure adequate care and monitoring, highlighting a gap in the facility's care planning process. Resident 45, with a gastrostomy and schizophrenia, frequently refused bolus tube feedings, as noted in the Medication Administration Record. Despite this, no care plan was developed to address the refusal of feedings, which could lead to weight loss. RN 2 and the Director of Nursing confirmed the absence of a care plan, emphasizing the need for interventions to manage the resident's nutritional needs effectively.
Failure to Monitor Antipsychotic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to monitor behaviors and side effects of antipsychotic medications for two residents, leading to potential risks of unnecessary medication and adverse effects. Resident 8, who was readmitted with a diagnosis of bipolar disorder, was prescribed Risperdal for excessive talking and screaming. However, there were no physician orders to monitor for these behaviors or the side effects of Risperdal. The Medication Administration Record (MAR) for December 2024 did not indicate any monitoring for behaviors or side effects. Both the Registered Nurse (RN) and the Director of Nursing (DON) confirmed the lack of monitoring, acknowledging the potential for worsening side effects if not monitored properly. Resident 23, admitted with diagnoses including sepsis, metabolic encephalopathy, and chronic kidney disease, was prescribed Risperidone and Valproic acid for mood disorders. The physician orders included monitoring for side effects and behavioral episodes, but there was no documentation of such monitoring on specific dates in December 2024. RN 1 could not provide evidence of monitoring, and the DON emphasized the importance of monitoring to adjust dosages and report adverse effects to the physician. The facility's policy on psychotherapeutic drug management required daily monitoring of psychotropic drug use and target behaviors, with documentation of adverse effects and behavioral presence. However, the facility failed to adhere to this policy, as evidenced by the lack of monitoring for the two residents. This deficiency was confirmed through interviews and record reviews with the nursing staff and DON.
Deficient Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as observed during a survey. A bag of frozen carrots and a bag of frozen corn were found in the freezer without labels and dates, which is against the facility's policy that requires all food items to be labeled and dated. This oversight was acknowledged by a staff member who removed the items from the freezer. Additionally, personal items such as a plastic bag full of clothing and shoes were found stored in the dry food storage area, which is not permitted according to the facility's policy. The staff member responsible for the kitchen confirmed that personal belongings should not be stored in the food storage areas. Further observations revealed that a staff member's jacket and hat were hanging on a shelf in the dry storage area, which was also against the facility's policy. The Dietary Supervisor confirmed that personal items are not allowed in the dry food storage area and removed the clothing. The facility's policies, reviewed during the survey, clearly state that personal belongings of dietary staff should be kept in designated areas only, and that food storage areas should be maintained in a manner that prevents cross-contamination and ensures food safety.
Failure to Label and Store Visitor-Brought Food Properly
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and storage of food items brought in by visitors for residents. During an observation and interview, it was noted that several food items, including cartons of Almond Breeze, a plastic container of string cheese, a plastic bottle of Gatorade, a carton of Ensure original, and a plastic container of clover honey, were stored in the designated residents' refrigerator without being labeled with the resident's name or the date they were brought in. This was confirmed by a Registered Nurse (RN 1), who acknowledged that labeling is crucial to ensure compatibility with the attending physician's diet order and to prevent spoilage. The Director of Nursing (DON) further confirmed that the facility's policy requires food from outside sources to be stored in sealed containers with the resident's name and the date it was brought in. The policy also states that perishable food requiring refrigeration should be discarded after 48 hours. The lack of labeling could lead to food spoilage, which the facility aims to prevent. The facility's policy and procedure titled "Food brought in by visitors," last reviewed in November 2023, clearly outlines these requirements.
Failure to Assess Resident's Oral Health
Penalty
Summary
The facility failed to comprehensively assess the oral health status of a resident, identified as Resident 40, upon admission and during subsequent evaluations. Resident 40 was admitted with several medical conditions, including acute kidney failure, atrial fibrillation, and anemia. The Minimum Data Set (MDS) indicated that the resident had intact cognition and required supervision for eating, along with moderate-to-maximal assistance for other activities of daily living. However, the MDS did not report any issues with dentures, despite the resident having missing upper teeth as noted in the History and Physical Examination. During an observation and interview, Resident 40 confirmed the loss of upper dentures prior to admission. A review of the Initial Nutritional Assessment by a registered nurse revealed that the assessment failed to document the missing teeth, which could lead to nutritional problems. The Director of Nursing acknowledged that an inaccurate assessment of the resident's oral health could result in further health deterioration. The facility's policy on nursing assessment, which requires comprehensive evaluation through observation and communication, was not adhered to in this case.
Failure to Conduct Quarterly Braden Scale Assessment for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident, who was at high risk for pressure ulcers, was assessed quarterly using the Braden scale assessment. The resident, admitted with a displaced fracture, difficulty walking, and anemia, had a stage 3 pressure ulcer and was receiving care for it. The Minimum Data Set (MDS) indicated the resident was at risk for pressure ulcers, and the Braden scale assessment showed a high risk with a score of 12. However, the last Braden scale assessment was performed on 8/9/2024, and the next one was due in 11/2024 but was not completed. Interviews with the RN and the DON confirmed the oversight, acknowledging that the Braden scale assessments are crucial for identifying the resident's risk level for developing pressure ulcers. The facility's policy required these assessments to be done quarterly, but this was not adhered to, leading to a potential risk of worsening the resident's pressure ulcer. The DON emphasized that without the assessment, necessary interventions might not be identified, which could lead to deterioration in the resident's condition.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to ensure the timely transmission of the Minimum Data Set (MDS) for a resident to the Centers for Medicare and Medicaid Services (CMS) system. The deficiency was identified during a review of the resident's admission record and MDS assessment. The resident, who was originally admitted in 2005 and readmitted later, had diagnoses including dementia, type two diabetes mellitus, and major depressive disorder. The MDS assessment indicated that the resident had severely impaired cognitive skills and was dependent on staff for various daily activities. The MDS dated a specific date was not transmitted to CMS within the required 14-day period, as it was submitted on December 11, 2024, and accepted on December 12, 2024, which was beyond the stipulated timeframe. During an interview and record review, the facility's Vice President of Clinical Services and the MDS Resource confirmed that the MDS was not transmitted timely, constituting a deficient practice. The facility's policy and procedure manual, dated October 1, 2023, outlined the requirement for timely transmission of MDS assessments in accordance with CMS guidelines. The failure to transmit the MDS within the required timeframe resulted in the potential for CMS not having the most updated resident information, which could delay services for the resident.
Incorrect LALM Setting for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to set a Low Air Loss Mattress (LALM) to the correct setting for a resident, identified as Resident 23, who was at risk for pressure ulcers. The resident, who was admitted and later readmitted to the facility, had diagnoses including idiopathic neuropathy, major depression, and anxiety, and was totally dependent on staff for all activities of daily living. The resident's Minimum Data Set indicated moderately impaired cognition, and the resident lacked the capacity to understand and make decisions. A physician order dated 3/27/2024 required the LALM to be set according to the resident's weight and monitored every shift. However, during an observation, the LALM was set to 120 pounds instead of the resident's weight of 99 pounds, as confirmed by Treatment Nurse 1. Further investigation revealed that the physician order for the LALM had been discontinued on 7/7/2024, yet the mattress was still in use. Registered Nurse 1 confirmed the absence of a current physician order for the LALM and acknowledged that using the mattress without an order and at an incorrect setting could cause discomfort and hinder the resident's skin condition improvement. The Director of Nursing emphasized the importance of following physician orders for LALM settings to prevent further skin injuries. The facility's policy on pressure ulcer prevention, last reviewed in 2023, stated the need to identify residents at risk and provide appropriate care to prevent pressure ulcers, which was not adhered to in this case.
Failure to Revise Fall Care Plan and Assess Fall Risk
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 35, received the necessary care and services to prevent accidents and falls. The resident, who was admitted with diagnoses including depression, lack of coordination, reduced mobility, and unsteadiness on feet, experienced multiple falls on specific dates. Despite these incidents, the facility did not revise the resident's fall care plan after falls on two occasions, which is contrary to the facility's policy that requires care plan revisions after each fall to identify and implement appropriate interventions. The facility also failed to accurately assess the resident's fall risk. The fall risk assessments conducted on certain dates incorrectly indicated that the resident had a low risk for falling, despite having a history of falls and multiple diagnoses. This incorrect assessment led to the resident not being considered a high risk for falls, and as a result, appropriate interventions were not implemented to prevent further falls. Interviews with the facility's staff, including a Registered Nurse and the Director of Nursing, confirmed these deficiencies. The staff acknowledged that the resident's care plan was not revised after each fall and that the fall risk assessments were not completed correctly. The facility's policies and procedures require that fall risk assessments be conducted upon admission, quarterly, and with any significant change in condition, and that care plans be reviewed and revised post-fall to ensure adequate supervision and assistance to prevent accidents.
Improper Storage of Latanoprost Eye Drops
Penalty
Summary
The facility failed to ensure that latanoprost eye drops, a medication requiring refrigeration, were stored according to the manufacturer's guidelines. During an observation of Medication Cart 1, an unopened bottle of latanoprost eye drops intended for a resident with glaucoma was found stored at room temperature instead of being refrigerated. The Licensed Vocational Nurse (LVN 1) acknowledged that the medication was new and unopened, and therefore should have been stored in the refrigerator until needed. The LVN noted that improper storage could render the medication less effective. The Director of Nursing (DON) confirmed that latanoprost should be refrigerated until opened, as per the manufacturer's guidelines. The manufacturer's product labeling from December 2022 specified that unopened bottles should be stored under refrigeration at 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit). The failure to adhere to these storage requirements could potentially compromise the effectiveness of the medication in treating the resident's eye condition.
Failure in Hand Hygiene During Eye Drop Administration
Penalty
Summary
The facility failed to implement its infection prevention and control program as per its policy titled 'Installation of Eye Drops.' During a medication administration observation, a Licensed Vocational Nurse (LVN) did not wash and dry her hands thoroughly between administering eye drops to each eye of a resident. The LVN sanitized her hands with an Alcohol Based Hand Sanitizer before administering the eye drops to the resident's right eye but did not remove her gloves or sanitize her hands before administering the drops to the left eye. This practice was contrary to the facility's policy, which requires hand hygiene between administering eye drops to each eye to prevent cross-contamination. The resident involved had been admitted with diagnoses including chronic systolic heart failure, essential hypertension, and schizophrenia. The resident's Minimum Data Set indicated mildly impaired cognition and a need for moderate-to-maximal assistance with daily activities. Interviews with the LVN, the Infection Preventionist, and the Director of Nursing revealed a lack of awareness and adherence to the facility's policy regarding hand hygiene during eye drop administration. The Director of Nursing acknowledged that the failure to perform proper hand hygiene could have led to cross-contamination or infection between the resident's eyes.
Failure to Provide Ordered ROM Exercises and Care Plans
Penalty
Summary
The facility failed to provide range of motion (ROM) exercises as ordered by the physician for two residents, Resident 2 and Resident 3. The restorative nursing assistants (RNA) did not perform the prescribed ROM exercises on specific dates, namely 11/5/24, 11/7/24, and 11/12/24. This omission was identified during a review of the Restorative Administration Record (RAR), which showed that these dates were not signed off, indicating that the exercises were not conducted as required. Resident 2 was admitted with diagnoses including a fracture of the right fibula, lack of coordination, and difficulty in walking. The physician had ordered passive and active ROM exercises for Resident 2's extremities to be performed daily, five times a week. Similarly, Resident 3, who was admitted with Huntington's disease and a movement disorder, had a physician order for active ROM exercises for the upper extremities. Both residents had recommendations for an RNA program from physical therapy, but the facility failed to ensure these exercises were consistently provided. Additionally, the facility did not create care plans addressing the restorative needs of Resident 2 and Resident 3. The registered nurse supervisor confirmed the absence of such care plans, which are essential for outlining the interventions required to meet the residents' restorative needs. The facility's policy mandates that the interdisciplinary care plan should reflect the written plan of care, including problems, measurable goals, and individualized approaches, but this was not adhered to in the cases of Resident 2 and Resident 3.
Failure to Develop Care Plan After Resident's Allegation
Penalty
Summary
The facility failed to develop a person-centered care plan following a change in condition for a resident who alleged that someone entered their room and placed a hand over their mouth. This incident was reported by the resident during a phone conversation with a family member, which was overheard by a licensed vocational nurse. Despite the resident's severe cognitive impairment and inability to provide detailed information about the incident, the facility did not create a care plan to address the resident's allegations or outline the necessary interventions and services. The resident, who was admitted with diagnoses including cerebrovascular disease with hemiplegia and hemiparesis, diabetes, and anxiety disorder, was assessed with severe cognitive impairment and required substantial assistance with daily activities. The facility's policies required that care plans be updated to reflect changes in a resident's condition, but this was not done in this case. Both the registered nurse supervisor and the director of staff development confirmed the absence of a care plan addressing the resident's allegations, which was a deviation from the facility's established procedures.
Failure to Provide Necessary Social Services After Allegation
Penalty
Summary
The facility failed to provide necessary social services for a resident who made an allegation of an incident involving a person entering her room and placing a hand over her mouth. The resident, who was admitted with diagnoses including cerebrovascular disease with hemiplegia and hemiparesis, diabetes, and anxiety disorder, reported the incident to a family member during a phone call. The licensed vocational nurse documented the conversation in the nurse progress notes, noting that the resident was unable to provide detailed information about the incident and had no visible injuries. The social service designee (SSD) was informed of the incident and spoke with the resident, filing a grievance report. However, the SSD did not document any additional services provided to the resident in the progress notes, as confirmed by the director of staff development. The facility's policy requires the director of social services to evaluate and document the resident's psychosocial status upon a change of condition, which was not adhered to in this case.
Inaccurate Documentation of Resident Allegation
Penalty
Summary
The facility failed to maintain accurate and concise medical records for a resident who alleged physical assault by a staff member. The incident was first noted when a licensed vocational nurse overheard the resident telling a family member over the phone that someone had entered their room and placed a hand over their mouth. Despite the resident's severe cognitive impairment and inability to provide detailed information about the incident, the registered nurse supervisor later documented in the Nurse Progress Notes that the resident alleged a staff member physically assaulted them. This documentation was later deemed inaccurate by the registered nurse supervisor. The resident involved had been admitted to the facility with diagnoses including cerebrovascular disease with hemiplegia and hemiparesis, diabetes, and an anxiety disorder. The Minimum Data Set indicated the resident had severe cognitive impairment and required substantial assistance with daily activities. The facility's policy on nursing documentation emphasized the need for concise, clear, pertinent, and accurate records, which was not adhered to in this case, resulting in an inaccurate medical record for the resident.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in harm. On June 26, 2024, Resident 2, who had a history of aggressive behavior, hit Resident 1 on the nose, causing pain and redness. Resident 2 had been admitted with diagnoses including Parkinson's disease, psychosis, and anxiety disorder, and had a documented history of sudden outbursts of anger and physical aggression towards staff. Despite these known behaviors, the facility did not adequately update or implement a care plan to prevent such incidents. Prior to the altercation, Resident 2's care plan included interventions to assist in developing appropriate coping methods and positive interactions. However, the care plan was not updated to reflect Resident 2's behavior of grabbing and spitting at staff, as noted in a Change of Condition form dated May 14, 2024. Additionally, Resident 2's Minimum Data Set assessment did not accurately reflect the resident's behavioral symptoms, indicating a discrepancy in the documentation of Resident 2's condition and behavior. Resident 1, who was admitted with schizoaffective disorder and depression, had previously reported not getting along with Resident 2. Despite this, both residents refused a room change. On the day of the incident, Resident 2 became angry and hit Resident 1, who was subsequently transferred to a hospital for further evaluation. The facility's policy on abuse prevention and resident altercations was not effectively implemented, as evidenced by the failure to prevent the altercation and protect Resident 1 from harm.
Failure to Develop Care Plan for Psychotropic Medications
Penalty
Summary
The facility failed to develop a care plan for a resident who was prescribed psychotropic medications, including Paxil, Seroquel, and Risperdal. The resident, admitted with diagnoses of unspecified psychosis, schizoaffective disorder, and depression, was receiving these medications as per the physician's orders. However, upon review, it was found that no care plan had been initiated for these medications, which is a requirement to ensure appropriate care and monitoring of potential side effects. Interviews with the Registered Nurse Supervisor and the Administrator confirmed the absence of a care plan for the psychotropic medications prescribed to the resident. The facility's policy mandates that a comprehensive care plan be developed for each resident, including measurable objectives and timetables to meet their medical, nursing, mental, and psychosocial needs. The lack of a care plan for the resident's psychotropic medications was identified as a deficiency, as it could potentially lead to the resident not receiving appropriate care and monitoring for adverse side effects.
Failure to Obtain Informed Consent for Medication Dosage Increase
Penalty
Summary
The facility failed to obtain informed consent for an increase in the dosage of Fluvoxamine Maleate for a resident diagnosed with depression. Initially, the resident consented to receive 50 mg of Fluvoxamine Maleate at bedtime, as documented in the Consent 3.0 document. However, following a psychiatric consultation, the dosage was increased to 100 mg without obtaining a new informed consent from the resident. This oversight was confirmed during interviews with the Registered Nurse Supervisor and the Administrator, who both acknowledged the absence of a consent form for the increased dosage. The facility's policy on Psychotherapeutic Drug Management requires informed consent for any changes in the dosage of psychotherapeutic medications, even if the change is within the same class of medication. Despite this policy, the resident received 20 doses of the increased medication without the necessary consent, potentially leaving the resident uninformed about the change and at risk of experiencing adverse side effects. The Director of Nursing was unavailable for comment during the investigation.
Failure to Inform POA of Resident's Financial Activities
Penalty
Summary
The facility failed to ensure that a resident's Durable Power of Attorney (POA) was informed of the resident's financial activities, despite the resident's medical condition indicating a lack of capacity to make informed decisions. The resident, diagnosed with unspecified dementia and major depressive disorder with psychotic symptoms, had a court-delegated POA responsible for financial decisions. However, the facility did not notify the POA of the resident's financial activities, including significant withdrawals from the resident's bank account. Interviews and record reviews revealed that the resident had a history of cognitive impairment and was admitted to a behavioral health care hospital for psychiatric evaluation. Despite this, the facility's staff, including the Social Services Director and Director of Nursing, believed the resident was capable of making her own decisions and did not consider the POA's authority necessary. This led to the resident making large financial withdrawals without the POA's knowledge, which raised concerns about the resident's safety and financial management. The facility's policy on informed consent and decision-making capacity was not adhered to, as it required the involvement of a surrogate decision-maker for residents without decision-making capacity. The facility's failure to notify the POA of the resident's financial activities was a violation of the resident's rights and placed the resident at risk of making uninformed decisions due to her medical condition.
Failure to Maintain Comfortable Sound Levels in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, identified as Resident 5 and Resident 6, by not maintaining comfortable sound levels in their shared room. Resident 5 and Resident 6 experienced disturbances due to their roommate, Resident 1, who played music and watched TV loudly late at night. This noise disrupted their sleep and caused discomfort, which was reported to the facility staff multiple times. Resident 5 was admitted with diagnoses including type 2 diabetes mellitus and depression, requiring maximal assistance for activities of daily living. Resident 6, admitted with diagnoses including diabetes, congestive heart failure, and insomnia, was totally dependent on staff for daily activities. Both residents had intact cognition for daily decision-making. Despite their complaints about the noise and smoke smell from Resident 1, who accessed the smoking patio through their room's sliding door, no care plan was developed to address these issues. Interviews with facility staff, including a Licensed Vocational Nurse, a Certified Nursing Assistant, a Registered Nurse, and the Social Services Director, confirmed awareness of the complaints. However, the facility's policy to provide a pleasant environment with person-centered care plans was not followed, as no care plans were created to mitigate the noise disturbances caused by Resident 1.
Failure to Implement Comprehensive Care Plan for Residents
Penalty
Summary
The facility failed to implement a comprehensive care plan for three residents, leading to a deficiency in addressing their individual needs. Resident 5 and Resident 6 experienced sleep disturbances due to the noise created by their roommate, Resident 1, at night. Despite being aware of the situation, the facility did not develop a care plan to address the complaints of Residents 5 and 6 regarding the noise and disturbances caused by Resident 1. Resident 5 was admitted with diagnoses including type 2 diabetes mellitus and depression, requiring maximal assistance for activities of daily living. Resident 6 was admitted with diagnoses including diabetes mellitus, congestive heart failure, and insomnia, and was totally dependent on staff for activities of daily living. Both residents had intact cognition for daily decision-making. They complained about Resident 1's behavior, which included playing loud music, watching TV late at night, and allowing smoke to enter their room from the patio. Resident 1, who was admitted with chronic obstructive pulmonary disease, unspecified dementia, and major depressive disorder with psychotic symptoms, was independent in activities of daily living and was taking antipsychotic medications. Despite multiple complaints from Residents 5 and 6, and acknowledgment from staff including the Social Services Director, Licensed Vocational Nurse, Certified Nursing Assistant, and Registered Nurse, no care plan was developed to address Resident 1's nighttime behavior or the complaints of Residents 5 and 6.
Failure to Assess Smoking Safety for Resident
Penalty
Summary
The facility failed to ensure that a resident who was a smoker was properly assessed for their ability to smoke safely before being allowed to smoke independently. The resident, who was admitted with diagnoses including nicotine dependence, COPD, unspecified dementia, and major depressive disorder with psychotic symptoms, was not given a specific care plan regarding smoking safety. The Minimum Data Set indicated the resident had modified independence cognition and was independent in activities of daily living, but the smoking assessment completed by a registered nurse inaccurately stated that the resident did not smoke. The registered nurse admitted to not conducting a thorough and accurate assessment, which led to the resident being at risk of smoking-related accidents. Despite the facility's policy requiring a safe smoking assessment and care plan for residents who wish to smoke, this was not followed. The resident's family had informed the nurse that the resident should not smoke due to COPD and a physician's order, but this information was not accurately reflected in the assessment or care plan.
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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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