Anaheim Terrace Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 141 South Knott Avenue, Anaheim, California 92804
- CMS Provider Number
- 056076
- Inspections on file
- 39
- Latest survey
- December 24, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Anaheim Terrace Care Center during CMS and state inspections, most recent first.
A resident who experienced poor oral intake and low BP was not monitored every shift for at least 72 hours following a change in condition, as confirmed by medical record review and staff interviews. Required documentation of ongoing monitoring was missing for three consecutive shifts.
A resident's medical record, including essential discharge documentation, was incomplete and not accessible when requested. The facility was unable to provide the full record due to missing documentation and incomplete tracking logs for records stored offsite, resulting in a failure to demonstrate that proper discharge planning and teaching were provided.
Surveyors observed that food preparation equipment was stored wet, kitchen utensils and surfaces were not properly cleaned, and food items in the refrigerator were either unlabeled or past their use-by dates. The Dietary Services Supervisor confirmed these lapses, which affected the majority of residents receiving kitchen services.
Two residents were administered new or increased psychotropic medications without informed consent being obtained prior to administration. In one case, trazodone was given before consent was documented, and in another, quetiapine was administered at one dosage without any record of consent, despite the resident's cognitive impairment. Facility staff confirmed the absence of required consent documentation.
A resident was found with artificial tears eye drops at their bedside and attempted to self-administer the medication without a documented assessment or physician's order authorizing self-administration, as required by facility policy. Staff confirmed that the medication should not have been left at the bedside and that the necessary assessment was not completed.
A resident dependent on GT feeding experienced a significant change in condition, including abdominal distention and respiratory symptoms. Although a nurse obtained STAT orders for imaging, there was a delay in both performing the imaging and communicating the abnormal results—severe colonic distention and possible aspiration—to the physician. The physician was not notified until over seven hours after the facility received the reports, resulting in a delayed transfer to acute care. Facility policy requiring immediate physician notification for significant changes was not followed.
A resident with moderate cognitive impairment had a wallet in their possession that was not documented on the Inventory of Personal Effects form, as required by facility policy. Staff were aware of the wallet but failed to list it, which was discovered after the resident reported the wallet missing. The omission was confirmed by the SSD and an LVN, and acknowledged by the ADON.
Two residents receiving psychotropic medications were not properly monitored as required, with missing or incomplete documentation of orthostatic blood pressure and nonpharmacological interventions. Nursing staff failed to consistently implement or record non-drug interventions before administering medications, and PRN medications were sometimes given without proper justification. Facility leadership and clinical staff confirmed these lapses in required monitoring and documentation.
A resident discharged to an assisted living facility did not have documented evidence in their medical record of receiving the required written notice of discharge or discharge summary. Staff interviews confirmed that the discharge process should include these documents, but they were unable to provide proof that the resident received them as required by facility policy.
A resident was admitted with an anxiety disorder and later developed major depressive disorder and bipolar disorder, but the facility did not update the PASARR screening to reflect these new serious mental illness diagnoses. The ADON confirmed that the PASARR was not completed or referred as required after the new diagnoses, resulting in an inaccurate assessment of the resident's mental health needs.
The facility did not develop or implement comprehensive care plans for two residents with dementia and depressive symptoms, and failed to follow a fall prevention care plan for another resident, as required by physician orders and facility policy. These deficiencies were confirmed through record review, staff interviews, and direct observation.
A physician's order for weekly orthostatic BP monitoring, including while standing, was not completed for a resident who could not stand without assistance. The order was not clarified to match the resident's functional status, and the standing BP checks were not performed as required.
Two residents were not protected from accident hazards due to the facility's failure to implement bilateral floor mats as ordered by a physician for one resident at risk for falls, and failure to obtain a physician's order or care plan for another resident who repeatedly left the facility on pass. These lapses were confirmed through observation, record review, and staff interviews.
Three residents did not receive oxygen therapy as ordered by their physicians, with staff administering incorrect oxygen flow rates or failing to document the need for and administration of PRN oxygen. Staff confirmed that the oxygen provided did not match physician orders, and required documentation was missing from the medical records.
Three residents did not receive pain management in accordance with physician orders, as pain assessments were not consistently documented every shift, and pain medications were administered outside of the prescribed pain level parameters. Non-pharmacological interventions were also not documented prior to medication administration, contrary to facility policy and orders. Facility staff confirmed these deficiencies during interviews and record reviews.
Two residents receiving dialysis care experienced incomplete and inaccurate documentation of their dialysis treatments, including missing assessments of access sites and failure to record fluid intake as ordered. Additionally, blood pressure medications were not documented as administered after dialysis, despite physician orders. Facility leadership and nursing staff confirmed these deficiencies during interviews.
The facility did not ensure proper documentation and administration of controlled medications for two residents, as doses were removed from the supply but not recorded in the MAR. Additionally, a resident received blood pressure medication without required documentation of BP readings, and the medication was not held as ordered when BP exceeded specified parameters. The ADON confirmed these documentation and administration failures.
A licensed nurse failed to administer the full dose of zinc and vitamin D3 to a resident receiving medications via gastrostomy tube, leaving significant residue in medication cups. This resulted in a medication error rate of 5.13%, exceeding the acceptable threshold, as confirmed by staff interviews and direct observation.
Surveyors found that expired and discontinued medications were not removed from medication carts, some medications were not labeled with opened dates, and oral and external medications were stored together. Insulin and eye drops were kept beyond their discard dates, and medication storage areas were unsanitary. Nursing staff and leadership confirmed these practices did not follow facility policy.
A cook did not follow the prescribed recipe for pureed spaghetti by omitting margarine and non-fat dry milk powder while preparing meals for residents on a pureed diet. This deviation from the recipe was confirmed by both the cook and the Dietary Services Supervisor, and it affected several residents who required pureed food to meet their nutritional needs.
Surveyors found that food brought in by visitors for residents was not stored according to facility policy, with the residents' refrigerator observed at 70°F due to being overfilled and left partially open. Additionally, a food container was found without required labeling for date and use by date. Both an LVN and the ADON acknowledged these deficiencies in food storage and labeling practices.
Surveyors observed a large accumulation of unused items and refuse, including soiled bins, broken equipment, and trash, left in the facility compound. The Maintenance Director confirmed these items were not in use and should have been discarded, acknowledging that their presence could attract pests. Facility policies require daily removal of garbage and maintenance of litter-free grounds, but these procedures were not followed.
Multiple documentation errors were identified, including a resident's EHR containing another individual's PASRR screening, inaccurate MAR entries for two residents on apixaban, an incorrect psychiatric diagnosis listed for a resident, a POLST form indicating an advance directive that did not exist, and an incomplete discharge summary for a resident transferred to a hospital. These issues were confirmed by facility staff and leadership.
The facility did not provide documentation that its QAPI committee monitored the effectiveness of corrective actions for previously cited deficiencies related to informed consents, medication records, kitchen sanitation, and immunization status. Although specific audits and reviews were outlined in the plans of correction, there was no evidence that the QAPI committee evaluated or tracked the outcomes of these actions.
Staff were observed storing a resident's food items on the floor and leaving unlabeled basins in shared restrooms. LVNs and the ADON confirmed these practices did not meet infection control standards, as personal items and care equipment should be properly labeled and stored to maintain a sanitary environment.
A resident with decision-making capacity was not offered the annual influenza vaccine as required by facility policy, and there was no documentation of the offer or consent in the medical record. Interviews with the IP, ADON, and DSD confirmed the absence of required documentation and the expectation that the vaccine be offered and consent obtained each year.
A resident who had previously declined the COVID-19 vaccine was not offered the vaccine or informed consent again on an annual basis, as required by facility policy. Review of the medical record and staff interviews confirmed the absence of documentation showing that the vaccine was offered annually, and facility staff acknowledged this lapse.
The facility failed to provide necessary care for two residents, leading to deficiencies in their treatment. A resident experienced a delay in receiving Ciprodex Otic suspension for ear pain due to lack of follow-up by the LVN. Another resident did not receive the prescribed ceftriaxone sodium IV medication as there was missing documentation and the medication was not delivered by the pharmacy. The DON confirmed these issues, emphasizing the importance of proper documentation in the MAR.
A resident was not administered the correct probiotic as ordered, receiving acidophilus instead of the prescribed saccharomyces boulardii. Interviews with LVNs confirmed the discrepancy, and the DON acknowledged that the nurses should have clarified the order with the physician.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in equipment management. A resident's oxygen tubing was not changed weekly, and their CPAP mask was improperly stored. Another resident's suction equipment was not maintained according to policy, with dried secretions present. A third resident's oxygen tubing was improperly stored and not changed weekly. Staff confirmed these findings, indicating non-compliance with care orders.
A resident was found with medications in their bedside drawer without being assessed for self-administration, as required by facility policy. The resident placed the medications in the drawer after the nurse left, as they did not want to take them all at once. The DSD confirmed the need for an assessment and physician's order, while the LVN admitted to not staying with the resident until all medications were taken.
A resident with severe cognitive impairment exhibited aggressive behavior, hitting another resident, due to inadequate management and lack of a care plan. Despite previous aggressive incidents, the facility failed to notify the physician or implement interventions to prevent further harm. Staff interviews revealed a lack of communication and awareness about the resident's behavior, contributing to the incident.
A facility failed to promote the dignity and respect of a resident during meal assistance. A CNA was observed standing over a resident while feeding her in bed, which was confirmed during an interview. This action did not align with treating the resident with respect, highlighting a deficiency in upholding the resident's rights.
A resident's call light was not accessible, violating facility policy. The call light was tied to the bed's handrail, out of reach for the resident in a wheelchair. The resident confirmed she couldn't reach it, and a CNA acknowledged the oversight. The DON was informed of the issue.
The facility failed to employ a full-time qualified individual to oversee food service operations, as required by the California Health and Safety Code. The Dietetic Services Supervisor (DSS) and Registered Dietitian (RD) worked part-time, and the full-time Dietary Manager was not certified. This non-compliance potentially jeopardized the health and well-being of 82 residents consuming food prepared in the facility's kitchen.
The facility failed to meet food safety and sanitation standards, including improper monitoring of TCS foods, inadequate labeling of refrigerated items, and unsanitary conditions for kitchen utensils and equipment. These deficiencies posed a risk of foodborne illnesses to residents consuming food prepared in the kitchen.
The facility failed to maintain effective infection control practices, including not adhering to Enhanced Barrier Precautions for residents, improper hand hygiene by staff, and inadequate infection control in the laundry room. Additionally, there were lapses in following contact precautions for a resident with an ESBL UTI, and the facility lacked consistent documentation of testing protocols for Legionella in the water system.
The facility failed to ensure antibiotics were prescribed and administered under the guidance of their antibiotic stewardship program. Antibiotics were prescribed to residents without meeting McGeer's criteria for a true infection, and there was no documentation of notifying physicians or tracking outcomes and adverse events. These failures could lead to unnecessary antibiotic use and antibiotic resistance.
The facility failed to maintain the ice machine according to the manufacturer's specifications, using incorrect cleaning and sanitizing products. This oversight, acknowledged by the Maintenance Director, DON, and Administrator, could potentially lead to food-borne illnesses among residents, as 83 out of 87 residents consumed food prepared in the kitchen.
A resident reported that his grievance about shrunken shoes and missing socks was not resolved by the facility. Despite the facility's policy requiring grievances to be documented and resolved promptly, the Administrator acknowledged remembering the grievance but did not document or follow up on it. The resident, who had no cognitive impairment, had spoken to the Administrator months ago about the issue.
A resident with renal failure experienced repeated delays in receiving dialysis due to transportation issues. Despite being scheduled for dialysis at specific times, transportation was often late or a no-show, leading to missed or delayed treatments. The facility failed to follow up with the resident's insurance carrier to resolve these issues, impacting the resident's health and routine.
A resident with fluctuating decision-making capacity was administered an increased dosage of mirtazapine without obtaining informed consent, as required by the facility's policy. Interviews and medical record reviews confirmed the absence of completed informed consent forms, with verification from the LVN, Medical Records Director, and DON.
The facility failed to accommodate the needs of two residents, impacting their care. One resident was unable to reach her meal tray due to improper bed positioning, despite needing assistance with eating. Another resident could not access the call light, as it was clipped out of reach, despite having fluctuating decision-making capacity. These oversights were confirmed by staff during observations.
The facility failed to provide the SNF ABN Form CMS-10055 to two residents, which is necessary to inform them of potential financial liabilities for services not covered by Medicare. The Business Office Manager acknowledged the oversight during a review, noting that the form was not given to the residents despite the facility's policy requiring advance notice of billing changes.
The facility failed to maintain privacy and confidentiality for three residents. A nurse did not fully close a privacy curtain during a procedure for a resident, and missing blind slats exposed the resident to an outside walkway. Additionally, unattended computer screens displayed personal and medical information of two residents, compromising their confidentiality. Staff acknowledged these oversights.
The facility failed to maintain a clean and homelike environment, as evidenced by dirty and stained carpets affecting mobility, walls with missing paint, and improperly hung curtains. A resident's room also had missing blind slats, compromising privacy. These issues were acknowledged by the facility's administrator and staff.
The facility failed to provide timely written notification of transfer or discharge to the resident's representatives and the LTC Ombudsman for two residents transferred to an acute care hospital. Despite physician orders for the transfers, the medical records lacked evidence of the required notifications. The Medical Records Department confirmed the absence of these notifications, acknowledging their responsibility to send them.
The facility failed to provide a written bed hold policy to two residents or their representatives upon transfer to an acute care hospital, as required by their policy. Despite the facility's policy mandating that the notice be provided within 24 hours of emergency transfers, this was not done for two residents, one with fluctuating decision-making capacity and another with full capacity. The MRD confirmed the oversight, acknowledging their responsibility to send the notices but failing to do so.
A resident was admitted without a mental illness diagnosis but later prescribed antipsychotic medications for psychosis. The facility failed to coordinate a level II PASRR assessment despite the resident's new mental disorder, as confirmed by RN 1 responsible for PASRR coordination.
A facility failed to conduct a new Level 1 PASRR Screening for a resident with a diagnosed mental illness after an acute care hospital discharge exemption lapsed. The resident remained in the facility for over two months without a new screening, risking the omission of a necessary Level II Mental Health Evaluation. This deficiency was confirmed during a review with an RN.
Failure to Monitor Resident After Change in Condition
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain the highest practicable well-being for a resident who experienced a change in condition. Specifically, after the resident was observed to have poor oral intake and low blood pressure, there was no documented evidence that the resident's condition was monitored every shift for at least 72 hours as required. Medical record review showed gaps in monitoring during three consecutive shifts following the initial change in condition. Interviews with nursing staff confirmed that the resident's medical record did not contain documentation of shift-by-shift monitoring after the change in condition was identified. Staff acknowledged that residents with a change in condition should be monitored every shift for a minimum of 72 hours, and that this monitoring should be documented in the medical record. The lack of documentation indicated that the required monitoring was not performed or recorded as per facility protocol.
Incomplete and Inaccessible Medical Record for Discharged Resident
Penalty
Summary
The facility failed to maintain a complete and readily accessible medical record for one of eight sampled residents. Specifically, the medical record for a resident who had been discharged was incomplete and not available upon request, as required by the facility's policies and procedures. The missing documentation included physician's orders, assessments, progress notes, and discharge planning information. This lack of documentation meant the facility could not demonstrate that appropriate discharge planning and teaching had been provided to the resident and their family member. Interviews with the Medical Records Director revealed that discharged residents' medical records were sent to an offsite storage company and were supposed to be retained for ten years. However, when the record was requested, it could not be located among the boxes received from storage, and the log used to track the location of stored records was incomplete and missing key information. As a result, the facility was unable to provide the required documentation for the resident's discharge, in violation of its own policies.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to follow food safety and sanitation guidelines in several key areas, as observed during a kitchen inspection and interviews with the Dietary Services Supervisor (DSS). Food preparation equipment, such as a red blender, was found stored while still wet, contrary to USDA Food Code requirements for air-drying to prevent microorganism growth. Additionally, kitchen equipment and utensils were not maintained in a sanitary condition: a red cutting board was heavily marred and had food residue, multiple red insulated plate bases were dusty, and two oven tray sheet pans had heavy dark brown residue. The DSS confirmed these items were ready for use and should have been properly cleaned or replaced. Further deficiencies were noted in the storage of food items. In the walk-in refrigerator, bins containing chopped strawberries and blueberries lacked date labels indicating when they were prepared, and 31 small cups of ranch dressing were found with expired use-by dates. The DSS acknowledged that all prepared, ready-to-eat food items should be labeled with preparation and use-by dates, and that expired items should be discarded. These failures were identified while 87 of 94 residents were receiving food from the kitchen.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering new or increased psychotropic medications for two residents. For one resident, trazodone was administered for depression before informed consent was obtained, as documented by a physician's order and a subsequent consent form completed after the medication had already been started. The Assistant Director of Nursing (ADON) confirmed that the medication was given prior to obtaining the required consent. For another resident with moderately impaired cognition and a diagnosis of schizoaffective disorder, quetiapine fumarate was ordered and administered in two different dosages. While informed consent was obtained for the 100 mg bedtime dose, there was no documentation of informed consent for the 50 mg daily dose, despite the medication being administered regularly. The ADON and Administrator both verified that the required consent for the 50 mg dose was not present in the medical record.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident was found with a bottle of artificial tears eye drops on their bedside table, which had been left there by a medication nurse three days prior. The resident attempted to self-administer the medication but was unable to do so. There was no documentation in the resident's medical record indicating that an assessment had been completed to determine if self-administration of medication was clinically appropriate or safe for the resident, as required by the facility's policy and procedure. The policy specifies that the interdisciplinary team (IDT) must assess a resident's cognitive and physical abilities before allowing self-administration of medication. Further review of the resident's medical record confirmed the absence of an assessment or a physician's order authorizing self-administration of the eye drops. Both a licensed vocational nurse (LVN) and the assistant director of nursing (ADON) verified that the medication should not have been kept at the bedside and acknowledged that the required assessment and order were missing. The resident had the capacity to make medical decisions, as documented in their history and physical examination, but the necessary steps to ensure safe self-administration were not followed.
Failure to Timely Notify Physician of Change in Condition and Abnormal Imaging Results
Penalty
Summary
The facility failed to ensure timely physician notification and intervention for a resident who experienced a significant change in condition. The resident, who was dependent on gastrostomy tube (GT) feeding, was observed with a distended abdomen and had a care plan in place requiring monitoring and reporting of symptoms such as aspiration, fever, shortness of breath, tube dislodgement, infection, abdominal pain, distention, and tenderness. On the day of the incident, the resident exhibited chest congestion, cough, and abdominal distention, prompting a licensed nurse to notify the physician and obtain orders for STAT chest x-ray, KUB, and labs. Despite these orders, there was a significant delay in both the completion of the imaging and the communication of the results to the physician. The radiology reports, which indicated severe colonic distention and possible aspiration or developing consolidation, were transmitted to the facility late at night. However, documentation showed that the physician was not notified of these critical findings until more than seven hours after the reports were received. Interviews with nursing staff revealed that attempts to contact the physician were either not made in a timely manner or not documented, and there was a lack of follow-up as required by facility policy when the physician could not be reached. The delay in notifying the physician and obtaining further orders resulted in a late transfer of the resident to an acute care hospital for evaluation and treatment. The facility's policy required immediate notification of the physician and resident representatives in the event of a significant change in condition, but this protocol was not followed. The deficiency was confirmed through observation, interviews, medical record review, and review of facility policies and procedures.
Failure to Safeguard Resident's Personal Property Due to Incomplete Inventory Documentation
Penalty
Summary
The facility failed to provide reasonable care for the protection of a resident's personal property, specifically by not listing the resident's wallet on the Inventory of Personal Effects form as required by facility policy. The policy states that all personal items brought into the facility must be documented on the inventory form, with signatures from the resident or their representative and a staff member. Despite this, the resident's wallet was not recorded, and both the Social Services Director (SSD) and an LVN confirmed that the wallet was in the resident's possession but not listed in the inventory. The resident involved had moderate cognitive impairment, as indicated by their MDS assessment. The omission was discovered after the resident reported his wallet missing, though it was subsequently found by staff. Interviews with the SSD and LVN revealed awareness of the resident's possession of the wallet, but both acknowledged that it should have been documented in the inventory to ensure proper safeguarding of the resident's belongings. The Assistant Director of Nursing (ADON) was informed and acknowledged these findings.
Failure to Monitor and Document Psychotropic Medication Use and Required Interventions
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications and that required monitoring and nonpharmacological interventions were implemented and documented as ordered. For one resident with moderately impaired cognition and diagnoses including schizoaffective disorder, depression, and anxiety, physician orders and care plans required regular monitoring of orthostatic blood pressure (BP) in multiple positions and the use of non-drug interventions prior to administering psychotropic medications such as quetiapine, aripiprazole, duloxetine, and lorazepam. However, medical record reviews revealed that orthostatic BP was not accurately or fully documented, with missing readings for required positions. Additionally, when behavioral episodes such as inconsolable screaming, anxiety, and disorganized speech were observed, the nonpharmacological interventions were either not attempted, not documented, or marked as 'not applicable' or '0', even when the behaviors were present and medications were administered. Further review of medication administration records showed that the resident received PRN lorazepam on multiple occasions without documentation of attempted or effective nonpharmacological interventions, and sometimes even when no behavioral episode was documented. Interviews with nursing staff and the ADON confirmed that the required interventions and documentation were not consistently completed, and that PRN medications were sometimes given despite documentation that nonpharmacological interventions were effective or not attempted at all. The ADON also verified that orthostatic BP monitoring was incomplete and not properly recorded in the resident's records. For a second resident, also with moderately impaired cognition and prescribed quetiapine for psychosis, physician orders and care plans required weekly orthostatic BP monitoring in different positions to detect potential orthostatic hypotension. However, medication administration records showed that BP readings were either identical across different positions or missing for some positions, indicating that the monitoring was not performed as ordered. The ADON confirmed that BP readings should differ between positions and acknowledged the incomplete documentation. Facility leadership was informed of these findings and acknowledged the deficiencies.
Failure to Provide Discharge Notice and Summary Documentation
Penalty
Summary
The facility failed to provide the required notice of discharge and discharge summary documentation for one of three sampled residents reviewed for closed records. Specifically, a resident who was admitted to the facility and later discharged to an assisted living facility did not have documented evidence in their medical record that they received the written notice of discharge or the discharge summary at the time of discharge. The facility's policy requires that such documentation be provided to the resident and/or their representative and included in the medical record. Interviews with facility staff, including the ADON and SSD, confirmed that the discharge process should include a transfer/discharge packet with the necessary documents, which are to be signed by the resident and documented in the medical record. However, both staff members were unable to produce evidence that these documents were completed or provided to the resident in question. The findings were acknowledged by the DSD and Administrator during the survey.
Failure to Update PASARR Following New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) process was accurate and updated for one resident. Upon admission, the resident had a diagnosis of anxiety disorder, and later developed additional diagnoses of major depressive disorder and bipolar disorder. The initial PASARR Level I Screening indicated that the resident did not have a serious mental illness, despite the presence of anxiety disorder at the time. The facility's policy required that all admissions have the appropriate PASARR completed and that state-specific guidelines be followed. Further review of the resident's medical record showed that no updated PASARR screening was completed when the resident was subsequently diagnosed with bipolar disorder and major depressive disorder after admission. During an interview, the ADON confirmed responsibility for ensuring PASARR accuracy and acknowledged that the screening should have been updated and referred accordingly when the new diagnoses were made. The failure to update the PASARR meant the resident's mental health status was not accurately reflected or reassessed as required.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents as required by its own policies and federal regulations. For one resident at risk for falls due to cognitive loss and lack of safety awareness, the care plan specified the use of bilateral floor mats. However, during multiple observations, only one floor mat was in place, and the other side of the bed was left without a mat, contrary to the care plan's interventions. This failure was confirmed by the Director of Staff Development (DSD) during an interview and observation. Additionally, the facility did not create care plans to address the use of dementia medications (Aricept and Namenda) for another resident, despite physician orders for these medications. The Assistant Director of Nursing (ADON) confirmed that a care plan should have been initiated for these medications but was missed. Another resident with documented depressive symptoms and ongoing psychological evaluation and treatment also lacked a care plan addressing these mental health needs. The ADON verified that the care plan problem for depressive signs and symptoms was not developed as required.
Failure to Clarify and Complete Orthostatic BP Monitoring Order
Penalty
Summary
A deficiency occurred when a physician's order for weekly orthostatic blood pressure (BP) monitoring while lying, sitting, and standing was not properly clarified or followed for one resident. The resident's medical record showed that the standing BP checks were not completed as ordered. During an interview and concurrent record review, the ADON confirmed that the resident was unable to stand without assistance from two staff members, making the standing BP check inappropriate for the resident's functional level. The physician's order was not clarified to reflect the resident's actual abilities, resulting in the order not being carried out as written.
Failure to Implement Fall Prevention Measures and Secure Physician Orders for Resident Passes
Penalty
Summary
The facility failed to ensure that two residents were free from accident hazards and that adequate supervision and physician oversight were provided. For one resident, a physician's order dated 10/25/24 required the use of bilateral floor mats due to the resident's risk for falls associated with cognitive loss and lack of safety awareness. However, multiple observations on 5/19/25 revealed that only one floor mat was in place at the bedside, contrary to the physician's order, and this was confirmed by the Director of Staff Development (DSD). For another resident, the facility did not obtain a physician's order prior to the resident going out on pass, as required by the facility's policy. Medical record review showed no such order or care plan allowing the resident to leave the facility unsupervised, despite documentation that the resident had left the facility for extended periods over several months. The Assistant Director of Nursing (ADON) confirmed that the resident frequently went out on pass and that there was no physician's order or care plan in place for these absences.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to three residents by not following physician orders for oxygen administration. For one resident, the oxygen concentrator was set at three liters per minute (LPM), but the nasal cannula was not in the resident's nose, and there was no documentation in the medical record or medication administration record (MAR) to indicate that oxygen was needed or administered as ordered. The resident's physician order specified oxygen at two LPM via nasal cannula as needed for shortness of breath, with titration to maintain oxygen saturation at or above 90%, and required documentation of administration and the reason for use. However, there was no evidence of shortness of breath, low oxygen saturation, or documentation of PRN oxygen administration in the records. Additionally, another resident was observed receiving six LPM of oxygen via nasal cannula, while the physician's order specified continuous oxygen at two LPM. A third resident was observed receiving five LPM of oxygen, despite a physician's order for three LPM. In both cases, staff verified that the oxygen being administered did not match the physician's orders. These discrepancies were confirmed through observation, staff interviews, and medical record reviews, indicating a failure to ensure that oxygen therapy was provided as prescribed.
Failure to Follow Pain Management Protocols and Documentation Requirements
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents by not following physician orders for pain assessment, documentation, and medication administration. For two residents, physician orders required pain to be monitored and documented every shift, but medical record reviews showed that pain assessments were not consistently performed or recorded as ordered. In several instances, pain levels were only documented sporadically, and there were gaps in the monitoring records for entire shifts. Additionally, pain medications were not administered according to the prescribed pain level parameters. One resident received acetaminophen for a pain level below the ordered threshold, and another resident was given hydrocodone-acetaminophen for pain levels that did not meet the criteria for severe pain as specified by the physician's order. These deviations from the prescribed medication protocols were verified by facility staff during interviews and record reviews. The facility also failed to ensure that non-pharmacological interventions were attempted and documented prior to administering pain medications, as required by both physician orders and facility policy. For one resident, there was no documentation of non-pharmacological pain interventions before medication administration, and staff confirmed that these interventions should have been implemented and recorded. The lack of adherence to pain management protocols and documentation requirements was acknowledged by the ADON, LVN, and other facility leadership during interviews.
Failure to Ensure Complete Dialysis Documentation and Adherence to Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents requiring such services, as evidenced by incomplete and inaccurate documentation and failure to follow physician orders. For one resident, the Hemodialysis Communication Records were missing critical information such as documentation of the dialysis access site, swelling, drainage, pain, and whether there were new orders from the dialysis center. The records also showed inconsistencies regarding the type of access site being used, and there was a lack of documentation for required assessments like bruit and thrill. These omissions were verified by both nursing staff and the Assistant Director of Nursing (ADON), who confirmed that the records should have been completed accurately to ensure proper assessment and monitoring of the resident's condition before and after dialysis treatments. Another resident's care was similarly deficient, with Hemodialysis Communication Records missing documentation of post-dialysis assessments, including thrill, site type, swelling, drainage, pain, and post-hemodialysis complications. Additionally, the facility failed to accurately document and monitor the resident's fluid restriction as ordered by the physician. Instead of recording the actual fluid intake, staff marked the medication administration record (MAR) with an "X" each shift, and there was no documentation of fluid intake during meals by certified nursing assistants (CNAs). The ADON and nursing staff acknowledged that the fluid restriction was documented incorrectly and that there was no record of total fluid intake per meal. Furthermore, the facility did not ensure that blood pressure medications were administered to the resident after dialysis as per physician orders. On multiple occasions, the MAR indicated the resident was away for dialysis, but there was no documentation that the medications were given upon the resident's return, despite orders allowing for post-dialysis administration. The ADON confirmed the absence of documentation for these medications on the relevant dates. These failures were acknowledged by facility leadership during interviews and had the potential to prevent the identification of negative outcomes for residents receiving dialysis.
Failure to Document and Administer Medications per Physician Orders
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by discrepancies in the documentation and administration of controlled medications and blood pressure medication. For two residents, doses of controlled medications (tramadol and Norco) were removed from the supply as recorded in the controlled drug logs, but there was no corresponding documentation in the Medication Administration Records (MAR) to show that these medications were administered. The Assistant Director of Nursing (ADON) confirmed that the doses should have been documented in the MAR, and acknowledged the lack of documentation for these administrations. Additionally, for another resident, the facility did not follow physician orders regarding the administration of midodrine, a medication for low blood pressure. The physician's order specified that the medication should be held if the systolic blood pressure (SBP) was greater than 130 mmHg. However, the MAR showed that the medication was administered without documentation of blood pressure readings prior to administration, and on two occasions, the medication was given when the SBP exceeded the hold parameter. The ADON verified that there was no documentation of blood pressure readings prior to administration and that the medication should have been held based on the recorded blood pressure values.
Medication Error Rate Exceeds 5% Due to Incomplete Administration via GT
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 5.13%. During a medication administration observation, one licensed nurse (LVN 1) did not administer the complete dose of two medications—zinc and vitamin D3—to a resident receiving medications via a gastrostomy tube (GT). After administration, significant residue of these medications was found in the medication cups, indicating that the full prescribed doses were not delivered as ordered. The facility's policies and procedures require that medications be fully administered according to prescriber orders and that medications given via enteral tube be properly diluted and mixed to ensure complete dosing. Interviews with LVN 1, the Assistant Director of Nursing (ADON), and other facility leadership confirmed that the expected practice is to add water and thoroughly mix any medication residue to ensure the entire dose is administered. LVN 1 acknowledged the failure to do so during the observed medication pass. The incident involved a resident with multiple medical conditions, including diabetes, hypertension, and the need for enteral feeding, who was prescribed several medications and supplements. The incomplete administration of zinc and vitamin D3 was directly observed and verified by facility staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices across two medication rooms and three medication carts. Expired medications were not removed after their discard or use-by dates, and discontinued medications for two residents remained on the medication carts without active orders. Additionally, some medications, such as eye drops and insulin, were not labeled with the opened date as required, and an insulin vial and flexpen were retained beyond the 28-day discard period. Orally administered medications were stored together with externally used medications, such as suppositories and topical solutions, contrary to facility policy. During inspections, surveyors observed that oral and external medications were stored together in both medication carts and storage rooms. In one instance, a box of bisacodyl suppositories was stored with oral medications, and acetylcysteine solution was stored beside lidocaine patches. A bottle of doxycycline had an illegible expiration date, and a discontinued topical medication was not properly disposed of. The medication storage room was also found to be unsanitary, with visible dust, debris, and discarded items on the floor. Interviews with nursing staff and facility leadership confirmed that the observed deficiencies were contrary to facility policies, which require proper labeling, timely removal of expired and discontinued medications, and separate storage of oral and external medications. Staff acknowledged that the responsibility for medication storage, cleanliness, and removal of discontinued or expired medications rested with the assigned licensed nurse, and that these procedures had not been followed as required.
Failure to Follow Pureed Diet Recipe During Meal Preparation
Penalty
Summary
The facility failed to ensure that the menu and recipes were followed when preparing pureed spaghetti for residents requiring a pureed diet. During observation, a cook was seen preparing seven servings of pureed spaghetti by measuring and blending the spaghetti with hot water but did not add margarine and non-fat dry milk powder as specified in the facility's recipe. The cook confirmed during an interview that these ingredients were omitted and acknowledged that the recipe required their inclusion. Review of facility documents showed that six residents were receiving pureed food from the kitchen, and the facility's policies required food to be prepared according to recipes to conserve nutritive value and meet residents' needs. The Dietary Services Supervisor (DSS) also confirmed that the cook should have followed the recipe when preparing pureed food. The failure to follow the recipe had the potential to result in meals that did not meet the nutritional needs of residents on a pureed diet.
Improper Storage and Labeling of Resident Food Brought by Visitors
Penalty
Summary
The facility failed to implement its policy and procedure regarding the storage and labeling of food brought in by family and visitors for residents. During an inspection of the residents' refrigerator, it was observed that the refrigerator door was partially open and the unit was overfilled with food, preventing the door from closing properly. The temperature inside the refrigerator was recorded at 70 degrees Fahrenheit, which is significantly above the required maximum of 41 degrees Fahrenheit as stated in the facility's policy. Additionally, a plastic container with two tacos was found inside the refrigerator without a label indicating the current date and use by date, contrary to the facility's policy that requires all such items to be labeled and discarded after 48 hours. These observations were verified by an LVN, who acknowledged that the refrigerator should be kept closed and at the correct temperature, and that food items should be properly labeled. The ADON was also informed of and acknowledged these findings. The failure to maintain proper storage conditions and labeling for food brought in by visitors represents a deviation from the facility's established policies and procedures.
Improper Disposal of Unused Items and Accumulation of Refuse
Penalty
Summary
The facility failed to properly dispose of unused items, as required by its own policies and procedures. During an observation, a large pile of items including plastic storage drawers, a wheelchair, a laundry cart in disrepair, a soiled laundry bin, bed wires, plastic bags, metal boxes, a front wheel walker, a bedside commode, and two trash bins, all covered in dust, was found in the facility compound on the left side of the building. The Maintenance Director confirmed that most of these items were not in use and needed to be discarded, and acknowledged that their accumulation could attract rodents and pests that carry disease. A review of the facility's policies showed that garbage and trash are not permitted to accumulate and must be removed daily, and that the grounds should be kept free of litter. The Maintenance Director verified the observation and the potential for pest attraction. The Administrator was informed of these findings and acknowledged them during an interview.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, resulting in multiple documentation errors. For one resident, the electronic health record (EHR) contained another individual's PASRR Level 1 screening, which was verified by the Assistant Director of Nursing (ADON) as an upload error. Additionally, the facility's Medication Administration Records (MAR) for two residents contained inaccurate documentation regarding monitoring for side effects of apixaban, an anticoagulant. The MARs indicated changes in condition that were not supported by corresponding progress notes, and the ADON confirmed these were typographical errors made by the same licensed vocational nurse (LVN), with no actual changes in condition reported or observed. Another resident's facesheet inaccurately listed a diagnosis of unspecified schizoaffective disorder, despite no supporting documentation in the history and physical examination, no related medications prescribed, and no evidence from the acute care hospital discharge records. The MDS coordinator clarified that this diagnosis was likely entered in error by a previous staff member and was not an active diagnosis for the resident. Furthermore, a review of a different resident's Physician Orders for Life-Sustaining Treatment (POLST) indicated the presence of an advance directive, but no such document was found in the medical record. The social services director (SSD) confirmed that the resident did not have an advance directive and acknowledged the POLST should have been updated to reflect this. Finally, the discharge summary for another resident who was transferred to an acute care hospital was incomplete, as it did not specify the reason for discharge. The ADON verified that the physician had not documented the basis for the transfer, leaving the discharge summary unfinished. These documentation failures were acknowledged by facility leadership and were not in accordance with the facility's policy on nursing documentation, which requires clear, accurate, and comprehensive records to communicate patient status and care provided.
Failure to Monitor QAPI Plan of Correction for Repeated Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement (QAPI) committee implemented and monitored the effectiveness of its plan of correction for previously cited deficiencies at F552, F812, and F883. According to the facility's QAPI program, the committee is responsible for developing monitoring tools, creating plans of correction, and evaluating corrective actions to ensure residents receive necessary care. However, during an interview and document review, the Administrator was unable to provide documentation that the QAPI committee had monitored the effectiveness of the corrective actions for these deficiencies. Specifically, the plans of correction for F552 involved audits of informed consents and medication records, for F812 included monthly unit inspections and kitchen sanitation audits, and for F883 required maintaining a log of residents' immunization status and regular audits of immunization records. Despite these outlined actions, there was no evidence that the QAPI committee reviewed or evaluated the outcomes of these corrective measures, as required by the facility's own program.
Failure to Maintain Infection Control with Improper Storage and Labeling
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices as evidenced by multiple observations and staff interviews. During an initial tour, a box of juice and a container of creamer belonging to a resident were found placed directly on the floor at the bedside. The attending LVN confirmed that personal belongings, especially food items, should not be stored on the floor due to infection control concerns and should instead be kept in bedside drawers. The ADON also acknowledged that such storage practices do not maintain infection control standards. Additionally, shared restrooms serving multiple residents were found to contain unlabeled basins placed on top of toilet tanks. Staff members, when questioned, were unable to identify the owners of these basins and confirmed that basins in shared restrooms should be labeled for infection prevention and control. The ADON was informed of these findings and acknowledged the lapses. These observations were supported by facility document and policy reviews, confirming that the facility did not ensure proper labeling and storage of personal care items and food, thereby failing to maintain a safe and sanitary environment.
Failure to Offer and Document Annual Influenza Vaccination
Penalty
Summary
The facility failed to ensure that one of five sampled residents was offered the influenza vaccination in accordance with its own policies and procedures. The facility's policy required that all residents without medical contraindications be offered the influenza vaccine annually, with documentation of either acceptance or refusal placed in the resident's medical record. Review of the medical record for the resident in question showed that the last influenza vaccine was administered on 11/4/23, but there was no documented evidence that the vaccine was offered again in the subsequent annual period, nor was there documentation of acceptance or refusal by the resident or their representative. Interviews with the Infection Preventionist (IP), Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) confirmed that the influenza vaccine should be offered annually and that consent forms are used to ensure residents or their representatives are informed of the risks and benefits. However, all parties verified that there was no documentation in the resident's record to show that the vaccine was offered after the last administration. The resident was determined to have the capacity to make medical decisions, and the lack of documentation indicated a failure to follow the facility's established procedures for annual influenza vaccination offers.
Failure to Annually Offer and Document COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccine in accordance with its own policy and procedures. The policy required that each resident be offered the COVID-19 vaccine unless medically contraindicated or already immunized, and that appropriate documentation be made if the vaccine was not administered due to contraindication, prior vaccination, or refusal. Review of the medical record for one resident revealed that after a documented declination of the COVID-19 vaccine by the resident's responsible party, there was no evidence that the vaccine or informed consent was offered again on an annual basis as required by the facility's policy. Interviews with the Infection Preventionist (IP), Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) confirmed that there was no documentation of an annual offer or consent for the COVID-19 vaccine after the initial declination. The staff acknowledged that the vaccine and consent should have been offered annually and that documentation was lacking. The resident in question had the capacity to make medical decisions, and the failure to offer and document the annual vaccine offering was verified by facility staff during the survey.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. Resident 8 experienced a delay in receiving Ciprodex Otic suspension for ear pain. Despite requesting an extension of the medication on 12/22/24, the resident did not receive it until 1/7/25, 16 days later. The licensed nurse, LVN 8, did not follow up with the physician regarding the resident's request, and there was no documentation of any follow-up calls made. The Director of Nursing (DON) acknowledged that the licensed nurses are expected to follow up with the physician for any resident's request or change in condition. Resident 13 did not receive the prescribed ceftriaxone sodium intravenous medication as ordered by the physician. The medication was scheduled to be administered on 12/12/24 at 2100 hours, but there was missing documentation in the Medication Administration Record (MAR) to confirm its administration. RN 1 verified the missing documentation and stated that all medication administration must be documented in the MAR. Further investigation revealed that the ceftriaxone medication was not delivered by the pharmacy, and there was no record of it being removed from the facility's emergency kit. The DON confirmed the missing documentation and stated that the medication was not administered since it was not documented. The DON emphasized that RNs must document in the MAR after administering any IV medications. These failures in medication administration and documentation had the potential to negatively affect the residents' health condition and well-being.
Failure to Administer Correct Probiotic as Ordered
Penalty
Summary
The facility failed to provide the appropriate pharmaceutical services for one of the residents, identified as Resident 8, by not administering the medication as ordered. The facility's policy and procedure (P&P) for medication orders require specific details such as the name, strength, dose, and route of administration. However, Resident 8, who was capable of understanding and making decisions, reported receiving a different probiotic than what was prescribed. The prescribed probiotic was saccharomyces boulardii, but the resident was given acidophilus instead, which led to changes in her bowel movements. Interviews with LVN 3 and LVN 8 confirmed that the resident was administered acidophilus because it was the facility's current supply, despite the order for saccharomyces boulardii. Both LVNs acknowledged the discrepancy between the prescribed and administered probiotics. The Director of Nursing (DON) stated that the nurses should have contacted the physician to clarify and adjust the order to match the available supply, acknowledging the findings of the surveyors.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in the management of respiratory equipment. Resident 3's oxygen tubing was not changed weekly as required, and the CPAP mask was improperly stored, with part of it hanging out of an open bag. This was confirmed by an LVN who verified the tubing was dated 11/24/24, indicating it had not been changed weekly as ordered. Resident 3 used the CPAP at night, and the staff was responsible for storing the equipment. Resident 4's suction equipment was not maintained according to the facility's policy and procedure. The Yankauer tip suction was found with thick brownish dried secretion and was stored in a bag dated 9/21/24, indicating it had not been cleaned or changed as necessary. The suction canister also had brownish dried residue. An IP verified these findings and acknowledged the need for equipment change. Resident 5's oxygen tubing was not stored properly, as it was found hanging over the side rails and not changed weekly as ordered. An LVN confirmed the nasal cannula was exposed and improperly stored, with the bag dated 12/1/24, indicating non-compliance with the weekly change order.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer medications safely. Resident 6 was found with a bottle of sealed Motrin 200 mg, a plastic medication cup containing one tablet of Oscal 500/200 with vitamin D, and two capsules of Docu Soft 100 mg inside the drawer of their bedside table. The resident had not been assessed for self-administration of medications, which is a requirement according to the facility's policy. The policy states that residents can self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team, and this decision must be documented in their medical records and care plans. During an observation and interview, Resident 6 indicated that they placed the medications in the drawer after the licensed nurse left the room, as they did not want to take all the medications at once. The DSD confirmed the presence of the medications and acknowledged that Resident 6 needed to be assessed for self-administration and required a physician's order for the Motrin. Additionally, LVN 3 admitted to not staying with Resident 6 until all medications were taken and confirmed there were no physician's orders, self-administration assessment, or care plan for Resident 6 to self-administer medications.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect Resident 2 from physical abuse by another resident, Resident 1. Resident 1, who had severe cognitive impairment and was unable to make decisions, exhibited aggressive behavior by hitting Resident 2 on the left shoulder and face. This incident occurred after Resident 1 had previously shown signs of aggression, such as pushing a nurse and pulling another staff member's hair, without provocation. Despite these behaviors, the facility did not implement a care plan to address Resident 1's aggression or notify the physician for further intervention. The facility's policies on abuse prohibition and behavior management were not effectively followed. The staff failed to identify and correct the situation where abuse was likely to occur, as Resident 1's aggressive behavior was not adequately managed. The interdisciplinary team did not evaluate Resident 1's behavior comprehensively, and no interventions were put in place to ensure the safety of other residents, including Resident 2. Interviews with staff revealed a lack of communication and awareness regarding Resident 1's aggressive behavior. CNA 1 and LVN 2 were not fully informed about Resident 1's actions, and RN 1 admitted to not initiating a care plan for Resident 1's behavior change. The Director of Nursing and the Administrator acknowledged that the physician should have been notified to manage Resident 1's behavior, but this step was not taken, leading to the incident with Resident 2.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, identified as Resident 2, during meal assistance. On August 7, 2024, at 0835 hours, a Certified Nursing Assistant (CNA 1) was observed standing over Resident 2 while feeding her as she lay in bed. This action was confirmed during an interview with CNA 1 at 0840 hours, where she acknowledged standing over the resident during the feeding process. The incident highlights a deficiency in promoting a dignified existence and respect for the resident's rights, as the manner of feeding did not align with treating the resident with respect.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a violation of their policy on answering call lights. During an observation and interview, it was noted that the call light for a resident, who was sitting in her wheelchair, was tied to the left handrail of the bed and was not within her reach. The resident confirmed that she could not reach the call light and understood the importance of having it accessible in case she needed help. This oversight was confirmed by a Certified Nursing Assistant (CNA), who acknowledged that the call light should have been placed within the resident's reach. The resident involved in this deficiency had been admitted and readmitted to the facility on unspecified dates and had a history and physical examination indicating she had the capacity to understand and make decisions. The Director of Nursing (DON) was informed of the situation and acknowledged the finding that the call light was not within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being, as it hindered her ability to call for assistance when needed.
Deficiency in Food Service Oversight
Penalty
Summary
The facility failed to ensure proper oversight of its food service operations by not employing a full-time qualified individual to manage and oversee these services. According to the California Health and Safety Code, a facility must employ a full-time dietetic services supervisor if the registered dietitian (RD) is not employed full-time. The facility's documentation and interviews revealed that the Dietetic Services Supervisor (DSS) was scheduled to work only part-time, two to three times a week, and the RD worked only once a week. Additionally, the Dietary Manager, who worked full-time, was not certified, which does not meet the regulatory requirements for overseeing dietetic service operations. The Administrator confirmed the part-time status of both the RD and DSS and acknowledged that the Dietary Manager was not certified. Despite the Administrator's belief that the Dietary Manager could be overseen by a part-time DSS, the facility was informed that this arrangement did not comply with the Health and Safety Code requirements. The deficiency was identified through observations, interviews, and a review of facility documents, which showed that the DSS was not present at the facility on a full-time basis, potentially jeopardizing the health and well-being of the 82 residents who consumed food prepared in the kitchen.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation requirements in the kitchen, as observed during a survey. The deficiencies included improper monitoring of Time/Temperature Control for Safety (TCS) foods, which are crucial to limit the growth of illness-causing bacteria. Specifically, the facility did not follow its policy and procedure (P&P) for cooling down hot food items, as evidenced by incomplete documentation on the Cool Down Log. For instance, the cooling process for potato salad and other items was not properly recorded, with missing times and temperatures, which is essential to ensure food safety. Additionally, the facility did not label refrigerated pasta salad with a prepared date and a use-by date, as required by its P&P. This oversight was confirmed during an observation of the Cooks' Refrigerator, where a container of pasta salad was found without proper labeling. Furthermore, the facility failed to discard food past its use-by date, as seen with diced red peppers that were not removed from the refrigerator after their expiration date. The facility also neglected to maintain sanitary conditions for kitchen utensils and equipment. Observations revealed dirty utensils, improperly covered thawing meat, and wet kitchen equipment that was not air-dried before storage. Moreover, the facility did not ensure that kitchen utensils were in good condition, with some items found to be damaged or chipped. Employee beverages were also stored alongside food prepared for residents, which is against the facility's policy. These failures posed a potential risk of foodborne illnesses to the 82 residents consuming food prepared in the kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. One significant issue was the failure to adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures. For instance, a Certified Nursing Assistant (CNA) was observed assisting a resident with a nephrostomy bag without wearing a gown, despite the requirement to do so. This oversight was acknowledged by the Infection Preventionist (IP), who confirmed that the CNA should have donned a gown when providing care. Another deficiency involved improper hand hygiene practices. A Licensed Vocational Nurse (LVN) was observed adjusting a resident's bed control with gloved hands and then proceeding to perform an abdominal assessment without changing gloves. The LVN admitted to the oversight, attributing it to nervousness. Additionally, there was an incident where a stethoscope that had fallen to the floor was not disinfected before being used on a resident, which was confirmed by the LVN involved. The facility also failed to maintain infection control in the laundry room, where soiled linen containers were overflowing, and staff did not wear appropriate personal protective equipment (PPE) when handling dirty linens. Furthermore, there were lapses in following contact precautions for a resident with an ESBL UTI, as visitors and staff entered the room without wearing the required gloves and gowns. The facility also lacked consistent documentation of testing protocols for Legionella and other pathogens in the water system, as verified by the Maintenance Director and Administrator.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure antibiotics were prescribed and administered under the guidance of their antibiotic stewardship program. Specifically, the facility did not monitor and address the use of antibiotics when residents' conditions did not meet McGeer's criteria for a true infection. This issue was identified for six nonsampled residents, who were prescribed antibiotics without meeting the necessary criteria. Additionally, the facility's antibiotic surveillance tracking forms did not include outcome and adverse events for several months, from January 2024 through May 2024. The infection preventionist (IP) acknowledged that residents were prescribed antibiotics without meeting McGeer's criteria and that there was no documented evidence of notifying the residents' physicians, potentially preventing the discontinuation of unnecessary antibiotics. Furthermore, the facility's monthly Infection Prevention and Control Surveillance Logs lacked documentation of outcomes and adverse events related to antibiotic use during the specified months. These failures had the potential to lead to the unnecessary use of antibiotics and the development of antibiotic-resistant bacteria.
Failure to Properly Maintain Ice Machine
Penalty
Summary
The facility failed to maintain essential equipment, specifically the ice machine, in safe operating condition as per the manufacturer's specifications. The ice machine was not cleaned and sanitized using the recommended products, which could potentially lead to food-borne illnesses among residents. The facility's policy and procedure, revised in September 2017, required all food service equipment to be clean, sanitary, and maintained according to the manufacturer's directions. However, the Maintenance Director used Manitowoc Ice Machine Cleaner and Sanitizer instead of the specified Scotsman Clear 1 Scale Remover and Nu-Calgon Sanitizer, as outlined in the Scotsman Ice Systems Installation and User's Manual. During interviews and observations, the Maintenance Director confirmed that he had always used the Manitowoc products, despite the manual's instructions to use specific chemicals for cleaning and sanitizing. This discrepancy was acknowledged by the Director of Nursing (DON) and the Administrator. The report highlights that 83 out of 87 residents consumed food prepared in the kitchen, indicating a widespread potential impact of this deficiency on the resident population.
Failure to Resolve Resident Grievance
Penalty
Summary
The facility failed to follow up on a grievance submitted by a resident, identified as Resident 25, which had the potential to violate the resident's rights to have grievances resolved. The facility's policy and procedure (P&P) on grievances, effective since 8/25/21, mandates that grievances be documented, tracked, and resolved promptly. However, during an interview and observation on 6/11/24, Resident 25 reported that he had spoken to the Administrator months ago about his Sketchers brand shoes being shrunk after being washed in the facility's laundry and requested reimbursement, but the grievance remained unresolved. Additionally, Resident 25 mentioned missing two pairs of socks. A review of Resident 25's medical records indicated no cognitive impairment, and the Administrator confirmed remembering the conversation but admitted to not documenting or following up on the grievance.
Failure to Provide Timely Dialysis Due to Transportation Issues
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis treatment received it at the prescribed time due to transportation issues. The resident, who has a medical history of renal failure, diabetes, and high blood pressure, was scheduled to receive dialysis on Mondays and Fridays at 0415 hours. However, transportation was consistently late or did not show up, causing the resident to miss or delay dialysis appointments. On one occasion, the resident had to cancel an appointment to change his dialysis access site because transportation arrived too late. The resident reported that these transportation issues had occurred multiple times, affecting his ability to receive timely dialysis treatment. Interviews with the Social Services Director and the Director of Nursing (DON) confirmed the ongoing transportation issues. The Social Services Director acknowledged the problem but had only contacted transportation drivers instead of following up with the resident's insurance carrier to resolve the issue. A review of the facility's email correspondence indicated that urgent solutions were needed, but no grievances had been filed with the insurance carrier. The resident expressed frustration with the unreliable transportation, which affected his health and routine, as he was accustomed to receiving dialysis at a specific time.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was informed about the use of psychotropic medications, specifically mirtazapine, which is an antidepressant. The resident, who had fluctuating capacity to understand and make decisions, was administered an increased dosage of mirtazapine without obtaining informed consent. The facility's policy requires verification of informed consent prior to administering psychotropic medications, but this was not adhered to in the case of the resident. Interviews and medical record reviews confirmed that the informed consent forms were not filled out, and there was no verification of informed consent for the increased dosage of mirtazapine. The Licensed Vocational Nurse (LVN), Medical Records Director, and Director of Nursing (DON) all verified that the facility failed to obtain the necessary informed consent for the medication change, highlighting a lapse in following the facility's policies and procedures regarding psychotropic medication administration.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, impacting their ability to receive care and maintain their psychosocial well-being. Resident 5 was observed lying in bed with the head of the bed elevated at 45 degrees, unable to reach her meal tray. Despite requiring setup or cleanup assistance when eating, as noted in her MDS Quarterly assessment, the resident was left waving for assistance and pointing to her breakfast tray, which was placed too high for her to access. This situation was confirmed by the Director of Staff Development (DSD), who acknowledged that the resident was positioned too low in the bed to see and eat the food from the tray. Resident 55 experienced a similar lack of accommodation, as the call light was not within reach, being clipped on the privacy curtain. This resident, who had fluctuating capacity to understand and make decisions, was observed looking for the call light to call for help. The resident's MDS 5-day assessment indicated a BIMS score of 10, showing the resident was able to make self-understood and usually understands others. A Certified Nursing Assistant (CNA) confirmed that the call light was not accessible to the resident, which could delay the resident's ability to call for assistance.
Failure to Provide SNF ABN Forms to Residents
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055 to two nonsampled residents, Residents 394 and 395. This form is crucial as it informs residents or their representatives about potential financial liabilities for services not covered by Medicare. The facility's policy, dated April 2021, mandates that residents be informed in advance of any changes to their billing. However, during the review, it was found that the SNF ABN Form was not provided to these residents due to an oversight by the Business Office Manager (BOM). For Resident 394, the medical record review revealed that the resident's Medicare Part A skilled services episode began on November 29, 2023, and the last covered day was December 20, 2023. Similarly, for Resident 395, the episode started on November 24, 2023, with the last covered day on December 12, 2023. In both cases, the facility initiated discharge from Medicare Part A services before the benefit days were exhausted, yet failed to provide the necessary SNF ABN Form to inform the residents or their representatives of the change and potential financial implications.
Privacy and Confidentiality Breaches in Resident Care
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information for three residents. In the case of Resident 8, a licensed nurse did not fully close the privacy curtain while administering medications via a gastrostomy tube (GT), and the window in the resident's room had missing blind slats, exposing the resident to the outside walkway. The nurse acknowledged the failure to provide complete privacy during the procedure. Additionally, the facility did not safeguard the confidentiality of residents' medical records. A computer screen on Medication Cart 3 was left unattended, displaying multiple residents' names and care information, including Resident 3. The nurse responsible admitted to leaving the screen open and acknowledged the breach of confidentiality. Similarly, a computer screen at Nursing Station 2 was left on and unattended, showing Resident 244's personal information to passersby. The Director of Staff Development confirmed the oversight and recognized the failure to protect the resident's privacy.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for several residents, as observed during a survey. Residents 65 and 74 expressed concerns about the condition of the carpets in the hallways, noting that they were dirty and stained, which affected the use of mobility aids like a front wheel walker. The administrator acknowledged these concerns and mentioned that the facility was in the process of replacing the carpets. Additionally, the walls near the entrances of Residents 14 and 75's rooms were observed to have missing paint and scrapes, which the administrator also acknowledged. Further observations revealed that Resident 8's room had a window with missing vertical blind slats, compromising privacy, which was not noticed by LVN 3 until pointed out during the survey. Resident 71's room had curtains that were improperly hung, a condition that had persisted for months despite being reported to staff. These deficiencies were noted to potentially impact the residents' quality of life, as they detracted from the homelike environment the facility's policies aimed to provide.
Failure to Notify Representatives and Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to the resident's representatives and the LTC Ombudsman for two residents who were transferred to an acute care hospital. The facility's policy and procedure required that such notifications be provided as soon as practicable before the transfer, and in a manner that the resident can understand, considering their educational level, language, communication barriers, and physical or mental impairments. However, for Resident 55, who had fluctuating capacity to understand and make decisions, and Resident 72, who had the capacity to understand and make decisions, the facility did not document that the required notifications were sent. The medical records for both residents showed physician orders for their transfers to the hospital, but lacked evidence of written notifications being provided to their representatives or the LTC Ombudsman. The Medical Records Department (MRD) confirmed the absence of these notifications and acknowledged that it was their responsibility to send them. The MRD was unable to send the written notices for the transfer dates identified, resulting in a failure to comply with the facility's policy and potentially leaving the residents' representatives unaware of their appeal rights.
Failure to Provide Bed Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy to the residents or their representatives upon transfer to an acute care hospital, as required by their policy. This deficiency was identified for two residents, Resident 55 and Resident 72, who were transferred to the hospital and subsequently readmitted to the facility. The facility's policy mandates that the notice of bed-hold and return policies be provided within 24 hours of emergency transfers, but this was not adhered to in these cases. Resident 55, who had fluctuating capacity to understand and make decisions, was transferred to the hospital on a physician's order but did not receive the required written notice. Similarly, Resident 72, who had the capacity to understand and make decisions, was also transferred without the notice being provided. The Medical Records Department (MRD) confirmed the oversight, acknowledging their responsibility to send the notices but failing to do so for the identified transfer dates.
Failure to Coordinate PASRR Level II Assessment for Resident with New Mental Disorder
Penalty
Summary
The facility failed to coordinate an assessment with the Pre-Admission Screening and Resident Review (PASRR) program for a resident who developed a newly evident mental disorder, requiring a level II review. This deficiency was identified during a medical record review and interview process. The resident, who was initially admitted without a diagnosis of mental illness, was later prescribed antipsychotic medications for psychosis, indicating a significant change in their mental health status. Despite this change, there was no documented evidence of coordination for a level II PASRR assessment. The resident's medical records showed that they were prescribed quetiapine fumarate and olanzapine for psychosis, which manifested as sudden mood changes and inconsolable screaming. The failure to initiate a level II assessment was confirmed during an interview with RN 1, who was responsible for coordinating PASRR assessments. RN 1 acknowledged that a level II assessment should have been conducted when the resident was diagnosed with psychosis and prescribed antipsychotic medications.
Failure to Resubmit PASRR Screening After Exemption Lapse
Penalty
Summary
The facility failed to ensure that a new Level 1 PASRR Screening was conducted for Resident 65 after the lapse of an acute care hospital discharge exemption. Resident 65, who had a diagnosed mental illness and was prescribed psychotropic medications, was initially screened on 4/3/24. The Level 1 PASRR Screening was negative, and a Level II mental health evaluation referral was not required due to the exempted hospital discharge. However, the screening indicated that if Resident 65 remained in the facility for more than 30 days, a new Level 1 PASRR Screening should be resubmitted on the 31st day. Despite this requirement, the facility did not resubmit a new Level 1 PASRR Screening after Resident 65 had stayed in the facility for approximately two months beyond the initial screening date. This oversight was confirmed during an interview and concurrent medical record review with RN 1 on 6/12/24. The failure to conduct a new screening posed a risk of not receiving a Level II Mental Health Evaluation, which could have impacted the resident's assessment, care planning, and transition of care.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
