Ararat Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2373 Colorado Blvd., Los Angeles, California 90041
- CMS Provider Number
- 555126
- Inspections on file
- 31
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Ararat Convalescent Hospital during CMS and state inspections, most recent first.
A high fall‑risk resident with dementia, prior rib fractures, and impaired mobility repeatedly reported pain and stated she had fallen, pointing to her right lower back and hip during morning care. A CNA notified an RN and LVN supervisor, who assessed the resident, but the RN did not believe a fall occurred due to lack of visible bruising, and no incident report or post‑fall protocol was initiated. The DON later confirmed that staff did not follow facility fall policies, which treat resident‑reported falls as falls and require post‑fall assessment, neuro checks for unwitnessed falls, incident reporting, and IDT review. The resident continued to report pain, and a later CT scan showed probable acute, nondisplaced right rib fractures, while documentation and interviews confirmed that the fall policies and required assessments were not implemented.
The facility did not report a COVID-19 outbreak involving three symptomatic residents to CDPH as required by policy and regulation. Staff interviews revealed miscommunication and lack of clarity regarding reporting responsibilities, and no documentation was provided to confirm that public health authorities were notified.
A CNA found a resident with severe cognitive impairment and high fall risk on the floor, moved her back to bed without notifying a nurse, and delayed reporting the incident for about 20 minutes. When a nurse assessed the resident, she was found to have a swollen, discolored foot and was later diagnosed with a metatarsal fracture. Facility policy required immediate nurse notification and assessment before moving any resident after a fall, which was not followed in this case.
A resident with dementia and a history of wandering was found tied to a wheelchair with a sheet by a CNA, who recorded the incident but failed to report it immediately. The resident's care plan allowed for safe wandering, but the restraint was not in line with facility policies. The delay in reporting the incident to the Administrator and DON resulted in a situation of immediate jeopardy.
The facility experienced a gastrointestinal illness outbreak due to failures in infection control practices. Staff did not consistently use PPE or perform hand hygiene, and there was a delay in reporting the outbreak to health authorities. These deficiencies contributed to the spread of the illness, affecting residents and staff.
A facility failed to ensure a call light was within reach for a resident with a history of falls and high fall risk. The resident required assistance with ADLs and had a care plan emphasizing the need for accessible call lights. On observation, the call light was found wedged and inaccessible, confirmed by multiple staff members. Facility policies required call lights to be within reach to accommodate resident needs.
A resident with severe cognitive impairment sustained an unknown injury, resulting in swelling on the left cheek. The facility failed to conduct neurological assessments or develop a care plan, as confirmed by staff interviews and a review of the resident's medical records. Facility policies required these actions for head or facial injuries, but they were not documented, potentially leading to inadequate care.
A resident's MDS assessment was found to be inaccurate as it failed to include an active diagnosis of depression, despite the resident's medical records indicating this condition. The DON confirmed that the MDS should reflect a comprehensive assessment, including medical history, but acknowledged the discrepancy could lead to a care plan mismatch.
The facility failed to properly administer oxygen therapy for two residents, as their oxygen tubing and nasal cannulas were observed on the floor, contrary to infection control standards. Both residents had significant medical conditions requiring oxygen therapy, and the facility's policy required weekly changes of oxygen equipment, which was not followed.
The facility did not ensure that three LVNs completed their annual competency assessments, relying on self-evaluation without verifying proficiency. The DON provided a skills checklist but did not confirm skill proficiency, and the facility lacked a policy for staff skills validation.
The facility failed to follow proper food labeling and storage practices. A container of sugar in the dry goods area had multiple dates without clear indication of its status, and a Styrofoam cup of Baba ghanoush in the refrigerator was unlabeled and undated. The Dietary Supervisor acknowledged that all food items should be labeled with the name and preparation date to prevent foodborne illnesses.
A resident with a history of CHF, acute respiratory failure, and COPD experienced a severe weight loss of 10.13% over three months. The facility failed to notify the physician of this significant change, as required by their policy. The DON confirmed the absence of documentation and communication regarding the weight loss, leading to delayed care and intervention.
A resident experienced a severe weight loss of 10.13% over three months, which the facility failed to report to the physician or address with a care plan. Despite the resident's diagnoses of CHF, acute respiratory failure, and COPD, the facility did not consult with a dietician or develop a care plan to mitigate the weight loss. The DON acknowledged the lack of documentation and adherence to facility policies regarding physician notification and care planning.
The facility did not meet the required minimum of 80 square feet per resident in four rooms, affecting space for residents and potentially impacting care. Despite this, observations showed adequate space for mobility and care, and no complaints were reported.
A resident with severely impaired cognition and requiring assistance for daily activities experienced an unwitnessed fall, resulting in a head laceration. The CNA on duty had informed the RN of the resident's confusion and agitation, but the RN claimed no prior notification before the fall. The facility's fall risk policy was not followed, leading to the incident.
A resident with severe cognitive impairment and a history of confusion and agitation experienced an unwitnessed fall in an LTC facility due to the lack of a Side Rail Utilization Assessment. The facility did not assess the need for bed rails, resulting in the resident sustaining injuries. Staff interviews revealed a misunderstanding of regulations regarding bed rail use, and the facility's policy requiring such assessments was not followed.
Failure to Implement Fall Response Protocol After Resident Reported Fall and Pain
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, and investigate a potential fall after a high fall‑risk resident reported pain and stated she had fallen. The resident had multiple right‑sided rib fractures, pneumonia, dementia, moderate cognitive impairment, used a wheelchair and walker, and required supervision and moderate assistance with ADLs. A Morse Fall Risk assessment identified the resident as high risk for falls with a score of 80 and a history of falls and overestimation of functional abilities. On the morning in question, a CNA reported the resident pointed to her right lower back and hip indicating pain during morning care. An RN and LVN supervisor assessed the resident, who again indicated pain and told the LVN supervisor she had fallen. Despite this, the RN did not believe a fall occurred because there was no visible bruising, and the DON later confirmed that no fall incident report was completed because the fall was unwitnessed and the CNA had not observed it. The facility’s own investigation summary documented that the resident had reported to multiple staff, including a CNA and therapy staff, that she had experienced a fall, and later that evening the resident reported pain while being assisted to the bathroom with a front‑wheel walker. A CT scan performed subsequently showed probable acute, nondisplaced fractures of the right 5th and 10th ribs, and progress notes documented that the resident stated she had fallen when asked about her pain. The DON acknowledged that staff did not implement the facility’s fall policies, which defined a fall as one that may be witnessed or reported by the resident or any observer and required post‑fall assessments, neurological monitoring for unwitnessed falls, incident reporting, reassessment of mobility status, and IDT review. As a result, required post‑fall assessments, 72‑hour neurological checks, incident reporting, and interdisciplinary review were not initiated when the resident first reported a fall and pain.
Failure to Report COVID-19 Outbreak to Public Health Authorities
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the California Department of Public Health (CDPH) as required by its own policy and state regulations. The outbreak involved three residents who tested positive for COVID-19 over a span of several days. Each resident had varying degrees of cognitive and physical impairment, and all were symptomatic at the time of testing. Documentation confirmed the positive test results and the presence of symptoms such as runny nose, cough, and weakness among the affected residents. Interviews with facility staff revealed confusion and miscommunication regarding the responsibility for reporting the outbreak. The Infection Preventionist (IP) believed another IP had reported the cases, while the Administrator assumed the IP had completed the notification. The Director of Nursing (DON) stated that the Department of Public Health had been notified, but was unable to provide documentation to support this claim. Another IP admitted to not knowing that reporting to CDPH was required and acknowledged that failing to report would result in a lack of outbreak support. A review of the facility's policy and procedure on communicable disease outbreaks indicated that the Administrator was responsible for reporting outbreaks to public health authorities. The policy defined an outbreak as one or more facility-acquired COVID-19 cases in a resident or three or more suspect, probable, or confirmed cases. Despite these clear guidelines, the facility did not notify CDPH of the outbreak, resulting in a failure to comply with both internal policy and regulatory requirements.
Failure to Notify Nurse and Improper Movement of Resident After Fall
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow facility policy and procedure regarding the response to resident falls. Upon finding a resident with severe cognitive impairment, muscle weakness, osteoporosis, and a history of falls lying on the floor, the CNA lifted the resident and returned her to bed without notifying a licensed nurse or waiting for a nurse's assessment. The CNA did not immediately report the incident to the licensed nurse, delaying notification by approximately 20 minutes. During this time, the resident was not assessed for injuries by a licensed nurse as required by facility policy. When the licensed nurse was finally notified and assessed the resident, she found the resident in bed, shivering and shaking in pain, with a swollen and discolored left foot. Subsequent X-ray imaging confirmed an acute nondisplaced distal fourth metatarsal neck fracture, with a possible additional fracture. The resident's care plans and assessments indicated she was at high risk for falls and fractures, required maximal assistance for mobility and transfers, and was to be handled gently to prevent injury. The facility's policy and CNA job description both required immediate notification of a licensed nurse and that residents not be moved after a fall until assessed by a nurse. Interviews with staff, including the CNA, licensed nurses, and the Director of Nursing, confirmed that the CNA did not follow established procedures. The CNA admitted to moving the resident without assistance and without notifying a nurse, stating he did not observe pain at the time and did not seek help because other staff were busy. The Director of Nursing and other nursing staff emphasized that moving a resident after a fall without a nurse's assessment could worsen injuries, and that the CNA's actions were not in accordance with facility policy.
Failure to Prevent and Report Resident Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. On a specific date, a Certified Nurse Assistant (CNA) observed a resident tied to a wheelchair with a white sheet during her shift. Instead of immediately addressing the situation or reporting it to a licensed vocational nurse (LVN) or other facility staff, the CNA recorded a video of the incident. The CNA did not untie the resident or report the incident to the appropriate authorities until two days later, which delayed the facility's response to the abuse. The resident involved had a history of dementia, anxiety disorder, and a history of falling, and was identified as a wandering risk. The care plan for the resident included interventions to allow safe wandering and to monitor the resident's whereabouts for safety. Despite these measures, the resident was found restrained in a manner that was not in line with the facility's policies, which require a restraint-free environment unless necessary for medical treatment. The delay in reporting the incident was compounded by the CNA's failure to inform the Administrator or the Director of Nursing (DON) immediately, as required by the facility's abuse prevention policy. The Administrator was informed of the incident only after the CNA showed the video in person, which was three days after the initial observation. This delay in reporting and addressing the abuse incident resulted in a situation of immediate jeopardy, as identified by the California Department of Public Health.
Removal Plan
- Staff including but not limited to license nurses, certified nursing assistants, office staff, kitchen staff, and housekeeping staff will have in-service education regarding elder abuse, reporting abuse and the use of physical restraints, conducted by the Director of Staff Development [DSD], DON and/or Administrator. The in-services are based on facility Policies and Procedures titled Restraints, Abuse Prevention and Prohibition Program, and Definitions.
- 50 out of 61 facility employees will have received in-service education regarding elder abuse, reporting abuse and the use of physical restraints.
- A posttest was created to verify staff competency on abuse and use of restraints. The post test will be given to all staff to determine understanding of in-service. Staff will be given repeat in-service on areas found to be lacking in knowledge until 100% score is received.
- Charge nurses were assigned to complete Abuse Rounds on a minimum once per shift to ensure there are no signs or symptoms of abuse or restraints. Rounds will continue once per shift for a minimum of three months.
- If a suspected abuse or improper restraint is identified charge nurse will immediately notify the Administrator and DON.
- The facility's Social Services Consultant will provide staff in-service regarding abuse.
- All charge nurses will be in-serviced on use of SOC 341 [a form used to report suspected abuse or neglect of dependent adults and elders].
- The Administrator will review facility's current Abuse Prevention Plan with DSD to develop a new yearly in-service schedule with increased abuse training. New employee Orientation abuse and neglect training will be reviewed and updated as needed during the facility's Quality Assurance and Performance Improvement (QAPI).
Infection Control Failures Lead to GI Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to a gastrointestinal illness outbreak affecting 15 residents and 7 staff members. Several instances of non-compliance with infection control protocols were observed. Certified Nurse Assistants (CNAs) and other staff members did not consistently use personal protective equipment (PPE) or perform proper hand hygiene. For example, CNA 1 did not remove PPE before leaving an isolation room, and CNA 2 failed to use hand sanitizer between resident interactions. Additionally, a kitchen assistant was observed handling food without gloves, and a family visitor entered the facility without a mask, despite clear signage indicating the need for masks due to the outbreak. The facility's staff also failed to adhere to contact precautions. CNA 7 entered a contact isolation room without donning PPE and did not perform hand hygiene after handling a resident's food tray. Housekeeping staff did not change gloves between tasks, potentially spreading contaminants. Furthermore, CNA 4 did not wear a gown when handling a resident's food tray in a contact isolation room, and a family member visiting a resident under contact precautions did not wear a gown, as required. The facility delayed reporting the gastrointestinal outbreak to the appropriate health authorities. The Director of Nursing (DON) initially considered the cases isolated and did not report them promptly, leading to a delay in implementing control measures. The facility's policies and procedures for infection control and reporting were not followed, contributing to the spread of the outbreak. The lack of timely communication and adherence to established protocols resulted in a failure to contain the outbreak effectively.
Failure to Ensure Call Light Accessibility for High-Risk Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident with a history of falls and a high risk for falling by not ensuring the call light was within reach. The resident, who was originally admitted on October 2, 2023, and readmitted later, had diagnoses including osteoporosis, generalized muscle weakness, and a history of falling. The Minimum Data Set (MDS) assessment indicated the resident required various levels of assistance with activities of daily living (ADLs), including supervision or touching assistance with toileting and personal hygiene, and partial/moderate assistance with bathing and dressing. The resident's care plan, revised on January 6, 2024, and August 6, 2024, emphasized the importance of having the call light within easy reach due to the resident's poor balance and potential for falls. On November 7, 2024, during an observation and interview, it was noted that the call light cord was wedged between the resident's mattress and headboard, making it inaccessible. Multiple staff members, including a certified nurse assistant, social service director, registered nurse, licensed vocational nurse, occupational therapist, and director of nurses, confirmed that the call light should be within reach to prevent falls and ensure the resident could request assistance when needed. The facility's policies on resident rights and communication systems also stipulated that call lights should be within residents' reach to accommodate their needs and ensure prompt communication with nursing staff.
Failure to Conduct Neurological Assessments and Develop Care Plan for Resident Injury
Penalty
Summary
The facility failed to meet professional standards of practice for a resident who sustained an unknown injury, specifically swelling on the left cheek. Despite the resident's severe cognitive impairment and inability to understand and make decisions, the facility did not conduct neurological assessments (NA) or develop a care plan in response to the injury. The resident's medical records lacked documentation of these necessary actions, which are crucial for monitoring potential head injuries and ensuring appropriate care. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Staffing Development (DSD), confirmed that NA should have been conducted for head or facial injuries, and a care plan should have been developed. The facility's policies and procedures also indicated that NA is required following falls or injuries involving head trauma, and care plans are essential for addressing residents' medical and psychosocial needs. The absence of these assessments and care planning could lead to inadequate monitoring and care for the resident.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, which is a federally mandated assessment tool. Specifically, the MDS for a resident did not include an active diagnosis of depression, despite the resident's face sheet indicating a diagnosis of depression along with other conditions such as chronic obstructive pulmonary disease (COPD) and chronic congestive heart failure. This omission was identified during a review of the resident's records, which showed that the resident lacked the capacity to understand and make decisions. During an interview with the Director of Nursing (DON), it was confirmed that the MDS assessments should include a comprehensive evaluation of the resident, incorporating direct observation, interviews, and a review of the resident's medical history. The DON acknowledged that an inaccurate MDS could lead to a mismatch between the resident's plan of care and their actual care needs. The facility's policy requires licensed nursing staff to complete an admission assessment using the Resident Assessment Instrument (RAI) specified by CMS, but this was not accurately reflected in the resident's MDS.
Oxygen Therapy Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen therapy according to accepted standards of clinical practice and its own policy for two residents. Resident 4, who was admitted with diagnoses including encephalopathy, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD), was observed with oxygen tubing on the floor. This observation was confirmed by a licensed vocational nurse (LVN), who acknowledged that the tubing should not be on the floor due to infection control concerns. The Director of Nursing (DON) also stated that oxygen tubing should not be on the floor to prevent bacterial contamination. Similarly, Resident 20, admitted with chronic obstructive pulmonary disease with acute exacerbation and chronic congestive heart failure, was observed with both oxygen tubing and nasal cannula on the floor. This was confirmed by another LVN, who stated that the tubing should never be on the floor due to potential infection control issues. The facility's policy, dated 8/1/2014, indicated that all oxygen delivery equipment should be changed weekly and when visibly soiled, which was not adhered to in these cases.
Failure to Complete Annual Competency Assessments for LVNs
Penalty
Summary
The facility failed to ensure that three out of five Licensed Vocational Nurses (LVNs) completed their annual competency assessments and evaluations, as required by the facility's assessment to determine necessary resources and services for resident care. The LVNs' employee records included an Orientation & Annual Evaluation Skills Check List, which was signed by both the employee and the Director of Nursing (DON). However, the DON admitted that the competency skills were not completed upon hire or annually, and the facility relied on self-evaluation by the nurses without verifying proficiency in the skills listed. During interviews, the DON stated that she provided the skills checklist to the nurses at the beginning of their shifts and discussed skills with those who rated themselves as somewhat experienced or not experienced. However, there was no verification of demonstrated proficiency. Additionally, the facility administrator confirmed the absence of a policy and procedure for staff skills validation and evaluation of competencies. The facility assessment, which was undated, indicated that staff competency evaluations were necessary to maintain and improve residents' well-being, but these evaluations were not effectively conducted.
Improper Food Labeling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and safe food handling practices as per their policy and procedure. During an observation, a plastic container containing sugar was found in the dry goods storage area with a label displaying three different dates, none of which indicated the received, opened, or expiration date. This lack of proper labeling could lead to confusion about the freshness and safety of the food product. Additionally, a Styrofoam cup containing Baba ghanoush was found in the refrigerator without any label indicating the contents or the date it was prepared. The Dietary Supervisor confirmed that all opened food items should be labeled with the name and preparation date to prevent foodborne illnesses. The facility's policy, dated November 1, 2014, requires that all storage products be labeled and dated, which was not followed in these instances.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who experienced severe weight loss. The resident, who was cognitively intact and had a history of congestive heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease, lost 10.13% of their body weight over three months. This weight loss was not communicated to the physician as required by the facility's policy, which mandates notification for a weight change of five pounds or more within a 30-day period. The Director of Nursing (DON) confirmed that there was no documented evidence of a nutritional assessment addressing the resident's weight loss from July to August, nor was there documentation in the progress notes indicating that the physician was notified. The facility's policy requires that such changes be documented and communicated to the physician, but this was not done, resulting in delayed necessary care and intervention for the resident.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to assess, evaluate, and determine the cause of severe weight loss for a resident, identified as Resident 23, who experienced an unplanned severe weight loss of 10.13% over three months. The facility did not report the severe weight loss to the physician from July to August 2024, which was necessary to determine if the weight loss was related to the resident's disease process. Additionally, the licensed staff did not consult with the dietician for an assessment or any new dietary recommendations. Resident 23 was readmitted to the facility with diagnoses including congestive heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. Despite being cognitively intact, the resident experienced a significant weight loss of 7.72% from July to August 2024, which was not addressed in the nutritional assessment. The facility's policy required notifying the physician and conducting a nutritional assessment upon significant weight loss, but these actions were not documented. Furthermore, the facility did not develop a care plan to address Resident 23's severe weight loss in August 2024. The Director of Nursing acknowledged the lack of documentation for notifying the physician, conducting a nutritional assessment, and developing a care plan. The facility's policies outlined the need for timely physician notification, comprehensive care planning, and nutritional assessments upon changes in condition, but these were not followed in this case.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in four out of twelve resident rooms, specifically Rooms 1, 3, 4, and 5. These rooms included two six-bed capacity rooms and two five-bed capacity rooms, which did not meet federal requirements for space per resident. The deficiency was identified through observation, interviews, and record reviews, revealing that the rooms measured less than the required space, with some rooms accommodating more residents than the space allowed. Despite this, the facility's administrator indicated that they intended to request a room waiver, asserting that the room sizes had not changed and that there were no complaints from residents, families, or staff regarding the room sizes. Observations conducted over several days showed that the affected rooms provided adequate space for residents to move freely and for the use of mobility aids such as wheelchairs, walkers, and canes. The rooms were equipped with beds and bedside tables, and the nursing staff was observed providing care without any apparent hindrance due to space constraints. The facility's policy, dated 2017, required resident rooms to measure at least 80 square feet per resident in multiple resident rooms, which was not adhered to in the identified rooms.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who experienced an unwitnessed fall, resulting in a laceration on the head and above the right eye that required medical attention. The resident, admitted with diagnoses including congestive heart failure, had severely impaired cognition and required moderate to maximum assistance for daily living activities. On the night of the incident, the resident was found on the floor by a CNA after returning from a break, indicating a lack of supervision during that time. Interviews revealed that the CNA had informed the RN at the beginning of the shift that the resident was awake, confused, and agitated. However, the RN stated that she was not informed of the resident's condition prior to the fall. The facility's policy on fall risk assessment mandates adequate supervision and assistance to prevent accidents, which was not adhered to in this case, leading to the resident's fall and subsequent injury.
Failure to Assess Bed Rail Need Leads to Resident Fall
Penalty
Summary
The facility failed to assess the medical need for the use of a bedside rail for a resident, which resulted in an unwitnessed fall. The resident, who was admitted with diagnoses including congestive heart failure, had severely impaired cognition and required moderate to maximum assistance for daily living activities. Despite these needs, the facility did not conduct a Side Rail Utilization Assessment during the resident's stay, which is a necessary step to determine if the use of side rails is appropriate. On the night of the incident, a CNA found the resident on the floor next to her bed with a laceration above her right eye and on her head, requiring medical attention. The CNA had been on a break and discovered the fall upon returning. The resident was known to have episodes of confusion and agitation, yet there was no care plan in place to address these behaviors. Additionally, the Fall Risk Assessment conducted after the incident was inaccurately completed, failing to reflect the resident's previous fall and predisposing conditions, which would have indicated a high risk for falls. Interviews with facility staff revealed a misunderstanding of regulations regarding the use of side rails, with some staff believing they were against regulations. The facility's policy required a Side Rail Utilization Assessment to determine the appropriateness of bed rail use, but this was not completed for the resident. The lack of assessment and care planning contributed to the resident's fall and subsequent injury.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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