Artesia Christian Home Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Artesia, California.
- Location
- 11614 E. 183rd St, Artesia, California 90701
- CMS Provider Number
- 055539
- Inspections on file
- 29
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Artesia Christian Home Inc. during CMS and state inspections, most recent first.
The facility did not report a suspected scabies outbreak involving three cognitively impaired, dependent residents to CDPH as required. Physician orders indicated treatment for suspected scabies, but the Infection Prevention Nurse was unaware of the reporting requirement and believed another party would notify authorities, resulting in the failure to follow facility policy for communicable disease reporting.
A resident with severe cognitive impairment and total dependence on staff was admitted with a left arm bruise that later increased in size. When a CNA observed the resident protecting her arm and reported a large bruise to the LVN, neither the LVN nor the RN assessed the resident, relying instead on previous chart documentation. This lack of assessment and reporting led to a delay in identifying an acute fracture, contrary to facility policy requiring prompt evaluation and notification of changes in condition.
A resident with severe cognitive impairment and a history of falls was not properly monitored after receiving a Dulcolax suppository, resulting in an unwitnessed fall and multiple skin tears. Despite having a pressure pad alarm, the resident was found on the floor, and staff interviews revealed a lack of adherence to monitoring protocols. A fall risk evaluation was not conducted post-fall, contrary to facility policy.
The facility failed to ensure monthly Drug Regimen Reviews (DRR) and Gradual Dose Reductions (GDR) for residents on psychotropic medications, affecting two residents with dementia and 23 others. A resident on multiple psychotropic medications showed signs of drowsiness, while another exhibited continuous disruptive behaviors. The interdisciplinary team managed medication regimens without consulting the pharmacist, leading to a lack of appropriate reviews and adjustments.
The facility failed to ensure residents on psychotropic medications were evaluated by a psychiatrist for medication appropriateness. Four residents with diagnoses such as major depressive disorder and dementia were affected, with no psychiatric evaluations conducted to assess medication effectiveness or dosage adjustments. The facility also did not include a psychiatrist in IDT meetings, leading to inadequate care planning and non-compliance with facility policies.
The facility failed to implement its infection prevention and control program for residents with suspicious skin rashes, leading to a situation of Immediate Jeopardy. Five residents in the dementia unit exhibited symptoms such as red, inflamed spots with bumps and itching, yet were not placed on isolation. The facility did not conduct proper infection surveillance or coordinate with the local Department of Public Health, increasing the risk of spreading the infection.
A resident developed a severe pressure injury due to the facility's failure to reposition them as per the care plan, update the care plan and Braden scale, and assess nutritional needs. The resident's condition worsened from a Stage 1 to a Stage 4 pressure injury without appropriate interventions or documentation.
A resident with a history of CHF and chronic kidney disease experienced critically low urine output, which was not reported to the physician by the facility. The resident's care plan required monitoring for dehydration, but this was not documented, leading to acute kidney injury and hospitalization. The facility failed to initiate a change of condition or monitor the resident's urine output over several weeks.
The facility's QAA Committee and QAPI program failed to identify deficiencies in medication management and infection control. The Licensed Pharmacist did not conduct monthly Drug Regimen Reviews for psychotropic medications, nor were psychiatric services obtained for residents on such medications. Additionally, an infection control program was not established for residents with suspicious skin rashes. The Medical Director, DON, and Administrator were unaware of these systemic failures, resulting in inadequate care for residents.
The facility failed to assess the use of pressure pad alarms and obtain informed consent from two residents or their representatives. One resident had severe cognitive impairment, while the other had intact cognition but required assistance with daily activities. The facility did not consider alarms as restraints and only obtained a physician's order, violating residents' rights to be free from restraints.
The facility failed to document 10 hours of annual continuing education in Infection Prevention and Control (IPC) for the DON, ADON, and DSD since 2019. This was identified during a review of the California Department of Public Health guidelines, which stress the importance of ongoing IPC training. The facility's infection control policy aims to ensure a safe environment, but the lack of documented education indicates a gap in policy adherence.
The facility failed to monitor the use of triple antibiotic ointment for two residents, despite having an antibiotic stewardship program in place. The residents had orders for the ointment on skin tears and abrasions, but the facility did not include this in their monitoring efforts. Interviews with the ADON and DON confirmed the lack of oversight, contrary to the facility's policy requiring data collection and review of antibiotic use.
The facility failed to document the COVID-19 vaccination status of 128 staff members, as revealed during a review with the ADON. This was in violation of a public health order requiring healthcare personnel to be vaccinated or provide a declination form. The DON acknowledged the need for updated vaccination records, and the facility's undated Infection Control Plan was not effectively implemented.
A facility failed to create a comprehensive care plan for a resident with chronic respiratory failure and a gastrotomy tube, who was noncompliant with his care plan. Despite the resident's intact cognition and specific care preferences, no care plan addressed his noncompliance with safety, feeding, and turning schedules. Interviews with the ADON and DON confirmed the absence of a care plan, which is required by the facility's policy to meet residents' needs.
A resident with multiple health issues developed a pressure injury that progressed from Stage 1 to Stage 4 without the care plan being updated. The facility's policy requires care plans to be revised with changes in condition, but this was not done, leading to a delay in addressing the resident's worsening condition.
A resident with dementia and limited ROM did not receive prescribed upper extremity ROM exercises and had a towel roll instead of a physician-ordered left-hand splint. The facility's failure to follow care plans and physician orders placed the resident at risk for further decline in physical condition.
A facility failed to provide necessary emergency dialysis supplies for a resident with end-stage renal disease (ESRD). The resident, dependent on renal dialysis, did not have an emergency dialysis kit at the bedside, as confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). The facility's policy required intervention in medical emergencies, but the absence of supplies indicated non-compliance with this policy.
A resident with moderately impaired cognition and difficulty walking was found with a bluish bump on her forehead, which was not reported to CDPH as required. The facility's investigation suggested the injury might have been caused by the resident's agitation during transfers using a stand-up lift, but no staff interviews were conducted to confirm this. The failure to report resulted in a delay of an onsite inspection.
A resident with moderate cognitive impairment developed a bluish bump on her forehead, which was not properly investigated by the facility. The DON assumed the injury was due to the resident's agitation with a stand-up lift, but did not interview staff involved on the day of the incident, contrary to the facility's policy requiring thorough investigation and reporting of all incidents.
A resident with moderately impaired cognition and difficulty walking sustained a forehead injury due to the continued use of a stand-up lift, despite exhibiting agitation and combativeness. The facility's investigation revealed that alternative transfer methods were not explored, and the use of the lift likely caused the injury. Staff interviews indicated a lack of adherence to the facility's policy on assessing the appropriateness of assistive devices for the resident's condition.
The facility failed to securely store controlled medications, as an emergency kit with Ativan was found in an unlocked refrigerator. An LVN confirmed the refrigerator was never locked, and the DON acknowledged the need for double locking to prevent misuse. The facility's policy required controlled drugs to be stored separately and under double lock, which was not adhered to.
A resident with dementia and mobility limitations did not receive a timely PT/OT evaluation as per physician's order due to a missed email by the Director of Rehab. The evaluation was delayed despite a physician's order and insurance authorization, contrary to the facility's policy on maintaining mobility.
A deficiency was identified in a LTC facility where six rooms did not meet the required square footage per resident. Rooms with four beds measured 305.5 sq ft, and those with two beds measured between 151 and 152 sq ft, below the 80 sq ft per resident requirement. The Maintenance Supervisor noted no negative impact on residents, and the DON requested a waiver. Observations showed no issues with access, furniture space, or care provision.
A facility failed to ensure an accurate assessment for a resident, as the MDS inaccurately indicated no dental issues, while the Nursing Admission Assessment noted missing teeth. The resident had severe cognitive impairment and was dependent on all ADLs. A nurse acknowledged the MDS error, and the DON emphasized the need for accurate assessments.
Failure to Report Suspected Scabies Outbreak to CDPH
Penalty
Summary
The facility failed to report a suspected scabies outbreak involving three residents to the California Department of Public Health (CDPH) as required. Record reviews showed that all three residents had severe cognitive impairment and were dependent on staff for hygiene and bathing. Physician orders for these residents included the administration of Permethrin cream and Ivermectin for suspected or suspicious scabies, indicating clinical suspicion of an outbreak. Despite these findings, there was no evidence that the facility reported the suspected outbreak to CDPH within the required timeframe. Interviews revealed that the Infection Prevention Nurse was unaware of the requirement to report a suspected scabies outbreak to CDPH. The Director of Nursing stated that the IP nurse believed the Public Health Nurse would make the report, which led to the failure to notify CDPH. A review of the facility's policy indicated that outbreaks of communicable diseases must be reported to the appropriate agency within 24 hours, but this protocol was not followed in this instance.
Failure to Assess and Report Change in Resident's Arm Condition
Penalty
Summary
Facility staff failed to assess and report a significant change in a resident's condition after a left arm bruise was observed and reported to a licensed nurse. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was admitted with a pre-existing bruise on the left arm. Over time, the bruise increased in size, and on the day in question, a certified nurse assistant noticed the resident protecting her arm and observed a large purplish bruise, which was reported to the licensed vocational nurse (LVN). The LVN, upon being informed, checked the resident's chart and noted the bruise had been documented at admission but did not physically assess the resident. The LVN instructed the CNA to notify the treatment nurse. The treatment nurse, a registered nurse (RN), also reviewed the chart and did not assess the resident's arm, believing it was not a change in condition. Both the LVN and RN acknowledged during interviews that an assessment should have been performed to determine if there were any changes to the resident's skin or condition. Subsequently, the resident was found to have an acute fracture of the left humerus, as indicated by a radiology report. The facility's policies required prompt assessment and notification of changes in a resident's condition, including new or worsening injuries. The failure of staff to assess and report the change in the resident's arm condition resulted in a delay of care and was identified as a deficiency during the survey.
Failure to Monitor Resident After Suppository Administration Leads to Fall
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and evaluated after an unwitnessed fall, which occurred on 12/7/2024. The resident, who had a history of falls and severe cognitive impairment, was given a Dulcolax suppository and was not adequately monitored afterward. Despite having a pressure pad alarm in place, the resident was found on the floor with multiple skin tears on the left forearm after attempting to get up without assistance. Interviews with staff revealed that the resident was known to be impulsive and did not use the call light, and it was acknowledged that residents should be checked every 30 minutes after receiving a suppository to prevent falls. The Assistant Director of Nurses (ADON) and the Director of Nurses (DON) both confirmed that a fall risk evaluation was not conducted after the resident's fall on 12/7/2024, which is a critical step in assessing changes in the resident's condition and updating the care plan. The facility's policy on falls and fall risk management emphasizes the importance of identifying interventions based on evaluations to prevent falls and minimize complications. The lack of a fall risk evaluation and inadequate supervision after administering a suppository contributed to the resident's fall and subsequent injuries.
Failure to Conduct Drug Regimen Reviews for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the consulting pharmacist conducted monthly and as-needed Drug Regimen Reviews (DRR) and made recommendations for Gradual Dose Reductions (GDR) or medication dosage adjustments for residents receiving psychotropic medications. This deficiency was identified for two residents with dementia and 23 other residents receiving psychotropic medications. The facility did not ensure that these residents were not receiving duplicate therapy or unnecessary medications, which placed them at high risk for potential side effects and uncontrolled behavioral symptoms. Resident 17 was admitted with diagnoses including dementia, bipolar disorder, and major depressive disorder. The resident was on multiple psychotropic medications, including Cymbalta, Ativan, Seroquel, and Depakote. Despite being on these medications, there was no documentation of a DRR or GDR assessment by the consulting pharmacist or a physician's documentation that a dose reduction was not recommended. Observations showed Resident 17 experiencing drowsiness and difficulty staying awake, which could be side effects of the medications. Resident 51, admitted with dementia and anxiety disorder, was also on psychotropic medications such as Donepezil, Seroquel, and Ativan. Similar to Resident 17, there was no DRR or GDR assessment conducted, and the physician had not documented that a GDR was clinically contraindicated. The resident exhibited continuous disruptive behaviors, including yelling, which interfered with daily activities and social interactions. The facility's interdisciplinary team managed the residents' psychotropic medication regimens without consulting the pharmacist, leading to a lack of appropriate medication reviews and adjustments.
Removal Plan
- The facility contacted the consulting PH to conduct a drug regimen review for Residents 17 & 51 who were on psychotropic medications for irregularities, appropriateness and make recommendations on GDR's. Additionally, the licensed pharmacist will complete psychotropic drug regimen reviews for the remaining 24 residents on psychotropic medications to assess for irregularities, appropriateness and make recommendations on GDR's.
- All licensed nurses working on 3-11 shift were in-serviced immediately on the need for a licensed pharmacist to review the resident's drug regimen and review duplicate therapy. The Director of Staff Development (DSD) will do another in service for those licensed nurses that were not at the facility. The DSD has a list of those on leave, vacation or who were not able to attend and when they are back on schedule will be in serviced as well.
- This facility will ensure the admission of residents whose needs we can meet according to our Facility Assessment through the utilization of the facility consulting pharmacist to conduct DRR for residents on psychotropic medications for irregularities, appropriate and make recommendations on GDR's. The facility's consulting pharmacist will conduct this monthly for all current and future residents.
- The DON will monitor that the consulting PH has conducted a drug regimen review for residents who are on psychotropic medications for irregularities, appropriateness and make recommendations on GDR's. The DON will report any recommendations made to the resident's physician. The DON will use the audit form to track all GDR recommendations and keep copies of the GDR recommendations in the audit binder with the audit form. The DON will monitor that 100% of the residents on psychotropic medications were reviewed by the consulting pharmacist and will report the findings to the facility's Quality Assurance Performance Improvement quarterly monitoring meetings with a threshold of 100%.
Failure to Provide Psychiatric Evaluations for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications were evaluated by a psychiatrist for the appropriateness of their medication regimen. This deficiency affected four residents who were on various psychotropic medications, including Cymbalta, Ativan, Seroquel, Depakote, Mirtazapine, Haloperidol, and Donepezil. These residents had diagnoses such as major depressive disorder and dementia, and the facility did not provide psychiatric evaluations to assess the appropriateness, effectiveness, and need for adjustments in their medication dosages. Resident 2, who had a diagnosis of major depressive disorder, was admitted to the facility and had been taking psychotropic medications since admission without a psychiatric evaluation since February 2023. Similarly, Resident 17, with diagnoses including dementia and bipolar disorder, had not been evaluated by a psychiatrist since November 2021, despite being on multiple psychotropic medications. Resident 19, admitted with dementia and agitation, had never been assessed by a psychiatrist for the need for psychotropic medication since admission. Resident 51, with dementia and psychotic disturbance, had a psychiatric consult ordered but had not been evaluated by a psychiatrist as of the report date. The facility also failed to include a psychiatrist in the Interdisciplinary Team (IDT) meetings to evaluate the residents' behavior and use of psychotropic medication. This oversight led to a lack of proper assessment and planning for the care of residents regarding the need and appropriateness of a gradual dose reduction of psychotropic medications. Additionally, the facility did not adhere to its policies and procedures related to dementia care, antipsychotic medication use, and behavioral assessment, intervention, and monitoring, which contributed to the deficiency.
Removal Plan
- Residents 2, 17, 19, and 51 will be evaluated by a psychiatrist, with evaluations completed. Ongoing monthly psychiatric services will be provided for these residents.
- Evaluations and routine psychiatric services will be completed for residents with psychiatric diagnoses upon admission, thereafter, and as needed by a Psychiatrist.
- The facility will have a monthly Behavioral Intervention Treatment meeting to discuss and review residents on psychotropic medication, with attendance from the Licensed Psychiatrist and the Licensed Pharmacist.
- Residents with a behavioral change in condition will be placed on a 72-hour change of condition monitoring using the facility's Behavior Log.
- All licensed nurses, including IDT members, the DON, the ADON, the ADSS, and the MDS coordinator, were in-serviced on psychiatric diagnosis and the need for a psychologist or psychiatrist consult for residents on psychotropic medication.
- The Director of Staff Development will conduct another in-service for those not present, and will schedule in-services for those on leave or vacation.
- The facility will ensure they can meet the needs of residents with psychiatric or behavioral needs based on the updated Facility Assessment.
- Psychiatric Services have been added to the Facility Assessment, and a psychiatric services company has been obtained to evaluate residents with psychiatric diagnoses.
- A Psychiatrist/Psychiatric Nurse Practitioner will participate in the monthly Behavioral Intervention Treatment meeting for residents receiving psychotropic medications.
- The Psychiatrist/Psychiatric Nurse Practitioner will make routine rounding visits to assess medication effectiveness and dosage needs.
- The facility's DON will monitor residents on psychotropic medications to ensure they receive monthly psychiatric services.
- The Associate Director of Social Services/SSD will report the number of residents and visits to the facility's Quality Assurance Performance Improvement quarterly monitoring meetings with a threshold of 100%.
Failure to Implement Infection Control Measures for Skin Rashes
Penalty
Summary
The facility failed to implement its infection prevention and control program, specifically regarding the management of suspicious skin rashes among residents. Five residents in the dementia unit exhibited symptoms such as red, inflamed spots with bumps and itching, yet were not placed on isolation to prevent potential spread. The facility also did not conduct proper infection surveillance by completing a line listing of residents with suspicious rashes, which is a critical step in monitoring and controlling potential outbreaks. Additionally, precautionary measures to contain the suspicious rashes were not implemented for the affected residents and others in the secured unit. The facility did not coordinate with the local Department of Public Health for guidance on handling the suspicious rashes, which could have provided essential support and direction in managing the situation. This lack of action increased the risk of spreading the infection to other residents, staff, vendors, and visitors. The report highlights specific cases where residents with dementia, who were dependent on staff for activities of daily living, were affected by the facility's failure to adhere to its policies. For instance, residents with generalized rashes were treated with permethrin cream, but the facility did not follow through with necessary isolation precautions or deep cleaning measures. The facility's policies on scabies identification and infection control were not adequately followed, leading to a situation of Immediate Jeopardy, where the health and safety of residents were at significant risk.
Removal Plan
- The facility conducted body skin assessments on the five residents listed on the IJ document and placed them on contact isolation.
- A line list was created for all 23 CCU residents and staff to monitor for rashes.
- The facility notified the Medical Director and Primary Care Physicians, and dermatology consults were ordered for affected residents.
- The Director of Social Services Department scheduled dermatology appointments for residents whose families agreed to consults.
- The facility notified the CDPH and coordinated with the local regional Public Health Nursing team for guidance.
- All Licensed Nurses and Certified Nursing Assistants were in-serviced on skin issues, infection control, use of PPE, and isolation precautions.
- The Infection Preventionist or designee will monitor and track residents with suspicious rashes, maintain an infection control program, and report findings to the quarterly QAPI monitoring meeting.
Failure to Prevent and Manage Pressure Injury
Penalty
Summary
The facility failed to prevent the development and progression of a pressure injury for a resident, identified as Resident 50, who was admitted with conditions including dysphagia, atrial fibrillation, and dementia. Initially, the resident was assessed as having no pressure injuries and was at moderate risk for developing them. However, the facility did not adhere to the care plan that required repositioning the resident every two hours to relieve pressure on the left buttock area. Observations showed that the resident was left in the same position for extended periods, contributing to the development of a pressure injury. The facility also failed to update the resident's care plan and Braden scale assessment as the pressure injury progressed from Stage 1 to Stage 4. The Registered Dietician did not assess the resident's nutritional status, which is crucial for wound healing, at any point during the progression of the pressure injury. Additionally, there was no interdisciplinary team meeting conducted to address the resident's nutritional needs or the pressure injury, and no weights were recorded for the resident during this period. Interviews with staff revealed a lack of follow-up and documentation regarding the resident's condition. The Treatment Nurse and Director of Nursing acknowledged that the care plan was not updated as the pressure injury worsened, and the facility did not conduct a change of condition assessment or update the Braden scale. The facility's policy and procedure for pressure injuries were not followed, resulting in the resident experiencing pain and the pressure injury advancing to a severe stage.
Failure to Monitor and Report Resident's Low Urine Output
Penalty
Summary
The facility failed to inform the physician of a resident's abnormally low urine output, which was significantly below the reference range. This occurred during a specific shift, and the physician was not notified of the resident's condition, which was a critical oversight given the resident's medical history. The resident, who had congestive heart failure, chronic kidney disease, and was taking diuretics, exhibited signs of dehydration, including sunken eyeballs and dry lips, but these were not communicated to the physician. Additionally, the facility did not initiate a change of condition (COC) when the resident's urine output was observed to be critically low. The resident's care plan included monitoring for signs of dehydration, but there was no documentation that this was done. The Assistant Director of Nursing acknowledged that the resident's low urine output should have prompted documentation and notification to the physician, but this did not occur. The facility also failed to monitor the resident's urine output over a period of several weeks. This lack of monitoring contributed to the resident developing acute kidney injury due to dehydration, which required hospitalization. The Director of Nursing confirmed that the physician should have been notified when the resident's urine output was below a certain threshold, but this protocol was not followed.
Failure in Medication Review and Infection Control
Penalty
Summary
The Quality Assessment Assurance (QAA) Committee and Quality Assurance Performance Improvement (QAPI) program at the facility failed to identify several critical deficiencies in the care provided to residents. Specifically, the Licensed Pharmacist (LP) did not conduct monthly Drug Regimen Reviews (DRR) of psychotropic medications, nor did they make recommendations for gradual dose reduction (GDR) or dosage adjustments for residents with dementia. Additionally, the facility did not obtain psychiatric services for residents receiving psychotropic medications, which is essential for managing their medications and behaviors effectively. Furthermore, the facility failed to establish and maintain an infection control program for residents with suspicious skin rashes. During interviews, the Medical Director (MD1) and the Director of Nursing (DON) along with the Administrator admitted to being unaware of these systemic failures. The facility's QAPI plan, which aims to proactively improve resident care, was not effectively implemented, as evidenced by these deficiencies. These failures resulted in residents not receiving the appropriate care and services needed to achieve or maintain their highest practicable mental, physical, and psychosocial well-being.
Failure to Obtain Informed Consent for Pressure Pad Alarms
Penalty
Summary
The facility failed to ensure that residents were assessed for the use of pressure pad alarms and that either the residents or their representatives were given the choice to provide informed consent. This deficiency was identified for two residents, one with severe cognitive impairment due to dementia and another with intact cognition but requiring assistance with daily activities. Both residents had pressure pad alarms in place to monitor their movements without having been informed of the risks and benefits, nor had they or their representatives provided informed consent. The facility's policy and procedure on the use of restraints indicated that any device that restricts a resident's freedom of movement and cannot be easily removed by the resident is considered a restraint. Despite this, the facility did not consider alarms as restraints and only obtained a physician's order for their use. The Director of Nursing acknowledged that they were unaware that alarms could be considered restraints and that all residents were equipped with alarms upon admission without proper assessment or consent. This oversight resulted in a violation of the residents' rights to be free from restraints.
Lack of Continuing Education in Infection Control for Key Staff
Penalty
Summary
The facility failed to provide documented evidence of 10 hours of continued education in the field of Infection Prevention and Control (IPC) for key staff members, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Director of Staff Development (DSD). During an interview, these staff members admitted that they had not completed the required annual continuing education in IPC since their initial training in 2019. This lack of ongoing education was identified during a review of the California Department of Public Health All Facilities Letter (AFL) 20-84, which emphasizes the importance of continuous IPC training to remain updated on new information, trends, and best practices. The facility's policy and procedure document, titled 'Artesia Christian Home Infection Control Program,' was also reviewed and found to be undated. The policy indicated that the facility should establish an infection control program to provide a safe, sanitary, and comfortable environment for residents and staff, aiming to prevent the development and transmission of disease and infection. However, the absence of documented continuing education for the key staff members responsible for infection prevention and control suggests a gap in adherence to these policies and procedures.
Failure to Monitor Antibiotic Ointment Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not monitoring the use of triple antibiotic ointment for two residents. Resident 1, who was admitted with chronic respiratory failure and generalized muscle weakness, had orders for the application of triple antibiotic ointment on skin tears on the right forearm and left wrist. Similarly, Resident 60, admitted with acute respiratory failure and anemia, had orders for the application of triple antibiotic ointment on a left lower shin abrasion. Despite these orders, the facility did not monitor or address the use of triple antibiotic ointment as part of its antibiotic stewardship program. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility did not include triple antibiotic ointment in its antibiotic stewardship efforts. The facility's policy on antibiotic stewardship indicated that data on antibiotic use should be collected and reviewed quarterly, and that the Infection Control Supervisor should report on antibiotic prescriptions. However, the facility did not follow these protocols for the use of triple antibiotic ointment, leading to a potential for inappropriate antibiotic use for the residents involved.
Failure to Document COVID-19 Vaccination Status for Staff
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination status for all employees, which was identified during an interview and record review with the Assistant Director of Nursing (ADON). The review revealed that the COVID-19 immunization status of 128 facility staff members was unknown. This lack of documentation was in violation of the County of Los Angeles Department of Public Health order, which requires healthcare personnel to either be vaccinated or provide a written declaration of vaccine declination by November 1 of each respiratory virus season. The Director of Nursing (DON) acknowledged the need for updated COVID-19 vaccination status for employees. The facility's policy and procedure, titled Infection Control Plan, aimed to prevent cross infections through immunizations, but the policy was undated and did not appear to be effectively implemented. The failure to document vaccination status had the potential to place staff and residents at risk for negative outcomes related to COVID-19.
Failure to Implement Care Plan for Noncompliant Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was noncompliant with his care plan. The resident, who was admitted with chronic respiratory failure, generalized muscle weakness, and a gastrotomy tube, required various levels of assistance for daily activities. Despite having intact cognition, the resident was noted to be particular about his care preferences and often did not comply with safety and feeding plans, as well as his turning schedule. This noncompliance was documented in the resident's Behavior Quarterly Management Follow Up, but no care plan was created to address these behaviors. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility recognized the need for a care plan to guide the resident's care and treatment. However, the ADON confirmed that no such care plan was in place for the resident's noncompliance. The facility's policy on care plans, revised in 2016, mandates the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's needs. The absence of a care plan for the resident's noncompliance was identified as a deficiency, with the potential to delay care and services.
Failure to Revise Care Plan for Pressure Injury
Penalty
Summary
The facility failed to revise the care plan for a resident who developed a pressure injury on the left buttocks area. Initially, the resident was admitted with conditions including dysphagia, paroxysmal atrial fibrillation, and unspecified dementia. The Minimum Data Set (MDS) indicated the resident had no pressure injuries at the time of assessment. However, the resident was dependent on staff for various activities of daily living. Despite the development of a pressure injury, the care plan was not updated as the injury progressed from Stage 1 to Stage 4. The Treatment Nurse acknowledged that the care plan was not revised to address the progression of the pressure injury. The Director of Nursing stated that the facility's policy requires care plans to be updated with changes in a resident's condition, but this was not done in this case. The facility's policy on comprehensive person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs, which was not adhered to, resulting in a delay in addressing the resident's worsening condition.
Failure to Provide Appropriate ROM Care and Splint Application
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion (ROM) and mobility issues, leading to a deficiency in maintaining and improving the resident's physical condition. The resident, who was admitted with dementia and severely impaired cognition, was dependent on staff for activities of daily living. Despite the care plan indicating the need for bilateral lower extremity active assist range of motion (AAROM) exercises, the resident was not receiving ROM exercises on the upper extremities as required by the facility's policy. The Restorative Nurse Assistant (RNA) confirmed that ROM was only being provided for the lower extremities, as it was believed the resident could move the upper extremities independently. Additionally, the facility did not adhere to a physician's order for the application of a left-hand splint, which was intended to prevent further contracture and promote joint extension. Instead, a towel roll was observed in the resident's left hand, contrary to the physician's order for a splint. The Director of Rehabilitation (DOR) assessed the resident and noted stiffness in the left hand, indicating that the resident would benefit from the use of a splint. The DOR also observed that the resident's right hand was at high risk for limitation without intervention, as the resident lacked the cognitive skills to maintain joint mobility independently. The facility's policies on resident mobility and the use of splints were not followed, as the resident did not receive the necessary services to prevent further decline in ROM and maintain mobility. The failure to provide the prescribed ROM exercises and the correct application of a splint placed the resident at risk for further decline in physical condition, including contractures and potential skin breakdown.
Lack of Emergency Dialysis Supplies for Resident
Penalty
Summary
The facility failed to provide necessary equipment and supplies for managing dialysis emergencies for a resident requiring dialysis care. Resident 6, who was admitted with diagnoses including muscle weakness, end-stage renal disease (ESRD), anemia, and dependence on renal dialysis, did not have an emergency dialysis kit at the bedside. This was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the absence of emergency supplies in the resident's room. Further interviews revealed that the Director of Nursing (DON) confirmed the lack of a dialysis bleed kit at the bedside, indicating that nurses would have to gather supplies in case of an emergency. The facility's policy and procedure for the care of residents with ESRD, revised in 2010, stated that residents should be cared for according to recognized standards, including intervention in medical emergencies such as hemorrhages. However, the facility did not adhere to this policy, as evidenced by the lack of emergency supplies at the resident's bedside.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who was found with a 1.5 cm by 1.5 cm bluish bump on the left side of her forehead. The resident, who had been admitted with pneumonia and difficulty in walking, had moderately impaired cognition and required assistance during transfers. The injury was discovered by the resident's responsible party and reported to the charge nurse, who noted the bump but did not have an explanation for its origin. The facility's investigation suggested that the injury might have been caused by the resident's agitation and dislike of the stand-up lift used during transfers, but no staff interviews were conducted to confirm this. The Director of Nursing (DON) acknowledged that incidents involving injuries of unknown origin should be reported to the California Department of Public Health (CDPH), but the bump was not reported as it was assumed to be related to the resident's behavior during transfers. The facility's policy requires that all such incidents be reported to the supervisor and further investigated by the Executive Director and DON, with necessary actions taken and reports made to state agencies. The failure to report the injury resulted in a delay of an onsite inspection by CDPH and had the potential for an ongoing unknown injury.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, identified as Resident 210, who had a 1.5 cm by 1.5 cm bluish bump on the left side of her forehead. The resident was admitted with diagnoses including pneumonia and difficulty in walking, and her cognition was moderately impaired. The incident was noted in the resident's progress notes, where it was reported that the resident's responsible party noticed the bump and informed the charge nurse. The charge nurse assessed the injury, but there was no report of any fall or injury from the outgoing staff. The facility's investigation suggested that the injury might have been caused by the resident's agitation during the use of a stand-up lift, which she disliked. The Director of Nursing (DON) acknowledged that incidents involving unusual bruises should be investigated and reported. However, the DON assumed the injury was due to the resident's agitation with the stand-up lift and did not interview the staff who worked with the resident on the day of the injury. The facility's policy requires all accidents or incidents to be investigated and reported, but this was not adequately followed in this case, leading to a deficiency in the facility's response to the incident.
Resident Injury Due to Inappropriate Use of Stand-Up Lift
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 210, was free from accidents during transfers using a stand-up lift. Despite Resident 210 exhibiting agitation and combativeness during the use of the lift, the staff continued to use it for transfers to and from the bed. This resulted in Resident 210 sustaining a 1.5 cm by 1.5 cm bluish bump on the left side of her forehead. The resident's admission record indicated diagnoses of pneumonia and difficulty in walking, and her Minimum Data Set (MDS) showed moderately impaired cognition, requiring assistance for transfers. The physician's order noted episodes of agitation, and the Medication Administration Record documented multiple episodes of agitation on a specific day. The facility's investigation concluded that the use of the stand-up lift, which the resident disliked, likely caused the injury. Interviews with staff, including a Certified Nurse Assistant (CNA) and the Director of Nursing (DON), revealed that the resident was uncooperative with the lift, and alternative transfer methods were not explored. The facility's policy on assistive devices emphasized assessing the appropriateness of equipment for the resident's condition, but this was not adequately addressed in Resident 210's case. The care plan for the resident included handling her gently to prevent bruising, but this intervention was insufficient to prevent the incident.
Failure to Securely Store Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were stored securely, as required by regulations. During an initial tour, it was observed that an emergency kit containing Ativan, a controlled medication, was stored in an unlocked refrigerator at both the North and South Stations. A Licensed Vocational Nurse (LVN) confirmed that the refrigerator was never locked, and the emergency kit with Ativan was kept inside. The Director of Nursing (DON) acknowledged that Ativan is a controlled medication and should have been kept double locked to prevent unauthorized access and potential misuse. The facility's policy and procedure for controlled drugs, revised in December 2015, indicated that controlled drugs should be stored separately from non-controlled medications and under double lock, especially for Schedule II drugs. However, this policy was not followed, leading to the deficiency.
Delayed PT/OT Evaluation for Resident
Penalty
Summary
The facility failed to provide a timely Physical Therapy (PT) and Occupational Therapy (OT) evaluation for a resident, as per the physician's order. The resident, who was admitted with a diagnosis of dementia and had moderate cognitive impairment, was dependent on staff for activities of daily living. A care plan indicated the need for rehab screening or treatment as necessary. A rehab screening note identified moderate to severe limitations in the resident's lower extremities and recommended PT/OT evaluation for contracture and orthotic management. However, despite a physician's order for PT/OT evaluation dated 11/26/2024, the evaluation was delayed. The delay occurred because the Director of Rehab (DOR) missed an email from the Social Services Director (SSD) regarding the insurance authorization received on 12/18/2024. The DOR acknowledged that the PT/OT evaluation should have been completed after receiving the insurance authorization. The facility's policy stated that residents with limited range of motion should receive appropriate services to maintain or improve mobility, but this was not adhered to, resulting in a delay in the resident's evaluation and treatment.
Room Size Deficiency in LTC Facility
Penalty
Summary
The deficiency involves the room sizes in a long-term care facility, where six out of eighteen rooms do not meet the required square footage per resident. Specifically, rooms with four beds each measure 305.5 square feet, and rooms with two beds each measure between 151 and 152 square feet, falling short of the regulatory requirement of 80 square feet per resident in multiple occupancy rooms. During an interview, the Maintenance Supervisor stated that the residents in these rooms were not negatively impacted and that there was sufficient space for nursing services. Additionally, the Director of Nursing requested a waiver for the room sizes. Observations during the survey period indicated no issues with residents' access, furniture space, or staff's ability to provide care.
Inaccurate Resident Assessment Due to MDS Discrepancy
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, as evidenced by discrepancies in the Minimum Data Set (MDS) and the Nursing Admission Assessment. The MDS, dated 10/14/2024, inaccurately indicated that the resident did not have any dental issues, while the Nursing Admission Assessment, dated 10/8/2024, noted that the resident was missing two front lower natural teeth. This inconsistency resulted in an inaccurate depiction of the resident's current health status. The resident, who was admitted to the facility with diagnoses including seizures, dementia, age-related osteoporosis, and muscle weakness, was found to have severe cognitive impairment and was dependent on all activities of daily living. During an interview, a registered nurse acknowledged the error in the MDS coding and stated that it should be amended to reflect the resident's dental issues. The Director of Nursing emphasized the importance of accurate assessments to provide a clear representation of the resident's condition.
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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