Bell Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Bell, California.
- Location
- 4900 E. Florence Ave, Bell, California 90201
- CMS Provider Number
- 056218
- Inspections on file
- 36
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Bell Convalescent Hospital during CMS and state inspections, most recent first.
A resident with a history of cellulitis and recent toe amputation was not weighed on admission or weekly for four weeks as required by facility policy. Nursing staff and the DON confirmed that weights were missing from the records and that no explanations were documented for these omissions, despite the resident's care plan specifying weight monitoring.
The facility failed to prevent falls and provide safety measures for two residents, leading to injuries and hospitalization. The facility did not conduct timely IDT assessments or implement person-centered interventions for fall prevention. Additionally, the facility did not provide padded siderails for residents at risk for seizures, increasing the potential for injury.
The facility did not act on the Medication Regimen Review (MRR) conducted for residents, resulting in delays in medication adjustments and care plans. The Consultant Pharmacist's recommendations for 35 residents were not communicated to physicians, as required by the facility's policy. The DON was unaware of these recommendations until months later.
The facility failed to ensure the cleanliness of the kitchen's ice machine, with yellow and white buildup observed on the inside gasket. The Dietary Supervisor and Maintenance Manager acknowledged the buildup, which could potentially be mold, posing a risk of contamination to the ice consumed by residents. The facility's policy required weekly cleaning of the gaskets to prevent such buildup.
The facility failed to maintain a sanitary garbage storage area, with trash bags and cardboard boxes on the ground and an overflowing dumpster with an open lid. The Maintenance Manager acknowledged the issue, which violated the facility's policy requiring closed dumpster lids to prevent pests and debris.
A LTC facility failed to implement infection control practices for three residents. A resident's nasal cannula tubing was not changed weekly, risking respiratory infection. Two residents had urinary catheter tubing and drainage bags touching the floor, contrary to care plans. One resident's catheter bag was encrusted with sediments, which staff failed to report, increasing infection risk. These deficiencies highlight lapses in adherence to infection control protocols.
The facility failed to maintain an effective pest control program, leading to an unresolved German cockroach infestation in the Admission's Office. Observations revealed clutter and water-damaged cardboard boxes, with live cockroaches seen over several days. The Administrator and Maintenance Manager acknowledged the inadequacy of current pest control measures, attributing the issue to the building's age and a neighboring carwash. Despite extermination efforts, the infestation persisted, indicating a failure to implement the facility's pest control policy effectively.
A resident received sertraline and aripiprazole without proper informed consent, as the facility obtained consent from an unauthorized family member instead of the resident, who had the capacity to make her own medical decisions. The resident was not informed about the medications or their potential side effects, violating her rights to be informed and make decisions about her care.
A resident with hemiplegia and other health issues was unable to reach or use the call light due to its inappropriate placement and type, leading to reliance on calling out for help. The facility's policy required the call light to be within reach, but this was not followed, resulting in a deficiency.
The facility failed to update the medical records of two residents to reflect their advance directive status. One resident's advance directive acknowledgment form was incomplete, missing essential signatures, while another resident's form was not obtained within the required 24 hours of admission. These deficiencies were identified during record reviews and interviews with staff, highlighting lapses in following the facility's policy on advance directives.
Two residents with severe cognitive impairments were involved in a verbal altercation, which was not reported to the State Agency in a timely manner. Despite facility policies requiring immediate reporting of abuse, the incident was delayed due to the alleged abuser's dementia diagnosis, leading to a delayed investigation and increased risk of further incidents.
A facility failed to ensure the accuracy of a PASRR Level I Screening for a resident with depression and psychosis. The screening did not reflect the resident's mental health diagnoses, leading to the omission of a necessary PASRR Level II Mental Health Evaluation. The DON acknowledged the inaccuracy, which contradicted the facility's policy to ensure appropriate placement and service provision for individuals with mental disorders.
The facility failed to develop comprehensive care plans for four residents, including those with mental health conditions, fall risks, and those using low air loss mattresses. This oversight led to potential risks and complications, as confirmed by staff interviews and record reviews.
Two residents with histories of falls and cognitive impairments experienced multiple falls without revisions to their care plans. Despite sustaining injuries, the facility did not update the fall prevention interventions, contrary to their policy. This deficiency in care planning led to repeated falls and injuries for the residents.
A facility failed to document medication administration and monitoring for a resident, including pantoprazole, insulin lispro, COVID-19 and vital signs, pain, and side effects of various medications. The resident, with conditions such as diabetes and hypertension, required these interventions as part of their care plan. The lack of documentation could delay necessary care, as acknowledged by RN 1.
The facility failed to adjust low air loss mattresses (LALMs) according to residents' weights, risking pressure ulcer development. A resident's LALM was set to 400 lbs despite weighing 224 lbs, and another's was set for 320 lbs while weighing 161 lbs. Staff lacked training on LALM setup, and care plans did not document necessary adjustments, leading to discomfort and potential injury.
A resident with multiple health conditions did not receive prescribed oxygen therapy due to a disconnection between the humidifier and the oxygen concentrator. An LVN confirmed the oversight, acknowledging it was her responsibility to ensure proper connection. The DON emphasized the importance of staff checking oxygen connections, as per facility policy.
The facility failed to provide dialysis emergency kits at the bedside for three residents requiring dialysis, placing them at risk for complications from uncontrolled bleeding. Observations revealed the absence of these kits, and interviews indicated staff were unaware of their necessity. The facility's policies did not adequately address the need for these kits, highlighting a systemic issue in ensuring resident safety during dialysis treatment.
The facility failed to implement a gradual dose reduction (GDR) for a resident on sertraline despite no depressive symptoms and did not obtain informed consent for trazodone administration to another resident. The sertraline GDR was recommended by the consultant pharmacist but not attempted, and the resident was unaware of receiving the medication. For trazodone, the resident's medical records lacked informed consent documentation, which is required by facility policy.
The facility failed to properly label and store food brought by visitors for four residents, including items like hot sauce, Popeyes food, desserts, and a sandwich, which were left at bedsides without labels or refrigeration. Staff were unsure of labeling requirements, leading to a deficiency in following the facility's policy.
A resident with a history of stroke and leg amputation was not screened for skilled therapy services upon readmission, despite physician orders. The resident did not receive passive range of motion exercises until months later, delaying necessary rehabilitative care. This failure prevented advocacy for skilled therapy services and could impact the resident's mobility and ADLs.
The facility failed to develop comprehensive Covid-19 care plans for three residents, including one with moderate cognitive impairment and another with severe cognitive impairment. Despite the facility's policy requiring care plans to address medical and psychosocial needs, the necessary interventions for Covid-19 were not identified or implemented.
The facility failed to implement proper Covid-19 infection control measures, including inadequate PPE use by staff, failure to test exposed staff, incomplete visitor screening, and not reporting an outbreak to the health department. These deficiencies were observed through staff actions and interviews, highlighting lapses in following established policies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and open wounds, despite the DON acknowledging the requirement. Additionally, the facility did not report three new Covid-19 cases during an outbreak, and staff were not trained or equipped with appropriate PPE. The ADM misunderstood EBP requirements, and the facility's outdated policies contributed to these deficiencies.
A resident received Hydrocodone-Acetaminophen (Norco) three hours earlier than prescribed due to a failure to follow the facility's medication administration policy. The resident, with a history of cerebrovascular disease and cognitive impairment, had already received a dose earlier for severe pain. The LVN did not document the early administration in the MAR, contrary to the facility's policy requiring documentation and adherence to prescribed times.
A resident with heart failure, asthma, and respiratory failure was observed receiving oxygen at a rate of four L/min instead of the physician-ordered two L/min. The DON confirmed the discrepancy, indicating a failure to follow the facility's policy for verifying and adjusting oxygen delivery according to physician orders.
A resident experienced inadequate pain management due to a nurse's failure to follow the facility's pain assessment policy. The nurse did not promptly address the resident's pain, use a standard pain assessment scale, or document the administration of pain medication. The resident, with a history of cognitive impairment and physical disabilities, expressed pain during a medication pass, but the nurse administered Norco without assessing the pain level. This led to the resident experiencing pain that interfered with daily activities.
The facility failed to provide timely assistance with ADLs for two residents, leading to them being left wet with urine. Despite requiring maximum assistance, one resident waited two hours for help, while another was found wet with urine, indicating a lack of timely incontinence care.
Failure to Obtain and Document Admission and Weekly Weights
Penalty
Summary
The facility failed to weigh one of three residents on admission and weekly for four weeks as required by its policy and procedure titled 'Weight Assessment and Interventions.' Specifically, the resident was not weighed upon readmission, and there were no recorded weights for the required weekly intervals following readmission. The resident's care plan included an intervention to monitor weight per policy due to a diagnosis of cellulitis of the right lower limb and acquired absence of other right toe(s). Despite this, the weight records did not include a weight taken on the day of readmission, nor were there documented reasons in the progress notes for missing weights on subsequent required dates. Interviews with facility staff, including an LVN, RN, and the DON, confirmed that the facility's policy was not followed, as weights were not obtained or documented as required. The DON acknowledged the absence of weight records and progress notes explaining the missed weights, and confirmed the importance of obtaining weights on admission to monitor residents' health status. The facility's policy clearly stated that weights should be measured on admission, the next day, and weekly for four weeks, and recorded in the appropriate records, which was not done in this case.
Failure to Prevent Falls and Provide Safety Measures
Penalty
Summary
The facility failed to ensure that two residents, Resident 17 and Resident 44, were free from avoidable accidents and hazards. For Resident 17, the facility did not conduct an Interdisciplinary Team (IDT) assessment following a fall on June 14, 2024, and failed to develop or implement person-centered interventions to prevent repeated falls on June 21, 2024, and August 3, 2024. As a result, Resident 17 sustained significant injuries, including a laceration, hematoma, and fractures, leading to hospitalization. The IDT assessments were not completed in a timely manner, and the interventions suggested were not appropriate given Resident 17's cognitive impairments. Resident 44 also experienced multiple falls due to the facility's failure to conduct timely IDT assessments and develop new, person-centered fall prevention interventions. Despite a history of falls, the IDT assessment did not address the cause of the falls or implement new interventions. Resident 44 sustained a forehead abrasion and complained of moderate pain after subsequent falls. The facility's policy required staff to assess and identify residents at risk for falls and develop appropriate care plans, which was not adhered to in this case. Additionally, the facility failed to provide padded siderails for Residents 44, 6, and 35 as ordered by their physicians. Observations revealed that these residents, who were at risk for seizures, did not have the necessary padded siderails to prevent injury. Staff interviews confirmed the absence of padded siderails, which increased the potential for injury. The facility's policy on safety and supervision required targeted interventions to reduce individual risks, which were not implemented correctly or consistently in these cases.
Failure to Act on Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act on the Medication Regimen Review (MRR) conducted for all residents between 8/19/2024 and 8/20/2024. The MRR, which is a thorough evaluation of a resident's medication regimen aimed at promoting positive outcomes and minimizing adverse consequences, was not reviewed or acted upon by the facility staff. The Consultant Pharmacist made recommendations for 35 out of 91 residents, but these recommendations were not communicated to the residents' physicians, resulting in delays in medication adjustments and care plans. During an interview and record review on 12/4/2024, the Director of Nursing (DON) acknowledged that the recommendations from the MRR were not reviewed or reported to the physicians. The DON was unaware of the recommendations until the interview date. The facility's policy and procedure, dated 4/2018, required that any offsite MRR recommendations be communicated to the physician, with the DON or their designee responsible for enforcing this policy. The Consultant Pharmacist emphasized the importance of timely acknowledgment and action on his recommendations to allow physicians to make informed decisions about residents' care plans.
Ice Machine Contamination Risk
Penalty
Summary
The facility failed to maintain the cleanliness of the kitchen's ice machine, specifically the inside gasket, which was found to have yellow and white buildup. During an observation and interview with the Dietary Supervisor, it was noted that the buildup could potentially be mold, which should not be present inside the ice machine. The Dietary Supervisor acknowledged that ice is considered food and that the presence of such buildup could contaminate the ice, posing a risk of foodborne illnesses to residents. The responsibility for cleaning the internal parts of the ice machine was attributed to the maintenance department. Further observation and interview with the Maintenance Manager confirmed the presence of dirty calcium buildup inside the ice machine, which was deemed inappropriate. The facility's policy and procedure on sanitation and infection control, dated 2018, indicated that ice should be produced, stored, and dispensed in a manner to avoid contamination. It also specified that the inside gaskets or seals should be wiped down weekly by the Department of Food and Nutrition Services to prevent mold or calcium buildup.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary condition, as observed during a survey. Trash bags and cardboard boxes were found on the ground, and the outside trash dumpster was overflowing with trash and had its lid open. During interviews, the Dietary Supervisor did not comment on the garbage area, indicating that maintenance was responsible. The Maintenance Manager acknowledged the unacceptable condition, noting that it could lead to disease and infection. The facility's policy and procedure on sanitation and infection control, dated 2018, required that dumpster lids be kept closed to prevent pests, animals, or debris from entering.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices for three residents, leading to potential health risks. For Resident 66, the nasal cannula tubing used for oxygen therapy was not changed every seven days as required. Observations on multiple occasions revealed that the tubing was dated 11/25/2024, indicating it had not been replaced in accordance with the facility's policy. Licensed Vocational Nurse 3 confirmed that the tubing should be changed weekly to prevent respiratory infections, as microorganisms could enter the respiratory tract through the nasal cannula. Resident 38's indwelling urinary catheter tubing and drainage bag were observed touching the floor on two separate occasions. This practice is against the facility's care plan, which aims to prevent urinary tract infections by ensuring the catheter bag and tubing are placed below the bladder level and away from the floor. Resident 38's cognitive skills were severely impaired, making them dependent on staff for personal hygiene and other activities, further emphasizing the need for staff vigilance in maintaining infection control standards. Resident 84's urinary catheter drainage bag was found to be encrusted with sediments and touching the floor, which was observed over several days. The presence of sediments in the urine and on the drainage bag was not reported by the staff, despite the facility's policy requiring such findings to be communicated to the charge nurse. The Infection Preventionist Nurse and other staff members acknowledged the potential for infection due to the dirty and improperly maintained catheter equipment. Resident 84's cognitive impairment and dependency on staff for personal care necessitated strict adherence to infection control protocols, which were not followed in this case.
Unresolved German Cockroach Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective, ongoing pest control program, resulting in an unresolved infestation of German cockroaches. Observations revealed that the Admission's Office, located next to the kitchen, was cluttered with desks, a couch, a refrigerator, a microwave, Christmas decorations, and cardboard boxes filled with paper documents. These boxes were stored on the floor and showed signs of water damage. A square hole with an uncovered electrical outlet and exposed wires was also noted on the wall adjacent to the kitchen. Live adult German cockroaches were observed in the Admission's Office, crawling from under a desk and hiding among the clutter. Interviews with the Administrator and Maintenance Manager revealed that the facility had ongoing issues with cockroaches, attributed to the building's age and a neighboring carwash, which allegedly contributed to the pest problem and excess moisture. The Administrator acknowledged the inadequacy of the current pest control measures and expressed the need for a more effective solution. Despite extermination efforts and the placement of roach baits, live cockroaches continued to be observed in the office over several days. The facility's policy on pest control, dated April 2018, indicated that employees should report any signs of pests, and the Maintenance Supervisor should take immediate action, which was not effectively implemented in this case.
Failure to Obtain Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications from the responsible party of a resident, identified as Resident 45. Instead, consent was obtained from a family member who was not designated to make medical decisions on behalf of the resident. This resulted in the resident receiving sertraline and aripiprazole without her knowledge or explicit consent, which is a violation of the resident's rights to be informed and make decisions about her own care. Resident 45 was admitted to the facility with diagnoses of depression and psychosis and had the capacity to understand and make medical decisions, as indicated in her medical records. Despite this, the facility obtained consent from a family member who was not authorized to act on her behalf. The resident's admission agreement indicated she had decision-making capacity, and she had signed her own consent for treatment upon admission. However, the informed consents for the medications were signed by the unauthorized family member. Interviews with the resident and the family member confirmed that neither was aware of the consent process or the administration of the medications. The Director of Nursing acknowledged that the resident should have been informed and provided consent herself. The facility's policy on informed consents emphasizes the importance of upholding residents' rights to make informed decisions, which was not adhered to in this case.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident 23 by not providing an appropriate call light device within reach, which prevented the resident from effectively communicating with staff. Resident 23, who was admitted with conditions including hemiplegia, hemiparesis, and other health issues, required maximal assistance for daily activities and was dependent on a wheelchair for mobility. The resident's care plan specifically indicated that the call light should be within reach to ensure prompt assistance and prevent falls. During an observation, Resident 23 was found unable to reach the call light, which was placed at ear level on the left side of the pillow. The resident was observed calling out for help, and a CNA confirmed that the call light was not accessible to the resident. The CNA placed the call light on the resident's chest, but Resident 23 struggled to use it due to limited mobility. The CNA acknowledged that the resident typically yelled for help and was unaware of the resident's inability to use the call light, suggesting the need for a paddle call light. The facility's policy required staff to assess residents' ability to use the call light and ensure it was within easy reach. However, this was not adhered to in Resident 23's case, as the resident was not provided with a suitable call light device. The Director of Nursing later acknowledged the need for reassessment and appropriate accommodation for Resident 23's call light needs.
Failure to Update Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that the medical records of two residents were updated to reflect their advance directive status, which is a legal document indicating a resident's preferences on end-of-life treatment decisions. For one resident, the facility did not complete the advance directive acknowledgment form (ADAF), which is part of the advance directive process. The form was missing essential signatures, including those of the resident's representative or witnesses, rendering it inactive. This oversight was identified during a review of the resident's admission record and confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the incomplete form could affect the resident's care. In the case of another resident, the facility did not obtain the ADAF within 24 hours of admission, as required by the facility's policy and procedure on advance directives. The resident's medical records, both physical and electronic, lacked the ADAF, which could potentially delay necessary care. The LVN confirmed the absence of the ADAF and stated that it was the charge nurse's responsibility to ensure its availability. The Director of Staff Development also noted that the ADAF should be readily accessible in the resident's chart for emergencies. The facility's policy on advance directives mandates that an acknowledgment of the resident's right to an advance directive be completed and included in the resident's medical file within 24 hours of admission. If the acknowledgment is not completed within this timeframe, the Admissions Coordinator or designee must document the reasons for the delay. The policy further states that any incomplete acknowledgment after five days should be forwarded to the facility Administrator for necessary actions. The failure to adhere to these procedures resulted in the deficiencies noted in the report.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to report an incident of resident-to-resident verbal abuse to the State Agency in a timely manner. On 12/29/2024, an unidentified staff member observed Resident 30, who has severe cognitive impairments and a mood disorder, throw a blanket at Resident 3 and yell at her. Resident 3, who also has severe cognitive impairments and is dependent on staff for all activities of daily living, was unable to understand or make decisions. Despite the observation of this altercation, the incident was not reported to the State Agency until 1/15/2024. The facility's policies and procedures require that all allegations of abuse, including verbal abuse, be reported immediately to the State Agency, regardless of the alleged abuser's cognitive condition. The Administrator acknowledged that the incident was not reported because Resident 30 had a diagnosis of dementia, which is not an acceptable reason for failing to report according to the facility's policies. This delay in reporting resulted in a delayed investigation by the State Agency and increased the potential for further incidents of abuse.
Inaccurate PASRR Screening for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for a resident with mental health disorders. The resident, who was admitted and readmitted to the facility, had diagnoses of depression and psychosis. However, the PASRR Level I Screening conducted upon their readmission did not reflect these diagnoses and was marked as negative. Consequently, a PASRR Level II Mental Health Evaluation was not deemed necessary, potentially impacting the resident's access to required services and care. During an interview and record review, the Director of Nursing acknowledged that the PASRR Level I Screening was inaccurate and should have included the resident's mental health diagnoses. The facility's policy and procedure on PASRR, dated December 2017, emphasized the importance of accurate screenings to prevent inappropriate placements in nursing homes for individuals with mental disorders or intellectual disabilities. The deficiency was identified as the facility did not review and correct the PASRR for accuracy, which is crucial for determining the necessity of additional services and ensuring appropriate admission.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential risks and complications. Resident 45, who was admitted with diagnoses of depression and psychosis, did not have a care plan addressing these mental health conditions. The Director of Nursing (DON) acknowledged the absence of care plans for these diagnoses, which would have included goals and interventions to manage the resident's conditions effectively. Resident 58, who had severe cognitive impairment and was at risk for falls, did not have a fall risk care plan despite evaluations indicating the need for one. A Certified Nursing Assistant (CNA) and a Registered Nurse (RN) both confirmed the lack of fall risk indicators and care plans, which posed a safety risk to the resident. The RN stated that the absence of a fall risk care plan was a significant oversight, as it would have included necessary interventions to prevent falls. Residents 32 and 77, both using low air loss (LAL) mattresses, did not have care plans addressing the use of these mattresses. The Licensed Vocational Nurse (LVN) and RN involved in their care confirmed the lack of documentation and care plans for the LAL mattresses, which are crucial for pressure injury prevention and skin maintenance. The facility's policy required that the use of such mattresses be documented in the care plan, but this was not done, potentially affecting the residents' care and comfort.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise the care plans for two residents following multiple falls, which is a deficiency in care planning and risk management. Resident 44, who has a history of falling and severe cognitive impairment, experienced three falls after the initiation of a fall risk care plan. Despite these incidents, the care plan was not updated to address the falls on 5/19/2024, 8/22/2024, and 9/14/2024. The resident sustained injuries, including a forehead wound and reported moderate pain, yet the care plan interventions remained unchanged. Similarly, Resident 17, who has osteoarthritis, osteoporosis, dementia, and a history of falls, experienced three falls without subsequent revisions to her care plan. The resident's falls on 6/14/2024, 6/21/2024, and 8/3/2024 resulted in injuries, including a puncture wound to the scalp and broken bones in the sacral region. Despite these significant events, the care plan interventions were not updated to prevent further falls and injuries. The facility's policy and procedure for fall risk and prevention assessment require the interdisciplinary team to develop and update care plans to address fall risks. However, the care plans for both residents did not reflect these requirements, as they were not revised following significant changes in the residents' conditions. This lack of action contributed to the residents' repeated falls and injuries, highlighting a failure in the facility's care planning process.
Failure to Document Medication Administration and Monitoring
Penalty
Summary
The facility failed to meet professional standards of quality care for Resident 62 by not documenting the administration of medications and monitoring as required. Specifically, the Medication Administration Record (MAR) lacked documentation for the administration of pantoprazole and insulin lispro on multiple occasions. Additionally, there was no documentation for COVID-19 and vital signs monitoring, pain monitoring, and significant side effects monitoring for anticoagulant and sedative/hypnotic medications on several dates. Resident 62, who was admitted with diagnoses including diabetes mellitus, hypertension, anemia, and depression, required various medications and monitoring as part of their care plan. The resident's Minimum Data Set (MDS) indicated they had intact cognitive skills but required varying levels of assistance with daily activities. Despite these needs, the facility's records showed gaps in documentation, which could potentially delay necessary care and services for the resident. During an interview, RN 1 acknowledged the missing documentation and stated that it was unacceptable, as it could delay necessary care. The facility's policies required immediate documentation of medication administration and monitoring, but these were not adhered to in Resident 62's case. The lack of documentation could lead to prolonged unnecessary medication usage and increased risk of side effects, as well as potential issues with blood sugar management for the resident.
Improper Adjustment of Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that the low air loss mattresses (LALMs) were adjusted according to the residents' weights, which is crucial for preventing and treating pressure ulcers. For Resident 32, the LALM was set to 400 lbs, despite the resident weighing 224 lbs. This discrepancy was observed during an interview and record review, where it was noted that the LALM should have been adjusted according to the resident's weight or comfort level, especially after the resolution of a Stage III pressure injury. The Licensed Vocational Nurse (LVN) acknowledged that there was no care plan or intervention documented for the LALM, which could lead to errors and potential injury. Similarly, for Resident 77, the LALM was set for a person weighing 320 lbs, while the resident's actual weight was 161 lbs. The resident expressed discomfort and difficulty moving in bed, indicating that the mattress was not set correctly. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), revealed a lack of knowledge and training regarding the proper setup and adjustment of LALMs. The facility's policy and procedure, as well as the user manual for the LALM, emphasized the importance of setting the mattress according to the resident's weight and comfort, which was not adhered to in these cases. The deficiency highlights a failure in the facility's processes to ensure that LALMs are used effectively for pressure injury prevention and resident comfort. The Director of Nursing (DON) confirmed that the LALM settings should be documented and care planned, but this was not done for the residents involved. The lack of proper documentation and training on LALM usage contributed to the potential risk of pressure ulcer development or worsening for the residents.
Failure to Administer Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received the prescribed oxygen therapy as ordered by the physician. The resident, who had a history of atrial fibrillation, heart failure, hypertension, asthma, and obstructive sleep apnea, was supposed to receive oxygen at 2 liters per minute via nasal cannula continuously. However, during an observation, it was found that the nasal cannula was connected to a humidifier, but the humidifier was not connected to the oxygen concentrator, resulting in the resident not receiving any oxygen. A Licensed Vocational Nurse (LVN) confirmed the disconnection and acknowledged that it was her responsibility to ensure the oxygen tubing was properly connected during her shift. The Director of Nursing (DON) also confirmed that the resident did not receive oxygen if the humidifier was not connected to the concentrator and emphasized that all staff were instructed to check and ensure oxygen was connected to residents. The facility's policy indicated that oxygen must be administered according to the physician's order and monitored by licensed nurses and the Respiratory Therapist.
Failure to Provide Dialysis Emergency Kits at Bedside
Penalty
Summary
The facility failed to provide dialysis emergency kits at the bedside for three residents who required dialysis, which is a treatment to cleanse the blood of wastes and extra fluids when the kidneys have failed. This deficiency was observed during multiple visits to the rooms of the residents, where it was noted that the necessary emergency kits were absent. The absence of these kits placed the residents at risk for ineffective emergency treatment and complications from uncontrolled bleeding, which could result in hospitalization or death. Resident 66, who was admitted with diagnoses including end-stage renal disease (ESRD), chronic obstructive pulmonary disease (COPD), heart failure, and hypertension, was observed without a dialysis emergency kit at the bedside on two separate occasions. The resident's care plan indicated a goal to avoid complications from dialysis, yet the necessary emergency supplies were not provided. Similarly, Resident 36, with diagnoses of ESRD, diabetes mellitus, hypertension, and anemia, also lacked a dialysis emergency kit at the bedside. Interviews with staff revealed a lack of awareness about the necessity of these kits, indicating a gap in training and policy implementation. Resident 63, who had a perm-a-cath for dialysis, was also found without an emergency kit at the bedside. The facility's Director of Nursing acknowledged the oversight and the absence of a policy requiring these kits at the bedside. The facility's existing policies and procedures did not adequately address the need for dialysis emergency kits, highlighting a systemic issue in ensuring the safety and preparedness for residents undergoing dialysis treatment.
Failure to Implement GDR and Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to implement a gradual dose reduction (GDR) for a resident receiving sertraline, a medication used to treat depression, despite the absence of depressive symptoms. The resident, who had been admitted with diagnoses including depression and psychosis, was monitored from May to October 2024, during which no episodes of depression were recorded. Despite recommendations from the facility's consultant pharmacist to attempt a GDR within the first year of medication use, no such reduction was attempted. Interviews with the resident and facility staff revealed that the resident was unaware of receiving sertraline and its associated side effects, and there was no documentation indicating that a GDR was contraindicated. Another deficiency involved the administration of trazodone to a different resident without obtaining informed consent. The resident, who had intact cognitive skills and required assistance with daily activities, began receiving trazodone for depression in October 2024. However, a review of the resident's medical records showed no evidence of informed consent for the medication. Interviews with nursing staff confirmed that informed consent was not obtained, which is a requirement for administering psychotropic medications. The facility's policy mandates that informed consent be documented in the patient's record, but this was not adhered to in this case. These deficiencies highlight the facility's failure to adhere to protocols regarding medication management and informed consent. The lack of a GDR for sertraline and the absence of informed consent for trazodone administration indicate lapses in ensuring that residents are not subjected to unnecessary medications and are fully informed about their treatment options and potential side effects.
Improper Storage and Labeling of Food Brought by Visitors
Penalty
Summary
The facility failed to ensure that leftover food brought by family members or visitors for four residents was stored according to the facility's policy and procedure. The policy required that food be labeled with the resident's name, the item, and the use-by date, and that perishable foods be stored in resealable containers in a refrigerator. However, observations revealed that food items such as hot sauce, Popeyes food, desserts, and a sandwich were left at residents' bedsides without proper labeling or refrigeration. Resident 69, who had diagnoses including diabetes mellitus, heart failure, hypertension, and chronic kidney disease, was observed with a used bottle of hot sauce on the bedside table without any labeling. Similarly, Resident 66, with conditions such as chronic obstructive pulmonary disease and end-stage renal disease, had outside food from Popeyes and desserts on the bedside table without labels. Both residents confirmed that the food was brought in by family members or themselves, and staff members were unsure about the labeling requirements. Resident 73, diagnosed with diabetes mellitus, dysphagia, heart failure, and hypertension, also had a bottle of hot sauce on the bedside table without labeling. Additionally, Resident 63, with end-stage renal disease and type 2 diabetes mellitus, had a half-eaten sandwich in a brown paper bag on the nightstand, which was not refrigerated. Staff interviews confirmed that the food should have been labeled and stored properly to prevent spoilage and potential illness, but this was not done, leading to the deficiency.
Failure to Provide Rehabilitation and Restorative Services
Penalty
Summary
The facility failed to conduct a rehabilitation screening and provide necessary rehabilitative and restorative nursing services for a resident who was readmitted with significant medical conditions, including a cerebral infarction and a below-knee amputation. Despite physician orders for skilled therapy evaluations upon readmission, the resident was not evaluated or screened for these services. This oversight prevented the Case Manager from advocating for the resident to receive skilled therapy services, which could have been beneficial given the resident's prior therapy history and discharge assessment. Additionally, the resident did not receive passive range of motion exercises until several months after readmission, despite active physician orders. The Director of Rehabilitation Services acknowledged that the restorative nursing services should have commenced upon the resident's readmission, as they did not require prior authorization. The delay in providing these services could potentially contribute to a decline in the resident's mobility and ability to perform activities of daily living.
Failure to Develop Covid-19 Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents diagnosed with Covid-19, which is a highly contagious respiratory disease. This deficiency was identified during a review of the residents' records and interviews with the Director of Nursing (DON). Resident 1, who had moderate cognitive impairment and was dependent on staff for activities of daily living (ADLs), did not have a Covid-19 care plan in place. Similarly, Resident 3, who was cognitively intact and required assistance for certain ADLs, and Resident 4, who had severe cognitive impairment and required substantial assistance for ADLs, also lacked Covid-19 care plans. The absence of these care plans meant that the necessary nursing care interventions to address the residents' Covid-19 infections were not identified or implemented. The facility's policy and procedure on care plans emphasized the importance of developing comprehensive care plans to meet the medical, nursing, and psychosocial needs of each resident, especially following significant changes in their status or condition. However, the facility did not adhere to this policy, as evidenced by the lack of Covid-19 care plans for the affected residents.
Inadequate Covid-19 Infection Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control measures for Covid-19, as evidenced by several observations and interviews. Staff did not adhere to proper PPE protocols when entering and exiting Covid-19 positive rooms. Specifically, a Licensed Vocational Nurse entered a Covid-19 positive room without donning PPE, and a Maintenance Supervisor exited a Covid-19 positive room without doffing PPE. These actions were contrary to the facility's policy, which required staff to wear appropriate PPE, including gloves, isolation gowns, eye protection, and respirators, when dealing with Covid-19 positive residents. The facility also failed to conduct close contact testing of exposed staff after a resident tested positive for Covid-19. The Director of Nursing admitted that staff testing was not initiated promptly, and the facility's policy required testing of all staff and residents with higher-risk exposure. This oversight was confirmed by a Public Health Nurse, who emphasized the importance of testing staff to prevent the spread of the virus. Additionally, the facility did not adequately screen visitors during a Covid-19 outbreak. The Visitor Screening Log was incomplete, with some sections left blank, which meant the facility could not determine if visitors had symptoms or exposure to Covid-19. Furthermore, the facility failed to report the Covid-19 outbreak to the California Department of Public Health, as required by their policy, which could have hindered their ability to receive assistance in controlling the outbreak.
Failure to Implement Infection Control Measures and Report Covid-19 Cases
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for 15 out of 16 residents who met the criteria for EBP implementation. These residents had various medical conditions, including the presence of indwelling medical devices such as gastrostomy tubes and urinary catheters, as well as open wounds. Despite the Director of Nursing (DON) acknowledging the requirement for EBP, the facility did not have a policy or procedure in place, and staff were not trained to implement EBP. The Administrator (ADM) was aware of EBP but mistakenly believed it was not mandatory, leading to a lack of implementation. Additionally, the facility failed to report three new cases of Covid-19 to the local health department during an active outbreak. Two staff members and one resident tested positive, but these cases were not reported, which would have extended the outbreak period. The facility's DON was aware of the positive cases but did not report them, and the facility did not conduct the required testing for new admissions or after identifying positive cases. This failure to report and test created a risk for further transmission of Covid-19 within the facility. Interviews with staff revealed a lack of understanding and adherence to infection control protocols. The DON and ADM did not ensure that staff wore appropriate personal protective equipment (PPE), such as N95 respirators, during the outbreak. The facility's policies and procedures for Covid-19 were outdated and not followed, contributing to the deficiencies in infection prevention and control.
Medication Administration Timing Error
Penalty
Summary
The facility failed to adhere to its policy and procedure for administering medications, resulting in a deficiency. Specifically, a Licensed Vocational Nurse (LVN) administered Hydrocodone-Acetaminophen (Norco) to a resident three hours earlier than the prescribed time. The facility's policy requires medications to be administered within one hour of their prescribed time unless otherwise specified. During an observation, the LVN was seen retrieving and administering the medication to the resident at 9:58 a.m., which was not documented in the Medication Administration Record (MAR). The resident involved, identified as Resident 19, had a history of convulsions, hemiplegia, and hemiparesis following cerebrovascular disease, and was moderately impaired in cognitive skills for daily decision-making. The resident's care plan indicated a focus on managing pain and comfort, with interventions to assess pain levels and administer medications as ordered. However, the MAR showed that the resident had already received Norco at 12:50 a.m. for severe pain, and the subsequent administration at 9:58 a.m. was not recorded. The Director of Nursing confirmed that licensed nurses must adhere to the five rights of medication administration, which was not followed in this instance.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer supplemental oxygen as ordered by the physician for a resident, identified as Resident 5. Resident 5 was admitted with diagnoses including heart failure, asthma, and respiratory failure, and required substantial assistance for daily activities due to impaired short-term memory and mild cognitive impairment. During an observation, it was noted that Resident 5 was receiving oxygen at a rate of four liters per minute, contrary to the physician's order of two liters per minute. The Director of Nursing confirmed the discrepancy between the observed oxygen delivery rate and the physician's order. The facility's policy and procedure for oxygen administration required staff to verify and review physician orders and adjust the oxygen delivery device to ensure the proper flow. However, this protocol was not followed, leading to the deficiency in care for Resident 5.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident, identified as Resident 19, by not adhering to its pain assessment policy and procedure. Licensed Vocational Nurse (LVN 5) did not promptly address the resident's pain when it was verbalized, nor did she use a standard pain assessment scale to determine the pain level. Additionally, LVN 5 did not ensure a thorough assessment of the resident's pain, including its location, frequency, quality, intensity, and duration, before administering pain medication. Resident 19, who was moderately impaired in cognitive skills and had a history of convulsions, hemiplegia, and hemiparesis, expressed pain during a morning medication pass. Despite the resident's request for pain relief, LVN 5 administered Norco without assessing the pain level or documenting the administration. The resident's care plan required pain to be controlled to their comfort level, with interventions including pain assessment and non-medication measures, which were not followed. The facility's policy required pain to be assessed with vital signs and documented using a standard scale, which was not done by LVN 5. The Director of Nursing confirmed that licensed nurses should know the medications they administer and always ask residents about their pain levels. The failure to follow these procedures resulted in Resident 19 experiencing pain that interfered with daily activities and had the potential for unrelieved pain.
Failure to Provide Timely Assistance with ADLs
Penalty
Summary
The facility failed to ensure that two residents, Resident 1 and Resident 3, were provided with adequate assistance for Activities of Daily Living (ADLs), specifically toileting and incontinence care. Resident 1, who has diagnoses including progressive supranuclear ophthalmoplegia and a history of falling, required maximum assistance with toileting and moderate assistance with personal hygiene. Despite this, Resident 1 reported waiting for two hours for staff assistance to use the restroom, resulting in episodes of incontinence. Similarly, Resident 3, who has diagnoses including lack of coordination and aphasia following a stroke, was dependent on staff for toileting and showers. Resident 3 was found wet with urine, indicating a lack of timely incontinence care by the staff. Interviews with staff members, including CNAs and the Director of Staff Development (DSD), revealed that Resident 1 and Resident 3 were not provided timely assistance, leading to them being left wet with urine. The DSD noted that an in-service was provided to reinforce the importance of timely changes, but documentation did not support that Resident 1 had refused a diaper change as claimed by CNA6. The Director of Nursing (DON) confirmed that being left wet with urine could lead to skin issues and infections, and emphasized that staff are expected to attend to residents' ADLs and document their actions. The facility's policy on ADLs supports the need for timely and appropriate care, which was not adhered to in these cases.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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