Bellflower Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellflower, California.
- Location
- 9710 E. Artesia Ave, Bellflower, California 90706
- CMS Provider Number
- 055408
- Inspections on file
- 28
- Latest survey
- October 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Bellflower Post Acute during CMS and state inspections, most recent first.
A facility failed to implement a comprehensive water management plan, did not monitor or document all required control measures for water quality, and did not review or update infection control policies as required. A resident with Legionella pneumonia was admitted without staff identifying or reporting the infection to public health authorities in a timely manner, due to incomplete review of medical records and lack of communication. The facility's policies for annual review and reporting were not followed, and there was no evidence of policy updates or quality assurance documentation.
The facility failed to maintain Jello items at the required temperature of 41 degrees Fahrenheit or lower. The Dietary Supervisor (DS) measured the temperature of Jello items in the kitchen, finding them at 54 degrees and 48 degrees, which is above the required temperature for cold food. The DS acknowledged that the Jello should be kept at 41 degrees or lower to prevent spoilage and maintain taste.
The QAA Committee failed to identify and address systemic issues affecting all residents, including medication administration, dialysis assessments, and food safety. The Administrator admitted these issues were not identified by the committee, despite the facility's policy requiring the QAA to address care and quality issues.
A facility failed to document a resident's pain level before removing Percocet from inventory and did not record the resident's refusal of the medication. The controlled drug record showed doses marked as wasted without proper documentation. Staff interviews revealed that the process for administering PRN pain medication was not followed, and non-pharmacological interventions were not documented as required.
A resident with Huntington's Disease and severe cognitive impairment was not properly monitored while using an abdominal binder to prevent g-tube removal. The facility failed to document assessments, and staff acknowledged inadequate monitoring. Policies on restraint reduction and reassessment were not followed, potentially leading to unnecessary restraint.
A facility failed to review and update a resident's care plans quarterly, as required. The resident, with conditions including acute respiratory failure and dementia, had care plans due for review but not updated by February 2025. Interviews with the MDS Coordinator and DON confirmed the oversight, which violated the facility's policy for quarterly care plan reviews.
A facility failed to document a resident's pain level before administering Percocet, leading to potential medication errors. Additionally, another resident with a penile erosion missed a urology appointment due to transportation issues, and the physician was not notified, delaying necessary care. These actions did not meet professional standards and increased the risk of infection.
A facility failed to change a resident's foley catheter drainage bag as ordered, despite the resident's diagnoses of acute kidney failure and acute cystitis. The order to change the bag every seven days was not followed on multiple occasions, as confirmed by the RN and DON. This deficiency in catheter care was identified through interviews and record reviews.
A facility failed to adhere to professional standards in oxygen administration for three residents. One resident lacked necessary signage for oxygen use, while two others had undated nasal cannulas, increasing infection risk. Additionally, one resident's oxygen use was not documented in the MAR, compromising care. The DON acknowledged these deficiencies, which contravened facility policies.
The facility failed to provide adequate dialysis care for three residents. A resident did not receive pre-dialysis assessments, and their dialysis form was incomplete. Another resident lacked emergency equipment at the bedside for potential bleeding from an AV shunt. A third resident did not receive post-dialysis assessments, with missing dialysis forms. The facility's dialysis care policy was not followed, leading to these deficiencies.
A facility failed to maintain an up-to-date competency checklist for an LVN, as the checklist was 11 months overdue. This oversight was identified during a review and interview with the DSD, who emphasized the importance of current competencies for ensuring proper nursing care. The DON confirmed that competencies are conducted annually and as needed, in line with the facility's policy to ensure staff competencies for resident safety and care.
The facility's medication administration policy was outdated, referring to paper MARs instead of the current eMAR system. The DON confirmed the need for policy updates to reflect the electronic documentation method, as the existing policy could lead to inaccurate records and potential drug loss or diversion.
Two residents received blood pressure medications despite their blood pressure readings being below the prescribed parameters. One resident with essential hypertension was given Metoprolol when their systolic blood pressure was below 110 mmHg, and another resident with end-stage renal disease received hydralazine hydrochloride under similar conditions. These actions were contrary to physician orders and acknowledged by facility staff.
The facility failed to properly store and label medications, with active medications found in a cabinet for discontinued drugs and multiple-dose containers lacking open dates. This led to potential medication errors, as observed by an LVN who confirmed the improper storage of 17 blister packs and outdated inhalation solutions.
A resident with multiple health conditions experienced a delay in laboratory test completion, with tests ordered on February 1 not drawn until February 18. The facility's policy requires timely completion and communication of lab results, which was not adhered to, potentially impacting the resident's care.
The facility failed to label and date food items, remove expired items, and test sanitizing solutions and dish machine temperatures. Unlabeled and expired items were found, and sanitizing solutions were not tested, posing contamination risks. The facility's policies were not followed, leading to potential resident safety issues.
A resident with end-stage renal disease had incomplete and falsified Dialysis Communication Records due to the failure of licensed nursing staff to document post-dialysis assessments accurately. An LVN admitted to falsifying records on days he was not working, leading to inaccurate medical records. The facility's policy requires timely and accurate documentation, which was not followed.
The facility failed to maintain proper infection control practices, including keeping a resident's foley catheter tubing off the floor, ensuring staff used appropriate PPE for a resident on Enhanced Barrier Precautions, and conducting an annual Legionella Risk Assessment. Staff interviews confirmed the importance of these practices, but deficiencies were observed, such as a lack of hand hygiene and inaccessible PPE.
A facility failed to offer and monitor flu and pneumococcal vaccinations for a resident with cognitive impairments and multiple health conditions. The resident's immunization status was not documented, and the vaccination tracking spreadsheet was outdated, leading to incomplete medical records.
A resident with severe cognitive impairment and multiple diagnoses was not included in their initial IDT care conference, violating their rights to participate in their care plan. The facility's policy requires resident involvement, but the resident was absent without documentation of refusal.
A facility failed to create a comprehensive care plan for a resident using anticoagulant medication. The resident, with acute respiratory failure and atrial fibrillation, required Apixaban via a gastrostomy tube but lacked a care plan to guide its use. Staff confirmed the absence of this essential plan, which is required by facility policy to ensure quality care.
The facility failed to document the COVID-19 vaccination status of all employees, including physicians and consultants, as required by their policy. The IPN was unaware of the immunization status of these individuals, and the DON emphasized the necessity of knowing the vaccination status of all staff in contact with residents. This oversight potentially endangered staff and residents by increasing the risk of COVID-19 infection.
The facility failed to meet the requirement of 80 square feet per resident in 20 out of 29 rooms, with measurements ranging from 69.16 to 79.6 square feet per resident. Despite this, residents reported no issues with room size, and staff were able to provide adequate care. The administrator acknowledged the deficiency but noted resident satisfaction and staff capability.
Failure to Implement Water Management and Infection Control Measures for Legionella
Penalty
Summary
The facility failed to implement effective infection control measures related to its water management program and reporting of Legionella infection. The maintenance supervisor was unable to provide evidence of a comprehensive water management plan beyond daily water temperature logs, and there was no documentation of monitoring or control measures for water quality or disinfectant levels. The infection preventionist nurse confirmed that the facility did not have a customized water management policy and was not monitoring all necessary control measures and limits as recommended by CDC guidelines. The facility's policy required a water management program with annual review, but there was no evidence of such review or updates since 2017. A resident was admitted and later readmitted with multiple diagnoses, including pneumonia and sepsis. The resident was diagnosed with Legionella pneumonia at a general acute care hospital, but this information was not identified or acted upon by facility staff upon readmission. The registered nurse supervisor and director of nursing both acknowledged that the resident's medical records were not thoroughly reviewed, resulting in a delay in recognizing the Legionella infection. The infection preventionist nurse was only made aware of the positive Legionella result after notification from a public health nurse, rather than through internal review or communication from the hospital. The facility also failed to report the confirmed case of Legionella infection to the California Department of Public Health as an unusual occurrence within the required 24-hour timeframe. Review of facility policies indicated that such events should be reported promptly, but staff were unaware of the infection until notified by public health authorities. Additionally, there was no documentation in the facility's quality assurance and performance improvement records to show that infection control and water management policies were reviewed or updated annually, as required by facility policy.
Failure to Maintain Proper Temperature for Jello Items
Penalty
Summary
The facility failed to maintain Jello items at the required temperature of 41 degrees Fahrenheit or lower, as observed during a survey. On multiple occasions, the Dietary Supervisor (DS) measured the temperature of Jello items in the kitchen, finding them at 54 degrees and 48 degrees, which is above the required temperature for cold food. The DS acknowledged that the Jello should be kept at 41 degrees or lower to prevent spoilage and maintain taste. The facility's policy, dated 2023, states that cold food items should be placed on trays as close to serving time as possible to ensure they remain below 41 degrees.
QAA Committee Fails to Address Systemic Issues
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to identify and implement corrective actions for systemic issues affecting all 47 residents. These issues included not following medication parameters when administering medications, not assessing dialysis residents before and after their treatments, and not ensuring that the kitchen stored, prepared, and distributed food according to professional food service safety standards. During an interview, the Administrator acknowledged that these systemic issues were not identified by the QAA committee. A review of the facility's Quality Assurance Performance Improvement Plan and Committee policy, revised in December 2024, indicated that the QAA committee was responsible for identifying and addressing specific care and quality issues and implementing action plans to resolve them. However, these deficiencies placed residents at risk of not receiving the necessary quality treatment to meet their highest practicable well-being.
Failure to Document Pain Level and Medication Refusal
Penalty
Summary
The facility failed to ensure proper documentation of a resident's pain level before removing pain medication from inventory and failed to document the resident's refusal of administration. This deficiency was identified for one resident who was prescribed Percocet for moderate to severe pain. During an observation, it was noted that the medication cart contained a blister pack of Percocet for the resident, and the controlled drug record showed two doses marked as wasted without corresponding documentation of the resident's pain level or refusal of the medication on the specified dates. Interviews with facility staff revealed that the process for administering PRN pain medication was not followed, as the resident's pain level was not documented in the electronic medication administration record (eMAR) before the medication was removed. Additionally, the facility's policy required that non-pharmacological interventions be performed and documented if the pain level did not meet the criteria for medication administration, which was not done. The director of nursing confirmed that the narcotic medication should not have been accessed if the pain level did not meet the prescribed criteria.
Inadequate Monitoring of Abdominal Binder Use
Penalty
Summary
The facility failed to appropriately assess and monitor a resident during the use of an abdominal binder, which was used to prevent the resident from pulling out a gastrostomy tube. The resident, who was diagnosed with Huntington's Disease and had severely impaired cognitive skills, was dependent on all aspects of activities of daily living. The resident's care plan required the use of an abdominal binder at all times, except during ADLs, to prevent the removal of the g-tube. However, the facility did not document or monitor the use of the abdominal binder properly, as indicated by the Medication Administration Record, which showed only an 'X' instead of detailed assessments. During an observation and interview, a Licensed Vocational Nurse confirmed that the resident always wore the abdominal binder to prevent pulling out the g-tube due to uncontrollable movements. The Director of Staff Development acknowledged that the documentation was inadequate and that the abdominal binder should have been monitored more closely. The Director of Nursing stated that while the abdominal binder was necessary to protect the g-tube, it required consent and monitoring for skin integrity and should be released during ADLs to prevent skin breakdown. The facility's policies and procedures on restraint assessments and physical restraints indicated that restraints should be gradually reduced and regularly reassessed for necessity. However, the facility did not follow these guidelines, as the need for the abdominal binder was not periodically reevaluated, and there was no documentation of attempts to minimize or eliminate its use. This lack of proper assessment and monitoring had the potential to place the resident under unnecessary restraint.
Failure to Review and Update Resident Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that a resident's care plans were reviewed and updated on a quarterly basis, as required. The resident, who was admitted with diagnoses including acute respiratory failure, type 2 diabetes, hypertension, and dementia, had care plans created on a specific date. These care plans, covering areas such as cognitive loss, communication, and cardiac circulation, were due for review in November 2024 but had not been reviewed by February 2025. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plans should have been reviewed and reevaluated since November 2024. The facility's policy requires that comprehensive, person-centered care plans be reviewed and revised at least quarterly to reflect any changes in the resident's condition and ensure that services provided are consistent with the resident's written plan.
Documentation and Consultation Failures in Pain Management and Urology Care
Penalty
Summary
The facility failed to ensure proper documentation and administration of pain medication for Resident 43. During an observation, it was noted that the nurse did not document the resident's pain level before removing Percocet from the inventory, nor was there documentation of the resident's refusal of the medication on two occasions. The facility's process requires that the resident's pain level be documented in the electronic medication administration record (eMAR) before preparing the medication. However, the eMAR did not reflect any pain episode or refusal, and the pain levels recorded did not meet the criteria for administering the medication. Additionally, non-pharmacological interventions were not documented as performed after the pain assessment. The facility also failed to ensure that Resident 48 received timely urology consultation and services to meet professional standards of practice. Resident 48, who was admitted with a penile erosion and other conditions, had a scheduled urology appointment that was missed due to transportation issues. The appointment was rescheduled, but the physician was not notified of the missed appointment. The resident's care plan identified a high risk for infection, and the Director of Nursing stated that it was unacceptable to delay the urologist's consult without notifying the physician, as this could lead to infections. The facility's policies and procedures require communication with the physician regarding negative responses to treatment or changes in the resident's condition. However, the failure to notify the physician of the missed appointment and the lack of timely urology consultation did not meet the standard of practice. This oversight had the potential to compromise the resident's care and increase the risk of infection due to the existing wound and other health conditions.
Failure to Change Foley Catheter Bag as Ordered
Penalty
Summary
The facility failed to ensure that a resident's foley catheter drainage bag was changed as ordered, which is a deficiency in providing appropriate catheter care. The resident, who was readmitted to the facility with acute kidney failure and acute cystitis, had an order to change the foley catheter bag every seven days. However, the task was not completed on the specified dates of 1/9/2025, 1/16/2025, and 1/23/2025, as indicated in the Treatment Administration Record (TAR). The Registered Nurse (RN) acknowledged that the orders were not followed and should have been clarified if deemed inappropriate. The Director of Nursing (DON) confirmed that physician orders must always be followed, and the facility's policy on indwelling catheter care, revised in 3/2021, mandates that catheter care be provided as ordered. The failure to adhere to the physician's orders for catheter care had the potential to result in complications that could negatively affect the resident's wellbeing. This deficiency was identified through interviews and record reviews conducted by the surveyors.
Deficiencies in Oxygen Administration and Documentation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for three residents receiving supplemental oxygen. Resident 5, who was readmitted with acute respiratory failure and asthma, was observed using oxygen without any visible signage indicating oxygen use, which is necessary for safety reasons. The Licensed Vocational Nurse confirmed the absence of signage, and the Director of Nursing acknowledged the need for such signage to prevent hazardous practices. Resident 30, diagnosed with chronic obstructive pulmonary disease, was observed using a nasal cannula that was not labeled with a date, which is essential for infection control. The Registered Nurse confirmed the lack of dating on the nasal cannula and emphasized the importance of dating to prevent infections. The Director of Nursing also noted that Resident 30 was at high risk for infections due to age and medical conditions, and the absence of dating could increase this risk. Resident 49, with pulmonary hypertension and hypoxia, was similarly observed using a nasal cannula without a date, posing a risk of infection. Additionally, the Medication Administration Record for Resident 49 did not document the use of oxygen, which is necessary for proper care. The Director of Nursing confirmed the omission in documentation and the risk of infection due to the resident's comorbidities and immunodeficiency. The facility's policy requires documentation of oxygen administration and regular replacement of nasal cannulas, which was not adhered to in these cases.
Inadequate Dialysis Care and Monitoring for Residents
Penalty
Summary
The facility failed to provide adequate dialysis care and services for three residents requiring hemodialysis. Resident 113, who was admitted with end-stage renal disease and had severely impaired cognition, did not receive a pre-dialysis assessment before being sent to the dialysis center. The dialysis form for Resident 113 was missing from the medical records, and the pre and post-assessment sections were not completed, indicating a lack of continuity of care. Resident 17, who had diagnoses including end-stage renal disease and type 2 diabetes mellitus, did not have the necessary emergency equipment at the bedside to manage potential bleeding from an arteriovenous shunt. A Licensed Vocational Nurse (LVN) noted the absence of an emergency kit and expressed concern about the potential for uncontrolled bleeding, which could lead to severe outcomes. The Director of Nursing (DON) emphasized the importance of having an emergency kit readily available for dialysis residents. Resident 27, admitted with end-stage renal disease and other conditions, also did not receive a post-dialysis assessment upon returning from the dialysis center. The dialysis forms for several dates were missing, and the post-assessment sections were not completed. LVNs and the DON highlighted the importance of post-dialysis monitoring to ensure residents' stability and the absence of complications. The facility's policy and procedure for dialysis care, which includes pre and post-dialysis checklists, was not followed, contributing to these deficiencies.
Outdated Competency Checklist for LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 9) had the necessary competencies and skills to care for residents, as evidenced by the outdated SNF Licensed Nurse Orientation Annual Competency checklist. LVN 9 was hired on August 22, 2023, and completed the competency checklist on September 18, 2023, with an expiration date of March 31, 2024. However, as of February 20, 2025, the checklist was 11 months past due. This lapse in maintaining up-to-date competencies was identified during a record review and interview with the Director of Staff Development (DSD), who acknowledged the importance of current competencies to ensure that nurses perform their duties correctly and adhere to facility policies. The Director of Nursing (DON) confirmed that competencies are conducted annually and as needed for all staff to ensure proper resident care. The facility's policy, dated January 2017, mandates periodic performance reviews to verify staff competencies, which are crucial for resident safety and effective care delivery. The failure to update LVN 9's competency checklist had the potential to result in residents not receiving appropriate nursing services and care, which could lead to injury.
Outdated Medication Administration Policy
Penalty
Summary
The facility failed to update its policy regarding medication administration documentation to align with its current practice of using electronic medication administration records (eMAR) instead of paper MARs. The existing policy, dated October 2017, still referred to the use of paper MARs, which were no longer in use. During an interview, the Director of Nursing (DON) confirmed that the facility had transitioned to eMARs and that the current practice involved nurses initiating a text box in the eMAR for documentation. The DON acknowledged that the policy needed to be updated to reflect this change. This oversight had the potential to result in inaccurate records, drug loss, and/or diversion.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to prescribed medication administration protocols for two residents, leading to potential health risks. Resident 112, who was admitted with essential hypertension, had a physician's order to hold Metoprolol if the systolic blood pressure was below 110 mmHg. Despite this, the medication was administered on two occasions when the resident's blood pressure readings were 100/74 mmHg and 106/68 mmHg, respectively. This oversight was confirmed during an interview with RN1, who acknowledged that the medication should not have been given under these conditions. Similarly, Resident 27, diagnosed with end-stage renal disease and essential hypertension, was prescribed hydralazine hydrochloride with instructions to hold the medication if the systolic blood pressure was below 110 mmHg. However, the medication was administered when the resident's blood pressure was recorded at 106/64 mmHg and 105/63 mmHg on separate occasions. The Director of Staff Development confirmed that the medication was given contrary to the physician's order, which could lead to further lowering of the resident's blood pressure. The Director of Nursing also acknowledged that not following the blood pressure parameters could result in hypotension for the residents.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that active medications for current residents were not stored in a cabinet labeled for discontinued medicines. During an observation in the medication room, a licensed vocational nurse (LVN 3) confirmed that 17 multiple-dose blister pill packs, which were active medications for 8 residents, were incorrectly stored in a cabinet meant for discontinued or discharged medications. The facility's policy indicated that newly delivered medications should be stored in the medication carts, but this was not followed, leading to the potential for medication errors. Additionally, the facility did not ensure that multiple-dose medication containers had an open date and that outdated medications were not stored in the medication cart. During an observation, it was found that two boxes of ipratropium bromide/albuterol sulfate inhalation solutions were improperly stored, with one box lacking an open date and the other being opened for more than two weeks, contrary to the manufacturer's instructions. The facility's policy required that medications be stored safely and outdated medications be immediately removed, which was not adhered to in this instance.
Delay in Laboratory Test Completion for Resident
Penalty
Summary
The facility failed to ensure timely completion of laboratory tests for a resident, resulting in a delay of care. The resident, who was admitted with acute respiratory failure, type 2 diabetes, hypertension, and dementia, had an order for several lab tests including a basic metabolic profile, prealbumin, Glycohemoglobin (Hb A1C), complete blood count, and thyroid stimulating hormone. These tests were ordered on February 1, 2025, but were not drawn until February 18, 2025, a delay of seventeen days. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the lab tests should have been completed sooner and that lab orders need to be completed as ordered with results relayed to the ordering physician promptly. The facility's policy indicated that laboratory reports should be performed as prescribed by the physician and filed in the resident's medical record, with abnormal results promptly communicated to the physician. The delay in completing the lab tests had the potential to result in a continued undiagnosed problem that could be harmful to the resident.
Deficiencies in Food Labeling, Expiration Management, and Sanitization Testing
Penalty
Summary
The facility failed to properly label and date food items, remove expired items, and test and document the concentration of sanitizing solutions and dish machine temperatures. During an observation, several food items, including an opened bottle of 'Thick and Easy', chicken noodle soup, zucchinis, celery, lettuce, tomatoes, and cookie dough, were found without proper labeling or date marking. The Dietary Supervisor (DS) could not confirm the opening or delivery dates for these items. Additionally, expired items such as Diabetisource AC and two bags of bread were found in the kitchen, with the DS unable to confirm the dates represented on the labels. The facility also failed to test and document the concentration of sanitizing solutions and dish machine temperatures prior to use. A red sanitary bucket was found with an expired test strip, and logs indicated that kitchen staff did not test or document the dish machine temperatures or sanitizing solutions before use. Interviews with the Director of Nursing (DON) and the DS confirmed that these practices could lead to contamination and foodborne illness. The facility's policies and procedures require proper labeling, dating, and testing, but these were not followed, leading to potential risks for residents.
Inaccurate and Falsified Dialysis Records for a Resident
Penalty
Summary
The licensed nursing staff at the facility failed to maintain and complete accurate medical records for a resident, identified as Resident 27, who was undergoing dialysis treatment. The deficiency involved the incomplete documentation of the Dialysis Communication Record (DCR) for specific dates, which were left blank, indicating that the necessary post-dialysis assessments were not conducted. Additionally, a Licensed Vocational Nurse (LVN 8) falsified the DCR by documenting assessments on days he was not working, thereby creating inaccurate records of the resident's condition. Resident 27 was admitted with diagnoses including end-stage renal disease, hypertension, and cardiomegaly, and required substantial assistance with daily activities. The Director of Staff Development confirmed that the post-dialysis documentation was not completed on the specified dates, and LVN 8 admitted to falsifying records by filling in the DCR on days he was not present. The Director of Nursing emphasized the importance of accurate and timely documentation, as per the facility's policy, which was not adhered to in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by several deficiencies observed during the survey. Resident 7's foley catheter tubing was found lying on the floor, contrary to the care plan instructions that required the tubing to be kept off the floor to prevent infection. Licensed Vocational Nurse 4 acknowledged the issue, stating that it is the nurses' responsibility to ensure the catheter is not dragging on the floor, as this can lead to breakage and potential infection spread. Interviews with other staff, including LVN 2 and the Director of Nursing, confirmed the importance of keeping the catheter tubing off the floor to prevent infection. Another deficiency was observed with Resident 15, who was on Enhanced Barrier Precautions due to having a g-tube. LVN 3 failed to perform hand hygiene before entering the resident's room and did not wear the appropriate PPE, such as a gown, when observing the g-tube. LVN 3 admitted that PPE was not easily accessible, which contributed to the oversight. The Director of Staff Development and the Director of Nursing emphasized the importance of hand hygiene and wearing gowns for infection control, especially for residents with devices like g-tubes or foley catheters. Additionally, the facility did not conduct an annual Legionella Risk Assessment for 2024, as required by their policy. The Administrator confirmed the absence of the assessment, and the Director of Nursing highlighted the importance of Legionella prevention due to the vulnerability of the elderly population. The facility's policies and procedures for indwelling catheter care, enhanced standard precautions, hand hygiene, and Legionella prevention were reviewed, revealing that the practices observed did not align with the established guidelines.
Failure to Monitor and Document Resident Vaccination Status
Penalty
Summary
The facility failed to offer and monitor the immunization status for influenza and pneumococcal vaccinations for one of the sampled residents, identified as Resident 9. Upon review of Resident 9's admission records, it was noted that the resident was admitted with diagnoses including gastrostomy, cerebral palsy, and asthma. The resident's cognitive skills were moderately impaired, and they were dependent on all aspects of activities of daily living. A review of the immunization history report indicated that Resident 9 had no record of receiving the flu or pneumococcal vaccines. Interviews with the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) revealed that the facility's procedures for offering and documenting vaccinations were not followed. The IPN admitted that the vaccination tracking spreadsheet was not up to date and did not include Resident 9. The facility's policies required that residents be evaluated for vaccination status upon admission and that education regarding the benefits and potential side effects of immunizations be provided. However, there was no documentation in Resident 9's clinical record to indicate that these steps were taken, resulting in incomplete medical records for the resident.
Resident Excluded from Care Plan Meeting
Penalty
Summary
The facility failed to involve a resident in the development and implementation of their person-centered plan of care. Specifically, Resident 26, who was admitted with diagnoses including metabolic encephalopathy, type 2 diabetes, and muscle weakness, was not included in their initial Interdisciplinary Team (IDT) care conference. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on staff for all activities of daily living. Despite these conditions, the resident was not present at the IDT care conference, and there was no documentation of the resident's refusal to attend. During interviews, Registered Nurse 1 confirmed that the IDT meeting was attended by nursing, dietary, and therapy staff, but not by the resident. The Director of Nursing stated that residents or their representatives should always be part of the IDT meetings, which are conducted upon admission and quarterly. The facility's policy on Comprehensive Care Planning, revised in 2017, also emphasized the importance of involving the resident or their family in care plan development. The failure to include Resident 26 in the care planning process violated their rights to be informed and to participate in their care plan.
Lack of Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically addressing the use of anticoagulant medication. The resident, who was admitted with acute respiratory failure and atrial fibrillation, was dependent on staff for all activities of daily living and had moderately impaired cognition. Despite having an order for Apixaban, an anticoagulant, to be administered via a gastrostomy tube, there was no care plan in place to guide the use of this medication. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the absence of a care plan for the resident's anticoagulant use. The facility's policy requires a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs, but this was not implemented for the resident in question. This oversight had the potential to result in poor quality of care and a delay in necessary services.
Failure to Document COVID-19 Vaccination Status for All Staff
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination status for all employees, including physicians and consultants, which is required to ensure the safety of residents and staff. During an interview and record review, the Infection Prevention Nurse (IPN) admitted to not knowing the COVID-19 immunization status of facility physicians and consultants. The Director of Nursing (DON) confirmed that the vaccination status of all employees, including those in contact with residents, must be known to prevent the risk of infection. The facility's policy, dated February 2025, mandates maintaining documentation of COVID-19 vaccination status for all staff, defined as anyone working or volunteering at the facility at least once a week, including contracted individuals. This lack of documentation potentially placed staff and residents at risk for negative health outcomes related to COVID-19.
Room Size Deficiency in Multiple Resident Bedrooms
Penalty
Summary
The facility failed to ensure that 20 out of 29 resident rooms met the regulatory requirement of providing at least 80 square feet per resident in multiple resident bedrooms. The rooms in question were designed to accommodate two residents each, but measurements revealed that the square footage per resident ranged from 69.16 to 79.6 square feet, falling short of the required space. This deficiency was identified through a review of the facility's Client Accommodations Analysis form, which detailed the specific measurements of each room. Despite the deficiency, observations and interviews conducted during the survey period indicated that residents did not experience difficulty moving in and out of their rooms, and there were no complaints regarding room size during the Resident Council meeting. The administrator acknowledged that some rooms were smaller than required but noted that residents were satisfied with the room size, and staff were able to provide adequate care. The report did not indicate any immediate negative impact on resident care or safety due to the room size deficiency.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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