Beverly Hills Rehabilitation Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 580 S San Vicente Blvd., Los Angeles, California 90048
- CMS Provider Number
- 555700
- Inspections on file
- 68
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Beverly Hills Rehabilitation Centre during CMS and state inspections, most recent first.
Two residents with indwelling Foley catheters, each with multiple comorbidities and care plans directing staff to monitor, record, and report UTI signs and symptoms, had Weekly Summary notes in which urine color, consistency, odor, and clarity were left blank, despite facility policy requiring documentation of urine characteristics. The MDS nurse stated that licensed nurses are responsible for completing these summaries, and the DON confirmed the omissions and acknowledged that this placed urine monitoring at risk. In a separate issue, a Foley catheter change reportedly performed for a resident was not documented in the medical record, even though an LVN stated the treatment nurse had changed the catheter and facility policy required recording the date, time, provider, assessment data, resident complaints, and tolerance of catheter care, as well as documenting all services provided.
Staff did not properly don PPE before entering the room of a resident on contact isolation for C. diff, with one CNA putting on PPE inside the room and an LVN entering without any PPE. Both staff were unclear about the reason for isolation, and no care plan was developed to address the resident's infection control needs, contrary to facility policy.
A resident with type 2 diabetes and moderate cognitive impairment was admitted with hospital orders for blood glucose checks three times daily and Levemir insulin at bedtime as needed, but these orders were not entered or implemented upon admission. As a result, the resident did not receive scheduled blood sugar monitoring or long-acting insulin for five days, as confirmed by the DON during record review and interview.
The facility did not maintain adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
A sitter providing care to a resident on enhanced barrier precautions did not wear required PPE due to lack of awareness and education, and the facility failed to remove expired hand sanitizer, COVID-19 test kits, and gloves from use. Staff interviews confirmed that these lapses placed residents at risk of infection and that expired supplies were not consistently checked or removed, despite facility policies requiring such actions.
A resident with a Foley catheter and a care plan intervention for a privacy cover was observed without the required cover on the catheter drainage bag. The resident and a CNA both confirmed the cover was missing, and the DON acknowledged this failure could impact the resident's dignity. Facility policy requires staff to treat all residents with respect and dignity, including maintaining privacy for urinary drainage bags.
A resident with heart failure and metabolic encephalopathy did not have a completed POLST form, despite being disoriented and having complex care needs. Staff interviews revealed confusion about who was responsible for completing the POLST, and the DON initially believed an advance directive was sufficient. Facility policy and state guidance indicated that the POLST should complement, not replace, an advance directive, but the form remained incomplete.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation for care.
Two residents with significant risk factors for pressure ulcers were found to have their Low Air Loss Mattresses (LALM) set incorrectly at 450 lbs, despite their actual weights being much lower. In both cases, the LALM settings were not adjusted according to the residents' weights as required by physician orders, care plans, manufacturer instructions, and facility policy. Additionally, one resident did not have a physician's order for the LALM at the time of admission. These failures were confirmed through staff interviews, record reviews, and direct observation.
Four residents receiving oxygen therapy did not have their oxygen equipment properly labeled or managed according to physician orders and facility policy. This included missing date labels on nasal cannulas and humidifiers, and the absence of an 'Oxygen in Use' sign for a resident on continuous oxygen. Nursing staff and the DON confirmed these lapses, which could result in the use of contaminated equipment and unaddressed safety hazards.
A resident with gastrointestinal conditions did not receive Balsalazide Disodium 750 mg with meals as ordered; instead, a nurse administered the medication before lunch was served and without food present, despite clear labeling and physician orders. Staff interviews and facility policy confirmed the importance of administering such medications with meals to prevent discomfort.
A CNA worked multiple shifts after her certification had expired, as confirmed by review of timecards and staff interviews. Both the DSD and DON acknowledged missing the expired status during their monthly checks, resulting in the CNA working while not meeting state and facility requirements for active certification.
Two residents with significant medical needs and dependence on staff for daily activities were found with their call lights out of reach, contrary to facility policy and care plan interventions. Staff interviews and observations confirmed that the call lights were on the floor and not accessible, increasing the risk of unattended needs and falls.
A resident with cognitive impairment and total dependence for ADLs was found with a cup of multiple medications left at the bedside after a nurse administered them but did not ensure they were taken. The resident was not authorized for self-administration, and facility policy prohibits leaving medications at bedside for such residents. Nursing staff confirmed the medications were left unattended, contrary to policy.
One of four exit doors on the resident floors was found to be unarmed, with staff able to open the door to the stairwell without triggering the required alarm. Multiple staff, including a CNA and the Housekeeping Supervisor, confirmed the alarm was not functioning despite attempts to engage it. The DON acknowledged that this failure could allow a confused individual to exit unsupervised, increasing the risk of accidents or falls.
Two residents with indwelling urinary catheters were found with catheter bags placed above the bladder, preventing proper urine drainage and potentially leading to urinary tract infections. The facility's policy requires catheter bags to be positioned lower than the bladder to prevent backflow and ensure proper drainage.
A resident with heart failure, COPD, and respiratory failure experienced a medical emergency and died after CPR was administered. The facility failed to complete the required documentation, including a physician's progress note and a death certificate, as per their policy. Interviews revealed that the necessary documentation was not requested or filed in a timely manner.
The facility failed to ensure staff wore complete PPE and performed proper hand hygiene during high-contact care activities for residents on enhanced barrier precautions. A treatment nurse did not wear a gown or sanitize hands between glove changes during dressing changes, while a CNA and student assistant did not wear gowns when changing an incontinent brief and linens. Another nurse did not change gloves during dressing and Foley catheter care. These lapses in infection control practices were acknowledged by the staff involved.
A resident with a history of hemiplegia, hemiparesis, chronic respiratory failure, and type II diabetes experienced multiple bleeding and emesis episodes. Despite these incidents, the care plan was not updated to address the actual bleeding and hospitalizations. The ADON acknowledged the need for care plan revisions following each episode, as per facility policy, but this was not done, potentially placing the resident at further risk.
A resident's PIV line was not properly managed, as it lacked a date on the dressing, and there was no timely removal after IV therapy completion. The DON and ADM confirmed the oversight, which was against the facility's policy requiring labeling and removal of the catheter once therapy is discontinued.
A resident with advanced dementia and a history of falls did not receive adequate care and supervision, leading to a fall and subsequent injuries. The facility failed to implement a proper care plan, including the use of a bed alarm and close supervision, despite the resident's high fall risk. The resident was found on the floor and later diagnosed with fractures after being transferred to a hospital. Staff interviews and record reviews indicated a lack of documentation and adherence to facility policies on fall risk management and dementia care.
A resident with dementia and a history of falls experienced a fall and sustained a bruise and cut on the right eye, which were not documented by the staff. The facility failed to conduct a comprehensive assessment as required by their policy, leading to a lack of proper documentation and understanding of the resident's condition post-fall.
The facility failed to follow infection control practices by not fit testing staff for the correct N95 masks and not ensuring staff wore the designated masks. Additionally, two residents lacked documented consent or refusal for the COVID-19 vaccine, contrary to facility policy. These deficiencies could lead to increased infection spread.
The facility failed to ensure proper documentation and communication for dialysis care, affecting three residents. A resident's dialysis progress form was incomplete, another's Epogen administration was undocumented, and a third did not receive prescribed Epogen. These lapses highlight deficiencies in maintaining accurate records and communication with dialysis centers.
A fly was observed in the kitchen during a tray line, indicating a failure in the facility's pest control program. The Dietary Director and Maintenance Supervisor acknowledged the potential for bacteria transmission and contamination, which could lead to infection control issues. The facility's policy stated an ongoing pest control program should be maintained.
The facility failed to develop timely, individualized care plans for three residents, leading to increased risk of harm. A resident receiving occupational therapy lacked a care plan for treatment, another highly dependent resident had no care plan for ADLs and transfers, and a third resident went out on pass without a care plan addressing an incident of being left unattended. These deficiencies highlight the need for comprehensive care plans to ensure resident safety and individualized care.
A facility failed to complete an Advance Directive Acknowledgment Form for a resident with multiple medical conditions, including cerebrovascular disease and Type II diabetes. The resident's medical chart lacked this crucial documentation, which is necessary for honoring medical decisions, especially regarding end-of-life care. Interviews with staff confirmed the oversight, and the facility's policy requires such documentation upon admission.
A resident was transferred to a hospital without receiving a written bed hold notification, as required by federal guidelines. The resident, who had moderately impaired cognitive skills, was not informed in writing about the facility's bed-hold policy upon transfer, despite a physician's order for a seven-day bed hold. Facility staff indicated that the policy was communicated during admission but not at the time of transfer.
A resident with severe cognitive impairment and multiple physical limitations did not have their PT and OT care plans updated to reflect changes in therapy services. Despite physician orders for adjusted therapy frequencies, the care plans remained outdated, as confirmed by the DOR and DON. This oversight could lead to the resident receiving incorrect services.
A resident with moderately impaired cognition and Spanish as their primary language was not provided with a communication device or board, hindering their ability to communicate with staff. Despite the facility's policy to use visual aids for language barriers, no such aids were implemented, leading to a deficiency in care.
A resident with a pressure ulcer was placed on a low air loss mattress (LALM) without a physician's order, and the mattress was set incorrectly for her weight. Staff acknowledged the importance of correct settings to prevent pressure injuries, but the facility's policy was not followed.
The facility failed to maintain an emergency drug supply (E-Kit) usage log and document wastage of a controlled drug. An LVN was unaware of an administration log, and the ADON presented a stack of slips without a proper log book. A slip for Oxycodone lacked wastage documentation, contrary to facility policy.
A resident was found with a bottle of Vitamin C at their bedside, contrary to the facility's medication storage policy. The resident, with intact cognition and diagnoses of anxiety and depression, used the vitamin for bowel movements. Interviews with an LVN and the DON confirmed that medications should not be left with residents due to overdose risks, highlighting a failure in maintaining secure medication storage.
The facility failed to label food items with received or use-by dates, risking foodborne illness, and served coffee in cups with a white residue from a malfunctioning water softener. The Dietary Director and Registered Dietician acknowledged these lapses, which contravened the facility's policies on food storage and sanitization.
The facility failed to maintain sanitary conditions in the dumpster areas, with two dumpsters overfilled and one with a broken lid, leading to potential pest issues. The Housekeeping Director and Maintenance Supervisor acknowledged the problem, noting the risk of infection control issues. Facility policies and FDA guidelines require dumpsters to be covered and in good condition.
The facility failed to provide timely and authorized rehabilitative therapy services for two residents. One resident did not receive a timely speech therapy evaluation despite having an order, while another received occupational therapy without an active physician's order. These deficiencies occurred due to non-adherence to facility policies requiring timely evaluations and continuous therapy orders.
A facility failed to maintain the Certification of Terminal Illness (CTI) for a hospice resident with multiple sclerosis and a Stage IV pressure ulcer. Despite a physician's order for hospice care, the CTI was missing from the resident's records, and staff were unaware of the hospice diagnosis. This deficiency indicates a lack of compliance and coordination with hospice services.
The facility failed to provide hand hygiene supplies in the OT gym, requiring staff to leave the area to sanitize hands after PPE use, contrary to infection control policies. Additionally, a resident receiving oxygen therapy had unlabeled tubing, with staff unsure of the required change frequency, risking respiratory infection. These deficiencies highlight lapses in infection control practices.
A resident with significant health conditions was not offered the influenza and pneumococcal vaccines as required by facility policy. Despite the facility's procedures to offer the flu vaccine annually and the pneumococcal vaccine within thirty days of admission, these were not provided to the resident, increasing the risk of illness and transmission.
The facility failed to offer the COVID-19 vaccination to two residents, one with severely impaired cognition and another with intact cognition but requiring assistance with daily activities. Despite the facility's policy to offer vaccinations year-round, neither resident was assessed for vaccination eligibility, as confirmed by the Infection Preventionist.
The facility failed to ensure a safe environment for two residents, leading to increased fall risks. A resident with severe cognitive impairment was transferred without a hoyer lift, despite being assessed as a high fall risk. Another resident was transported without wheelchair foot rests, increasing the risk of injury. Facility policies emphasized safety, but these were not followed, resulting in potential hazards.
A resident with moderately impaired cognition received a discontinued medication, gabapentin 100 mg, because it was not removed from the medication cart despite being discontinued in the electronic charting system. The error was confirmed by the DON during an interview and record review.
A resident reported being slapped by a family member, who returned the next day and repeated the abuse. Despite the facility's policy on abuse prevention, the family member was able to re-enter the resident's room and cause further harm.
Failure to Document Urine Characteristics and Foley Catheter Change per Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and procedures for urinary catheter care and documentation for two residents with indwelling Foley catheters. One resident was admitted with multiple diagnoses including hypertension, hyperlipidemia, congestive heart failure, muscle weakness, difficulty in walking, chronic kidney disease, and obstructive and reflux uropathy, and had an MDS indicating minor memory problems and dependence on staff for ADLs, with an indwelling urinary catheter in place. Another resident was admitted with diagnoses including cerebral infarction, fractures of the left lower leg and left radius, acute respiratory failure with hypoxia, endocarditis, dysphagia, and atrial fibrillation, and also had an MDS indicating minor memory problems, total dependence on staff for ADLs and bed mobility, and an indwelling urinary catheter. Both residents had care plans for indwelling catheters related to obstructive uropathy that included interventions to monitor, record, and report signs and symptoms of UTI such as pain, burning, blood-tinged urine, cloudiness, deepening of urine color, and foul-smelling urine. Record review showed that for both residents, the Weekly Summary notes did not include required urine characteristics. For the first resident, Weekly Summary notes dated 2/28/26 and 3/14/26 had the urine color, consistency, odor, and clarity sections left blank. For the second resident, Weekly Summary notes dated 3/7/26 and 3/14/26 also had the urine color, consistency, odor, and clarity sections left blank. The MDS nurse stated that Weekly Summary notes are completed by licensed nurses and should be complete, including urine characteristics. In a concurrent interview and record review, the DON confirmed that the urine characteristics were not documented for these residents and stated that monitoring for urine would be at risk from this omission. The facility’s catheter care policy required documentation of the character of urine, including color, clarity, and odor, and the charting and documentation policy required that all services provided and any changes in the resident’s condition be documented in the medical record. A separate deficiency was identified for the same first resident regarding lack of documentation of a Foley catheter change. The resident’s records showed an indwelling urinary catheter and a care plan directing staff to monitor, record, and report signs and symptoms of UTI. During a telephone interview, an LVN reported that when she came on the 3 pm–11 pm shift on 3/3/26, she was informed that the treatment nurse had changed the resident’s Foley catheter and that she was to administer pain medication; she further stated that the nurse who changes the Foley should document it in the chart. During a concurrent interview and record review, the DON verified that there was no documentation in the progress notes for a Foley catheter change on that date and acknowledged that if the catheter was changed, the nurse should have documented it. The facility’s catheter care policy required documentation of the date and time catheter care was given, the name and title of the individual providing care, all assessment data obtained, any problems or complaints related to the procedure, and how the resident tolerated the procedure, and the charting and documentation policy required that all services provided be documented in the medical record.
Failure to Follow Contact Isolation Precautions and Develop Care Plan for Infection Control
Penalty
Summary
Staff failed to follow transmission-based precautions for a resident who was placed on contact isolation due to a Clostridium difficile (C. diff) infection. Observations revealed that a Certified Nurse Assistant (CNA) donned personal protective equipment (PPE) inside the resident's room, rather than before entering, and a Licensed Vocational Nurse (LVN) was present in the room without any PPE. Both staff members were unsure of the reason for the contact isolation, despite signage indicating the need for precautions. Facility policy requires PPE to be donned prior to room entry to prevent contamination and the spread of infection. Additionally, there was no care plan developed or implemented to address the resident's contact isolation precautions. The Director of Nursing (DON) confirmed that a comprehensive, resident-centered care plan should have been created by the interdisciplinary team to outline specific interventions and staff responsibilities for infection control. The lack of a care plan and failure to follow PPE protocols were identified through observation, interviews, and record review, and were not in accordance with the facility's own policies and procedures.
Failure to Transcribe and Implement Blood Glucose Monitoring and Insulin Orders on Admission
Penalty
Summary
The facility failed to ensure that blood glucose monitoring was performed three times daily and that Levemir insulin was accurately transcribed and administered upon admission for one resident. Upon review, it was found that the resident was admitted with orders from a general acute care hospital for blood glucose checks three times a day and Levemir insulin to be given at bedtime as needed for elevated blood sugar. However, these orders were not entered into the facility's system at the time of admission, resulting in the resident not having her blood sugar checked throughout the day as indicated and not receiving long-acting insulin for five days after admission. The resident involved had a history of type 2 diabetes mellitus, moderate cognitive impairment, and required significant assistance with daily activities. The Director of Nursing confirmed during an interview and record review that the admitting nurse missed entering the orders for blood sugar checks and insulin, which were only added several days later. Facility policy required that physician admission orders, including medication and routine care orders, be provided and implemented at or prior to admission, but this process was not followed in this case.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices, which revealed that staffing levels and licensed nurse coverage were insufficient to meet regulatory requirements.
Failure to Ensure Proper Infection Control Practices and Removal of Expired Supplies
Penalty
Summary
The facility failed to follow infection control practices in two main areas. First, a sitter providing supervision to a resident on enhanced barrier precautions (EBP) did not wear the required personal protective equipment (PPE) while in the resident's room. The resident had diagnoses including heart failure and metabolic encephalopathy, was not oriented to time, and had poor recall. Observations showed that PPE was available both outside and inside the room, but the sitter was unaware of the need to use PPE and stated there was no sign indicating EBP. Facility staff interviews revealed that the facility was not informed by the family about the sitter's presence, and the sitter had not received orientation or education on infection control or EBP requirements. Staff acknowledged that this situation placed the resident at risk of cross-contamination. Second, the facility failed to ensure that expired infection control supplies were removed from use. Observations found expired hand sanitizer, COVID-19 test kits, and disposable gloves in various locations, including hallways, storage rooms, and medication carts. Staff interviews confirmed that expired hand sanitizer would be ineffective, expired COVID-19 test kits could give inaccurate results, and expired gloves would not provide adequate protection and could cause skin irritation. Staff also stated that it was their responsibility to check for expired items, but multiple expired supplies were still present throughout the facility. A review of the facility's policies indicated that standard and enhanced barrier precautions should always be used when caring for residents, and that staff, visitors, and sitters should be educated on infection control practices. Policies also required that expired or damaged supplies be removed from service immediately. Despite these policies, the facility did not ensure that all individuals were properly educated or that expired supplies were consistently removed, resulting in deficiencies in infection prevention and control.
Failure to Provide Privacy Cover for Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of a resident by not ensuring that the resident's urinary catheter drainage bag was covered with a privacy bag. The resident, who had multiple diagnoses including multiple sclerosis, neurogenic bladder, and muscle weakness, had a physician's order for a Foley catheter and a care plan intervention specifying the use of a privacy cover to promote dignity. During an observation, the resident was found without a privacy cover on the catheter drainage bag and stated she usually had one but was unsure of its whereabouts. A Certified Nursing Assistant confirmed that the privacy cover should have been in place to maintain the resident's dignity. Further interviews with facility staff, including the DON, acknowledged that the absence of a privacy cover could compromise the resident's dignity and potentially cause psychosocial distress. Review of the facility's policy indicated that all residents should be treated with kindness, respect, and dignity, and that staff are expected to assist residents in exercising their rights. The failure to provide the privacy cover was inconsistent with both the resident's care plan and the facility's stated policies.
Failure to Complete POLST for Resident with Significant Medical Needs
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life-Sustaining Treatment (POLST) was completed for a resident with significant medical conditions, including heart failure and metabolic encephalopathy. Upon review of the resident's admission record, it was found that the resident was not oriented to time, had poor recall, and exhibited symptoms such as trouble concentrating and feeling down or hopeless. During observation, the resident was found in bed with bed rails up, receiving oxygen via nasal cannula, and had a Foley catheter in place. Interviews with facility staff revealed confusion regarding responsibility for obtaining and completing the POLST form. The Registered Nurse Supervisor indicated that the POLST was blank and deferred responsibility to Social Services, who in turn stated that nursing staff should complete the form. The DON stated that an advance directive had been obtained and believed that a POLST was not necessary if an advance directive was present, although later acknowledged that the POLST should not replace the advance directive and that all residents should have a POLST. A review of facility policy and state guidance confirmed that the POLST is a legally valid physician order intended to complement, not replace, an advance directive. Despite this, the resident's POLST was not completed, and staff interviews demonstrated a lack of clarity regarding the process and responsibility for ensuring the form was in place. This failure had the potential to result in the resident's end-of-life wishes not being followed in the event of an emergency, as the necessary documentation was not available or completed as required by facility policy.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on the surveyor's observation that the care plan did not comprehensively cover the resident's needs, and there was an absence of clear, measurable objectives and interventions to guide staff in providing appropriate care.
Failure to Maintain Proper Low Air Loss Mattress Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to maintain appropriate settings on Low Air Loss Mattresses (LALM) for two residents, both of whom were at risk for or had existing pressure ulcers. For one resident with a Stage 4 pressure ulcer and severe cognitive impairment, the LALM was set at 450 lbs, despite the resident weighing only 127 lbs. Both the licensed nurse and the Director of Nursing confirmed that the mattress should have been set according to the resident's actual weight, as specified in the physician's order, care plan, manufacturer’s instructions, and facility policy. The incorrect setting was observed during a room visit and acknowledged as improper by staff. For the second resident, who had multiple diagnoses including severe cognitive impairment, malnutrition, and was dependent on staff for most activities of daily living, the LALM was also set at 450 lbs, while the resident weighed 137 lbs. Additionally, there was no physician’s order for the LALM at the time of admission, and the order was not placed until several days later. Staff interviews revealed that nurses were aware of the need for physician orders and proper settings based on resident weight, but these procedures were not followed. Both cases were documented through observation, interviews with nursing staff and administration, and review of medical records, care plans, and facility policies. The facility’s own procedures and the manufacturer’s guidelines require LALM settings to be based on resident weight and a physician’s order, particularly for residents who are cognitively impaired or non-verbal. These requirements were not met for the two residents, resulting in a failure to provide appropriate pressure ulcer care and prevention.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents by not adhering to established protocols for oxygen therapy and equipment management. For one resident with chronic heart failure and end stage renal disease, the nasal cannula used for oxygen therapy was not labeled with the date it was changed, despite physician orders and facility policy requiring weekly changes and labeling. Interviews with nursing staff and the DON confirmed that the absence of labeling could result in the use of contaminated equipment, increasing the risk of infection. Another resident, who was dependent on staff for all activities of daily living and required continuous oxygen therapy due to respiratory conditions, did not have an 'Oxygen in Use' sign posted in or outside the room. Facility policy and staff interviews indicated that this sign is necessary to alert staff and visitors to the presence of oxygen, which is a combustible gas, and to prevent potential hazards such as fire or explosion. Additionally, two residents receiving continuous or high-concentration oxygen therapy had humidifiers attached to their oxygen equipment that were not labeled with the date of last change. Both the facility's policy and physician orders required that all oxygen tubing and components, including humidifiers, be labeled and changed weekly. Staff interviews confirmed that the lack of labeling could result in the use of expired or unclean equipment, posing a risk of infection.
Failure to Administer Medication With Meals as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple gastrointestinal diagnoses, including ulcerative colitis and a history of abdominal surgery, did not receive Balsalazide Disodium 750 mg as ordered with meals. The resident's care plan specified the need for medication administration as ordered to manage pain and discomfort related to gastrointestinal conditions. The physician's order required the medication to be given by mouth with meals three times daily. During a medication pass observation, a nurse administered the medication to the resident before lunch was served, and no meal was present at the bedside at the time of administration. The medication packaging was clearly labeled to indicate it should be given with meals and at noon. Interviews with nursing staff and the Director of Nursing confirmed that medications intended to be taken with food are ordered that way to prevent gastrointestinal upset and discomfort. The facility's policy required medications to be administered in accordance with physician orders. The failure to administer Balsalazide Disodium with meals as ordered constituted a deficiency in pharmaceutical services, as it did not meet the resident's needs or comply with established medication administration protocols.
CNA Worked with Expired Certification
Penalty
Summary
The facility failed to ensure that one of five sampled staff, a Certified Nursing Assistant (CNA), maintained the necessary qualifications for employment as required by state law. Review of the CNA's timecards showed that the CNA worked multiple shifts at the facility after her CNA certification had expired. During an interview and record review with the Director of Staff Development (DSD), it was confirmed that the CNA's certificate had expired and that the DSD was unaware of the expiration until after the CNA had already worked post-expiration. The DSD acknowledged that the CNA was not in compliance with facility policy, which requires an active CNA certification for employment. Further interview with the Director of Nursing (DON) revealed that both the DON and DSD typically review CNA certification expiration dates monthly, but they missed the expiration in this instance. The DON confirmed that the CNA worked at the facility while her certification was expired and reiterated that maintaining an active certification is required by both facility policy and state law. Review of the facility's job description for CNAs also indicated that an active CNA license is a qualification for employment.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, both of whom had significant medical conditions and were dependent on staff for assistance with activities of daily living. For one resident with diagnoses including diabetes mellitus, osteoarthritis, hypertension, metabolic encephalopathy, muscle weakness, and failure to thrive, the call light was observed on the floor by the roommate’s nightstand, out of the resident’s reach. Staff, including a CNA and the Activities Director, were unable to locate the call light initially, and the Activities Director confirmed that the call light should be within the resident’s reach. Multiple staff interviews, including with an LVN, RN Supervisor, and the DON, confirmed that the call light should always be accessible to the resident to ensure their needs are met and to minimize fall risk. Another resident, admitted with difficulty walking, muscle weakness, history of falls, and age-related cataract, was also found with the call light on the floor and out of reach while lying in bed with bed rails up. The DON observed this and placed the call light within the resident’s reach, acknowledging the risk for unattended needs and falls. The resident’s care plan included interventions to keep the call light within reach and to encourage its use for assistance, reflecting the resident’s impaired vision and need for help with self-care and mobility. A review of the facility’s policy and procedure titled “Answering the Call Light” indicated that when a resident is in bed or confined to a chair, the call light should be within easy reach. Both residents’ care plans also specified the need for the call light to be accessible. The observations and staff interviews confirmed that the facility did not follow its own policy and care plan interventions, resulting in the call light being out of reach for these two residents.
Medications Left Unattended at Bedside for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident, who was admitted with diagnoses including type II diabetes mellitus, difficulty walking, and muscle weakness, was found with a medication cup containing five different pills at her bedside. The resident had been assessed as mildly cognitively impaired and totally dependent on staff for activities of daily living, and had indicated she did not wish to self-administer medications. Physician orders required several medications to be administered by staff in the morning. During observation and interviews, the resident stated that staff left the medications on her bedside table without explaining what they were, and she had not taken them. Further interviews with nursing staff confirmed that medications should not be left at the bedside for residents who are not authorized to self-administer. The nurse who administered the medications admitted to leaving the room without ensuring the resident took the medications. Facility policy requires medications to be administered safely and as prescribed, and only allows self-administration if the resident is assessed and approved by the care team. The failure to follow these procedures resulted in the resident's medications being left unattended at the bedside.
Exit Door Alarm Failure Creates Elopement and Accident Hazard
Penalty
Summary
A deficiency was identified when one of four exit doors on the resident floors was found to be unarmed, failing to sound an alarm when opened. During an observation, a staff member was seen opening the exit door to the stairwell without the alarm activating or using a key to deactivate it, despite signage indicating that the alarm should sound if the door is opened. Certified Nursing Assistant (CNA) 1 confirmed during an interview that the door should alarm when opened but did not know why it was not functioning. The Housekeeping Supervisor also attempted to arm the door with a key but was unsuccessful, stating that the alarm must be broken. The Director of Nursing (DON) acknowledged in an interview that the lack of an alarm on the exit door poses a risk, as someone who is confused could open the door and potentially have an accident or fall. The facility's policy, revised in January 2025, states that the environment should be as free from accident hazards as possible and that staff are trained to identify and report such hazards. However, the failure to maintain the alarm system on the exit door represents a lapse in these safety measures.
Improper Catheter Placement Leads to Potential UTIs
Penalty
Summary
The facility staff failed to ensure proper placement of indwelling urinary catheters for two residents, leading to potential urinary tract infections. Resident 2, who was admitted with diagnoses including benign prostatic hyperplasia and obstructive uropathy, was observed with a catheter bag placed above the bladder, causing urine not to drain properly. The Licensed Vocational Nurse (LVN) confirmed the improper placement and noted that the catheter bag should be below the bladder to ensure proper drainage. Similarly, Resident 3, admitted with conditions such as cerebral infarction and neurogenic bladder, was also found with a catheter bag placed above the bladder, with the tubing twisted and kinked, preventing urine from draining. The Director of Nursing (DON) acknowledged that improper placement of the catheter bag could lead to urine backing up into the bladder, potentially causing infections. The facility's policy requires that catheter bags be positioned lower than the bladder to prevent backflow and ensure proper drainage.
Incomplete Documentation of Resident's Death
Penalty
Summary
The facility failed to ensure complete assessment and documentation concerning a resident's death, as required by their policy and procedure titled 'Death of a Resident.' The resident, who had been admitted with diagnoses including acute on chronic diastolic heart failure, chronic obstructive pulmonary disease, and respiratory failure, experienced a medical emergency. Despite receiving a breathing treatment and experiencing a panic attack, the resident passed out and subsequently died after CPR was administered and paramedics took over the emergency response. Upon review, it was found that the resident's medical records lacked a physician's progress note and a death certificate, which should have been completed and filed according to the facility's policy. Interviews with the Medical Record Director and the Director of Nursing revealed that there was no death certificate on file, and the cause of death was not recorded in the medical records. The Director of Nursing acknowledged that a death certificate should have been requested and documented per their policy, which mandates that the attending physician record the cause of death and file a death certificate within 24 hours of the resident's death.
Infection Control Deficiencies in PPE Usage and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection control measures by not ensuring staff wore complete personal protective equipment (PPE) during high-contact care activities for residents on enhanced barrier precautions. Specifically, a treatment nurse was observed performing dressing changes on a resident's gastrostomy site without wearing a gown and not sanitizing hands between glove changes. The nurse admitted to not checking the resident's orders before starting the procedure and acknowledged the lapse in infection control practices. In another instance, a certified nursing assistant and a student assistant were observed changing an incontinent brief and linens for a resident without wearing gowns, despite the resident being on enhanced barrier precautions. The certified nursing assistant admitted to not noticing the precaution signage and acknowledged the risk posed by not wearing full PPE during the procedure. Additionally, a treatment nurse was observed performing dressing changes and Foley catheter care for another resident without changing gloves throughout the procedures. The nurse admitted to this oversight, recognizing the risk of infection spread due to improper infection control practices. The facility's infection preventionist confirmed the necessity of full PPE and proper hand hygiene during such care activities, as outlined in the facility's policies.
Failure to Revise Care Plan for Resident at Risk of Bleeding
Penalty
Summary
The nursing staff failed to revise the care plan for a resident who was at risk of bleeding and hospitalizations. The resident, who had a history of hemiplegia, hemiparesis, chronic respiratory failure, and type II diabetes mellitus, experienced multiple episodes of bleeding and emesis. Despite these occurrences, the care plan was not updated to reflect the resident's actual bleeding incidents and hospitalizations. This oversight was identified through a review of the resident's progress notes, which documented several instances of vomiting and bleeding that required emergency department transfers. During an interview, the Assistant Director of Nursing acknowledged that the resident's care plan should have been revised following each bleeding episode and hospitalization. The facility's policy on comprehensive, person-centered care plans mandates that care plans be updated when there is a significant change in the resident's condition or following a hospital readmission. However, this was not done for the resident in question, potentially placing them at risk for further complications.
Failure to Properly Manage IV Line and Site
Penalty
Summary
The facility failed to ensure proper care for a resident's peripheral intravenous (PIV) line and site. The PIV site was not labeled with the date, and there was a lack of proper documentation and timely removal of the PIV after the completion of intravenous (IV) therapy. This oversight was observed during a visit on December 16, 2024, when the resident's PIV line was found without a date on the transparent dressing. The Licensed Vocational Nurse (LVN) confirmed that the resident had been receiving IV antibiotic medications, which had been completed on December 15, 2024. The Director of Nursing (DON) and Administrator (ADM) acknowledged that the PIV dressing site should have been dated to ensure timely dressing changes and PIV line removal. The facility's policy and procedure for Peripheral IV Catheter Insertion, revised in January 2024, required labeling the dressing with the date and time of placement, as well as removing the catheter once therapy was discontinued. The failure to adhere to these protocols had the potential to place residents at risk for developing infections at the IV site.
Failure to Implement Adequate Fall Prevention for Dementia Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident diagnosed with dementia, who had a history of falls and was at high risk for further falls. The resident was admitted with advanced dementia, a history of falling, difficulty walking, and muscle weakness. Despite these conditions, the facility did not develop an adequate care plan through an Interdisciplinary Team (IDT) approach to address the resident's dementia and fall risk. The care plan lacked specific interventions for monitoring or supervising the resident, and it did not include the use of a bed alarm or other safety measures to prevent falls. On 10/20/2024, the resident attempted to get up unassisted, resulting in a fall. The facility's response was inadequate, as there was no proper staff assessment conducted hours after the fall. The resident was found on the floor, and it was not until a family member noticed bruising and a cut above the resident's right eye that the resident was transferred to a General Acute Care Hospital (GACH) for further evaluation. At the hospital, the resident was diagnosed with an acute impacted fracture of the right femoral neck and an acute nondisplaced right anterior third rib fracture. Interviews with facility staff and a review of the resident's records revealed that the resident did not have a bed alarm in place prior to the fall, and there was no documentation of the resident's injuries or the circumstances of the fall. The Director of Nursing acknowledged that the resident should have been moved closer to the nurse's station and provided with a bed alarm and supervision due to the high risk of falls. The facility's policies on fall risk management and dementia care were not adequately followed, contributing to the resident's fall and subsequent injuries.
Failure to Conduct Comprehensive Assessment After Resident Fall
Penalty
Summary
The facility failed to conduct a comprehensive assessment after a resident experienced a fall on 10/20/2024. The resident, who had a history of dementia, difficulty walking, muscle weakness, and previous falls, attempted to get up independently, lost balance, and fell. Although the Change in Condition (CIC) Evaluation report noted the fall and that the resident forgot to use the call light, it did not document any injuries or indicate that a comprehensive assessment was completed. The resident had a bruise and a cut on the right eye, which were not documented by the staff, leading to a lack of proper assessment and documentation of the injury. The resident's family member observed the injuries during a visit on 10/23/2024 and reported that the facility staff were unsure of the cause. The Director of Nursing (DON) later confirmed the lack of documentation and acknowledged that an assessment should have been conducted. The facility's policy on falls required nurses to assess and document any recent injuries, especially fractures or head injuries, which was not adhered to in this case.
Infection Control and Consent Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, specifically in the fit testing and use of N95 masks among staff. During an observation, it was noted that three different types of N95 masks were present in the COVID unit, and one Licensed Vocational Nurse (LVN) was wearing a mask for which they had not been fit tested. The LVN confirmed that they had never been fit tested for the correct N95 mask, which is crucial to prevent exposure to COVID-19. Additionally, eight staff members, including the Director of Nursing (DON) and the Infection Prevention Nurse (IPN), were observed wearing the incorrect N95 mask, which was not the one designated from their fit testing. The DON acknowledged the oversight and the potential risk of infection spread due to improper mask fitting. The facility also failed to implement its policy and procedures regarding consent for COVID-19 vaccination. Two residents did not have documented consent or refusal for the COVID-19 vaccine. One resident, admitted with severe cognitive impairment and other health issues, had a record indicating the representative declined the vaccine multiple times, but there was no signed consent form. Similarly, another resident with moderate cognitive impairment and respiratory issues also lacked a signed consent form, despite the representative's refusal being noted. The IPN and DON both acknowledged the absence of signed consents, which are necessary to confirm the residents' wishes and ensure the facility's compliance with its policies. The facility's policies, including the Respiratory Protection Program and Admission Criteria, were not followed as required. The Respiratory Protection Program mandates fit testing for respirators to ensure proper use and protection, which was not consistently applied. The Admission Criteria policy requires verification of consents for treatments, including vaccinations, which was not documented for the two residents. These deficiencies in following established protocols had the potential to increase the spread of infection within the facility.
Deficiencies in Dialysis Care Documentation and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for three residents, leading to deficiencies in documentation and communication with dialysis centers. Resident 144, who was admitted with end-stage renal disease and required hemodialysis, did not have the Dialysis Unit Progress form and Post Dialysis Checklist completed upon returning from dialysis. The facility staff, including a registered nurse and the medical records assistant, did not contact the dialysis center to complete the necessary documentation, which was crucial for monitoring potential complications such as hypotension or fluid imbalance. Resident 39, who also had end-stage renal disease and was dependent on dialysis, did not have documentation in the communication notes indicating that Epogen was administered during dialysis sessions. Despite the dialysis center confirming that Epogen was given, this information was not recorded in the facility's Communication Dialysis Record. The Director of Nursing acknowledged the importance of maintaining accurate records to ensure the resident received the necessary care and services. Resident 294, readmitted with end-stage renal disease and diabetes, did not receive the prescribed Epogen during a dialysis session, as confirmed by the dialysis center. The Dialysis Communication Record lacked evidence of Epogen administration, and the resident's low hemoglobin level indicated a need for the medication. The facility's administrator emphasized the importance of completing the dialysis communication form and following up with the dialysis center to ensure residents received appropriate care.
Deficient Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the observation of a fly in the kitchen area during a tray line. This incident was noted during a concurrent observation and interview with the Dietary Director (DD), who expressed concern about the potential for bacteria transmission and subsequent infection among residents. The Maintenance Supervisor (MS) also acknowledged the risk of infection control issues, allergic reactions, and contamination of food or water if insects or rodents were present in the facility. A review of the facility's policy and procedure on pest control, dated January 2024, indicated that the facility was supposed to maintain an ongoing pest control program to keep the building free of insects and rodents.
Failure to Develop Timely, Individualized Care Plans
Penalty
Summary
The facility failed to develop timely, person-centered care plans for three residents, leading to an increased risk of harm and a lack of individualized care. Resident 117, who was receiving occupational therapy (OT) services, did not have a care plan for OT treatment. Despite receiving OT treatments on multiple occasions, there was no care plan in place to guide staff on the therapy's objectives and interventions. The Director of Rehabilitation confirmed the absence of an OT care plan and emphasized its importance for staff awareness and individualized care. Resident 51, who was highly dependent and at high risk for falls, did not have a care plan detailing the type and level of assistance required for activities of daily living (ADLs) and transfers. During an observation, staff used an inappropriate transfer method, sliding the resident with a bed sheet instead of using a Hoyer lift. The Registered Nurse Supervisor acknowledged the lack of a care plan and highlighted the potential risk of fall incidents due to improper transfer methods. Resident 136, who had a history of mild cognitive impairment and required assistance with various ADLs, went out on pass with a family member who left the resident unattended for several hours. Despite this incident, no care plan was initiated to address the accident and prevent future occurrences. The Director of Nursing confirmed the absence of an accident care plan and stressed the need for measurable objectives to meet the resident's needs following such incidents.
Failure to Complete Advance Directive Acknowledgment Form
Penalty
Summary
The facility failed to ensure that an Advance Directive Acknowledgment Form was completed and included in the medical chart of Resident 133. This oversight was identified during a review of the resident's medical records, which revealed the absence of the necessary documentation. Resident 133 was admitted to the facility with several medical conditions, including cerebrovascular disease, myocardial infarction, and Type II diabetes. The resident's Minimum Data Set indicated moderately impaired cognition and a need for substantial assistance with daily activities. Despite these conditions, the resident's medical chart lacked the Advance Directive Acknowledgment Form, which is crucial for honoring the resident's medical decisions, particularly regarding end-of-life care. Interviews with facility staff, including the Social Services Designee and the Director of Nursing, confirmed the absence of the Advance Directive Acknowledgment Form in Resident 133's chart. The Director of Nursing acknowledged that the form should have been completed upon admission to ensure the resident's end-of-life wishes could be honored. The facility's policy on Advance Directives, revised in January 2024, mandates that residents or their representatives receive written information about their rights to make medical decisions, including the formulation of advance directives, upon admission. The failure to adhere to this policy resulted in a deficiency that could potentially impact the resident's medical care decisions.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to provide a written bed hold notification to a resident or their representative at the time of transfer to a hospital, which is a requirement under federal guidelines. This deficiency was identified for one of the three sampled residents, who was transferred to a hospital for further evaluation and management of bloody stool. The resident, who had moderately impaired cognitive skills and required assistance with daily activities, was not informed in writing about the facility's bed-hold policy upon transfer, despite a physician's order for a seven-day bed hold. Interviews with facility staff, including a Registered Nurse Supervisor, the Medical Records Director, and the Administrator, revealed that the facility's practice was to inform residents and their families about the bed-hold policy during admission, but not to provide a written notice at the time of transfer. The facility's policy and procedure, revised in March 2023, stated that residents or their representatives should be informed of the bed-hold policy prior to transfers, but this was not adhered to in the case of the resident transferred on July 11, 2024.
Failure to Update Therapy Care Plans
Penalty
Summary
The facility failed to update the care plans for a resident receiving physical therapy (PT) and occupational therapy (OT) services, which could lead to the resident receiving incorrect services. The resident, who was admitted with cerebral edema, muscle weakness, and difficulty walking, had severe cognitive impairment and required substantial assistance with daily activities. Despite changes in the frequency and type of therapy services ordered by the physician, the care plans were not updated to reflect these changes. The Director of Rehabilitation (DOR) confirmed that the care plans did not match the current therapy services being provided, and emphasized the importance of updating care plans to reflect changes in therapy. The Director of Nursing (DON) also stated that care plans should be individualized and updated based on the current care provided to the resident. The facility's policy requires care plans to be revised as the resident's condition changes, but this was not done in this case.
Failure to Provide Communication Aids for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication device or board in the language understood by a resident, identified as Resident 133, who was admitted with conditions including cerebrovascular disease, myocardial infarction, and type two diabetes. The resident had moderately impaired cognition and required substantial assistance with daily activities. Despite being able to make needs known, the resident could not make medical decisions and primarily spoke Spanish. The facility's records indicated that the resident's primary language was Spanish, yet no communication device or board was provided to facilitate communication with staff. Observations and interviews revealed that the resident's family member noted the absence of Spanish-speaking staff and communication aids, which hindered the resident's ability to communicate effectively. The Activity Director acknowledged the need for a communication board, and the Director of Nursing admitted that a care plan should have been developed to address this communication barrier. The facility's policy on communication language barriers emphasized the use of visual aids for residents with such barriers, but this was not implemented for Resident 133, leading to a deficiency in care.
Failure to Obtain Physician's Order and Correctly Set LALM
Penalty
Summary
The facility failed to obtain a physician's order for a low air loss mattress (LALM) and did not maintain the correct setting for a resident, leading to a deficiency in pressure ulcer care. Resident 128, who was admitted with a pressure ulcer on the right hip, was observed on a LALM set at 180, which was incorrect for her weight of 108 pounds. The facility's policy required that LALMs be set according to the resident's weight and physician's orders, but this was not followed. Licensed Vocational Nurse 5 and Treatment Nurse 1 both acknowledged the importance of setting the LALM correctly to prevent pressure injuries. The Director of Nursing confirmed that licensed nurses were responsible for obtaining a physician's order for the LALM and ensuring it was set correctly. The facility's policy emphasized the need to select appropriate support surfaces based on the resident's characteristics and risk factors, but this was not adhered to in the case of Resident 128.
Failure to Document E-Kit Usage and Controlled Drug Wastage
Penalty
Summary
The facility failed to maintain an emergency drug supply (E-Kit) usage or administration log, as well as documentation for the wastage of a controlled drug removed from the E-Kit. During an observation and interview, an LVN was unaware of an administration log or binder for the E-Kit, indicating a lack of proper documentation procedures. The LVN mentioned that nurses fill out an emergency drug kit slip and place it in the E-Kit after removing a medication. However, the RN Supervisor stated that these slips were turned in to the ADON, who presented a Ziploc bag containing a stack of yellow slips, indicating that the facility did not have a proper log book or binder for recording E-Kit usage. Further investigation revealed that a slip dated 4/17/2024 for Oxycodone, a controlled substance, lacked proper documentation of wastage. The ADON, upon reviewing the electronic health record and consulting with the pharmacist, discovered that the nurse likely took out two tablets of Oxycodone 10 mg and wasted half a tablet, but failed to document this wastage. The facility's policy required documentation of emergency medication dispensing and wastage, but the ADON admitted that there was no accountability record for controlled substances stored in the E-Kit, as there was for those regularly dispensed from the pharmacy.
Improper Medication Storage at Resident's Bedside
Penalty
Summary
The facility failed to maintain proper storage of medications for one of the sampled residents, identified as Resident 76. During an observation, a bottle of Vitamin C was found at the resident's bedside. The resident, who was admitted with diagnoses including anxiety, muscle weakness, and major depressive disorder, stated that they used the Vitamin C to aid in bowel movements. This practice was against the facility's policy, which requires medications to be stored securely and not left at the bedside. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that medications should not be left with residents, as it poses a risk of overdose or unsupervised consumption. The facility's policy mandates that medications be stored in an orderly manner in designated areas to prevent mixing and ensure safety. The presence of the Vitamin C bottle at the bedside indicated a lapse in adherence to these storage protocols, potentially compromising the resident's safety.
Deficiencies in Food Storage and Utensil Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food storage and labeling, as observed during a survey. Several food items, including mozzarella cheese, white cheese, cheddar cheese, shredded cheese, tomatoes, bell peppers, lemons, and oranges, were found without proper labeling of received or use-by dates. The Dietary Director acknowledged the absence of labels and expressed concern about the potential risk of foodborne illness to residents. The Registered Dietician confirmed that all food should be labeled with delivery dates to prevent spoilage, as per the facility's policy on food receiving and storage. Additionally, the facility did not maintain sanitary conditions for serving coffee to residents. During an observation, 12 out of 20 plastic coffee cups were found with a white residue, identified by the Dietary Director as salt from a malfunctioning water softener. The Director of Nursing emphasized the importance of ensuring utensils are clean before use, as dirty utensils could harm residents. The facility's policy on sanitization requires that all food contact surfaces and utensils be cleaned and sanitized, which was not adhered to in this instance.
Improper Trash Disposal and Sanitation Issues
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster areas in a sanitary manner, as observed during a survey. Two out of four garbage dumpsters were overfilled with plastic bags and a cardboard box, while one dumpster had its lid open, and another had a broken lid cut in half. These conditions were observed during a concurrent observation and interview with the Housekeeping Director, who acknowledged that the dumpsters should have been closed and not overflowing with trash. The presence of a foul odor and flies around the dumpsters was noted, raising concerns about potential infection control issues if flies entered the facility and contaminated residents' food. The Maintenance Supervisor also confirmed that the dumpster lids should have been closed to prevent attracting insects or rodents, which could pose an infection control problem if they entered the facility. The facility's policy and procedure on sanitation, dated January 2024, required that garbage and refuse containers be in good condition, without leaks, and properly contained in dumpsters with lids. Additionally, the FDA Food Code 2022 specified that receptacles for refuse should be kept covered with tight-fitting lids or doors if kept outside, and stored in a manner inaccessible to insects and rodents.
Failure to Provide Timely and Authorized Rehabilitative Therapy Services
Penalty
Summary
The facility failed to provide timely and appropriate rehabilitative therapy services for two residents, leading to deficiencies in care. Resident 136, who was admitted with conditions including acute embolism, thrombosis, muscle weakness, and difficulty walking, did not receive a timely speech therapy evaluation. Despite having an order for a speech therapy evaluation and treatment, the evaluation was delayed, which the Director of Rehabilitation acknowledged as a potential delay in care. The facility's policy required evaluations to be initiated within the first business day following weekends and holidays, but this was not adhered to in Resident 136's case. Resident 117, admitted with diagnoses such as brachial plexus disorders, muscle weakness, and difficulty walking, received occupational therapy services without an active physician's order. The resident was receiving therapy three times a week, but the Director of Rehabilitation confirmed that the order for continuation of occupational therapy treatment had not been renewed as required. The facility's policy stated that there should be no gaps in dates between clarification and reclarification orders, but this was not followed, resulting in therapy being provided without the necessary physician approval. These deficiencies highlight the facility's failure to adhere to its own policies and procedures regarding the timely initiation and continuation of therapy services. The lack of timely evaluations and the absence of renewed therapy orders could potentially delay necessary care and result in therapy being administered without proper authorization, as observed in the cases of Residents 136 and 117.
Failure to Maintain Certification of Terminal Illness for Hospice Resident
Penalty
Summary
The facility failed to ensure that the hospice resident's binder contained a copy of the Certification of Terminal Illness (CTI) for one resident, identified as Resident 8. This deficiency was identified through observation, interview, and record review. Resident 8 was readmitted to the facility with diagnoses including multiple sclerosis and a Stage IV pressure ulcer. A physician's order indicated the resident was to be admitted to a hospice agency for routine care due to the pressure injury and protein calorie malnutrition. However, during a review of the hospice chart and electronic medical records, the CTI was not found, and the Licensed Vocational Nurse (LVN) was unaware of the hospice diagnosis. Further interviews revealed that the Registered Nurse Supervisor confirmed the hospice diagnosis but also could not locate the CTI in the resident's medical chart. The Director of Nursing stated they would contact the hospice agency to obtain the CTI. The facility's policy requires that the CTI be maintained in the resident's hospice chart, as it is necessary for the resident to qualify for hospice benefits under Medicare. The absence of the CTI indicates a failure to comply and coordinate with hospice services, as required by the facility's policy and the hospice and facility contract.
Infection Control and Oxygen Tubing Labeling Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of hand hygiene supplies in the occupational therapy (OT) gym. During an observation, it was noted that therapy staff were required to don and doff personal protective equipment (PPE) when working with residents under enhanced barrier precautions (EBP). However, there was no sink or hand sanitizer available inside the OT gym for staff to perform hand hygiene immediately after removing PPE. Staff had to walk outside the gym to access hand sanitizer, which contradicted the facility's policy that emphasized the importance of immediate hand hygiene to prevent the spread of infections. Additionally, the facility failed to properly label oxygen tubing for Resident 12, who was receiving oxygen therapy. The resident, with a history of traumatic subdural hemorrhage, acute pulmonary edema, and chronic respiratory failure, was observed receiving oxygen via a nasal cannula without a label indicating when the tubing was last changed. The Licensed Vocational Nurse (LVN) confirmed the absence of labeling and was unsure of the frequency for changing the tubing, which was supposed to be every seven days according to the facility's policy. This oversight had the potential to lead to respiratory infections for the resident. The facility's policies and procedures, which were reviewed and revised in January 2024, clearly outlined the requirements for hand hygiene and oxygen administration. The failure to adhere to these policies in both the OT gym and in the care of Resident 12 demonstrated a lapse in the facility's infection control practices, potentially compromising the health and safety of residents and staff.
Failure to Offer Required Vaccinations to Resident
Penalty
Summary
The licensed nursing staff at the facility failed to offer the influenza and pneumococcal vaccines to a resident, identified as Resident 12, as required by the facility's policies. Resident 12, who was admitted with significant health conditions including heart failure, end-stage renal disease, and a Stage IV pressure ulcer, had not received the flu vaccine since 2020. The facility's policy mandates that the influenza vaccine be offered annually to all residents without medical contraindications and within five working days of admission during the flu season. Additionally, the pneumococcal vaccine should be offered within thirty days of admission if the resident is eligible. However, these protocols were not followed for Resident 12. Interviews with the Infection Preventionist and the Administrator confirmed that the facility did not offer the required vaccines to Resident 12 since their admission. The Infection Preventionist acknowledged that the resident should have been offered both vaccines to prevent illness and infection. The Administrator stated that the facility typically offers the flu vaccine from September to April and the pneumococcal vaccine year-round, but this was not done in the case of Resident 12. This oversight placed the resident at increased risk of acquiring and transmitting the flu and pneumonia within the facility.
Failure to Offer COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to offer the COVID-19 vaccination to two residents, Resident 12 and Resident 132, which was identified during a survey. Resident 12 was readmitted to the facility with diagnoses including acute respiratory failure, schizophrenia, and atrial fibrillation. The Minimum Data Set (MDS) indicated that Resident 12 had severely impaired cognition and was totally dependent on staff for daily activities. The resident's history and physical assessment confirmed the lack of capacity to understand and make decisions. Despite these conditions, the facility did not offer the COVID-19 vaccination to Resident 12. Resident 132 was admitted with diagnoses including diabetes, heart failure, and peripheral vascular disease. The resident's internal medicine history and physical assessment indicated the capacity to understand and make decisions, with no known allergies. The MDS showed that Resident 132 had intact cognition but required assistance with certain daily activities. However, the facility also failed to offer the COVID-19 vaccination to Resident 132. During interviews, the Infection Preventionist acknowledged that neither resident had been assessed for vaccination eligibility, despite the facility's policy to offer vaccinations year-round.
Failure to Ensure Safe Transfers and Wheelchair Use
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, leading to increased risks of falls and injuries. For Resident 51, who was diagnosed with metabolic encephalopathy, hemiplegia, and hemiparesis, the facility did not use a hoyer lift for transfers despite the resident being assessed as a high fall risk and completely dependent on assistance. Observations revealed that staff used a bed sheet and manual lifting methods instead of the recommended hoyer lift, which was clearly indicated on a sign in the resident's room. Interviews with staff, including the Director of Rehabilitation and the Registered Nurse Supervisor, confirmed that the hoyer lift was the recommended and safer method for transferring Resident 51. For Resident 19, who had severe cognitive impairment and was admitted with muscle weakness and osteoarthritis, the facility failed to ensure foot rests were applied to the resident's wheelchair during transport. The resident's care plans did not include instructions for using foot rests, and observations confirmed that the resident was transported without them on at least one occasion. Interviews with the Resident's Representative and the Occupational Therapist highlighted the potential risks of not using foot rests, such as the resident's feet dragging and causing injury. The facility's policies and procedures emphasized the importance of providing appropriate support and assistance with transfers and ensuring resident safety to prevent accidents. However, the failure to adhere to these policies in the cases of Resident 51 and Resident 19 resulted in increased risks of falls and injuries, as the recommended safety measures were not implemented during transfers and wheelchair use.
Failure to Remove Discontinued Medication from Cart
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, Resident 1, who had moderately impaired cognition and required limited assistance for daily activities, received a discontinued medication, gabapentin 100 mg. The medication was not removed from the medication cart despite being discontinued in the electronic charting application, Point Click Care (PCC). This error was identified during an interview and record review with the Director of Nursing (DON), who confirmed that the medication had been discontinued per the physician's orders but was still administered to the resident because it was not removed from the medication cart. Resident 1 was admitted with diagnoses including aftercare following joint replacement surgery, primary osteoarthritis of the left knee, legal blindness, difficulty walking, and muscle weakness. The error was discovered when the Charge Nurse reported administering the discontinued gabapentin, and the DON verified that the medication had been discontinued in the PCC but not physically removed from the medication cart. The facility's policy on administering medications, reviewed in August 2023, mandates that medications be administered safely and timely, as prescribed, which was not adhered to in this instance.
Failure to Protect Resident from Family Member Abuse
Penalty
Summary
The facility failed to protect Resident 1 from abuse by a family member. Resident 1, who was admitted with diagnoses including encephalopathy, essential hypertension, and chronic pain syndrome, reported to the facility staff and police that her family member slapped her in the face on 2/26/2024. Despite this report, the family member returned to the facility the next day and was found in Resident 1's room, where he again made open hand contact with Resident 1's left cheek. This incident was confirmed by the facility's Change in Condition documents and an investigation report. During interviews, Resident 1 downplayed the incident, stating it was blown out of proportion, while the Administrator confirmed the sequence of events, including the family member's return and subsequent second slap. The facility's policy on abuse prevention, dated 1/2024, emphasizes the protection of residents from abuse by anyone, including family members. However, the facility's failure to prevent the family member's return and subsequent abuse placed Resident 1 at increased risk for further harm.
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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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