Blythe Post Acute Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Blythe, California.
- Location
- 285 West Chanslor Way, Blythe, California 92225
- CMS Provider Number
- 555383
- Inspections on file
- 45
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Blythe Post Acute Llc during CMS and state inspections, most recent first.
A resident with a history of marijuana use, heart failure, COPD, and nicotine dependence was re-admitted without a comprehensive care plan addressing tobacco or marijuana use, despite facility policy and previous positive THC tests. Both RN and DON confirmed the absence of a smoking care plan in the resident's records after re-admission.
A CNA provided direct care to residents while lacking an active State-approved CNA certification and a current CPR certificate. The CNA was scheduled and worked shifts despite these missing credentials, as confirmed by employee records and staffing schedules. Both the DSD and DON acknowledged the oversight, and facility policies required current certification and licensure for such positions.
The facility did not ensure the high temperature alarm for hot water was functioning and failed to monitor and record hot water temperatures on several days, resulting in a lack of safeguards against excessively hot water for residents. Interviews with the Maintenance Supervisor and Administrator confirmed these lapses, which were not in accordance with facility policy.
The facility did not assess or document vital signs before transferring two residents with significant medical conditions to a general acute care hospital for further evaluation. In both cases, the last recorded vital signs were from the previous day, and no updated assessments were documented prior to transfer, despite facility policy and DON expectations that vital signs be obtained and recorded before such transfers.
A resident with left-sided paralysis and intact cognition alleged that a CNA was rough during care, resulting in pain and a wrist bump. The incident was reported, the resident was assessed, and the CNA was sent home, but the Administrator allowed the CNA to return to work before completing required interviews with the resident and others. Facility policy required suspension and a thorough investigation, which was not completed prior to the CNA's return.
A dietary staff member in the facility was unable to accurately verbalize the proper cool down process for cooked foods, which is crucial to prevent foodborne illnesses. The staff member incorrectly stated the cooling times, which did not align with the facility's policy requiring cooling from 135°F to 70°F within 2 hours and then to 41°F or below within the next 4 hours. This misunderstanding had the potential to expose 44 residents to foodborne illnesses.
The facility failed to maintain safe food storage and preparation practices, with turkey and bologna stored at unsafe temperatures, a dietary aide not wearing a beard net, and a dirty air conditioning grill above the food prep area. Additionally, a cleaning agent was improperly stored near food, and an expired sanitizer test kit was used, risking foodborne illness.
A resident received an expired Atrovent inhaler due to an LVN not checking the expiration date during medication preparation. The resident had been receiving this medication for COPD treatment. Additionally, an inspection revealed expired carisoprodol tablets in an E-Kit. Facility policies require the removal of expired medications and monthly inspections of emergency kits, which were not adhered to.
The facility failed to provide the required minimum of 80 square feet per resident in seven multi-resident rooms, accommodating three residents each with only 79.6 square feet per resident. Despite this, no complaints or negative impacts on residents' comfort were observed, and residents reported being comfortable.
The facility failed to ensure a licensed pharmacist conducted thorough monthly drug regimen reviews, leading to inconsistent procedures by nursing staff for holding blood pressure medications without physician-ordered hold parameters. This affected three residents, with medications being held or administered based on nursing judgment rather than standardized guidelines.
A resident with dementia was given Seroquel without prior non-pharmacological interventions or a psychiatric consult. The facility did not document attempts to assess the resident's mental status or distress level, violating their policy on psychotropic drug use.
A medication error rate of 11.11% was identified in an LTC facility, involving two residents. Errors included improper administration of an Advair inhaler due to language barriers, use of an expired Atrovent inhaler, and incorrect dosing of acetaminophen. These actions were contrary to the facility's medication administration policies.
A resident with muscle weakness and failure to thrive was served fish despite a clear preference against it, as indicated on their meal ticket. This oversight was acknowledged by the dietary manager, who noted the potential for reduced food intake. The facility's policy stresses the importance of honoring food preferences.
The facility failed to post necessary signage for Enhanced Barrier Precautions (EBP) in rooms of residents with conditions requiring such precautions. Interviews with staff confirmed the absence of signage indicating required PPE for residents with wounds or indwelling devices, despite facility policy mandating these precautions to prevent the spread of multidrug-resistant organisms.
A resident experienced an unwitnessed fall and hit her head, but the facility failed to conduct timely neurological assessments as per protocol. Despite the resident's history of falls and being on blood-thinning medication, the required neuro checks were not performed. The responsibility for monitoring was inadequately transferred between staff, and the Director of Nursing confirmed the protocol was not followed.
The facility failed to develop care plans for two residents who used marijuana, despite incidents indicating the need for such plans. One resident, with a history of embolism and thrombosis, reported feeling unwell after marijuana use, but no care plan was initiated. Another resident, with asthma, was found unresponsive and later confirmed to have used marijuana, yet no care plan was developed. The facility's policy requires care plans to be updated as conditions change, which was not followed.
A resident reported feeling like having a stroke and using marijuana, but the facility failed to monitor her condition or update her care plan. Despite the resident's cognitive intactness and history of embolism and thrombosis, the RN did not assess her or notify the physician, and the DON was unaware of the incident, indicating a breach in the facility's Change of Condition policy.
The facility failed to ensure correct medication orders for two residents. One resident received an incorrect dosage of Sertraline, while another did not have orders for her asthma medications, Symbicort and albuterol, upon admission. The DON confirmed the errors, which were against the facility's medication therapy policy.
The facility failed to maintain an effective pest control program, leading to an increase in flies in common areas and resident bedrooms. Multiple residents, including those with cognitive impairments and serious medical conditions, were affected by the flies. The removal of fly traps and lack of a contracted pest control service since April 2024 contributed to the issue, despite the facility's policy requiring an ongoing pest control program.
The facility failed to report alleged abuse and unauthorized medication administration involving three residents to the CDPH within the required timeframe. A resident was verbally abused by a CNA, while two others were allegedly given sleeping medicine without authorization. The Administrator delayed reporting these incidents, waiting for a written statement, which resulted in a delayed investigation and risk to the residents.
A resident's electric wheelchair was improperly stored in the maintenance office without a protective cover, and facility belongings were placed on it. Interviews with the Maintenance Supervisor and DON confirmed the lack of adherence to the facility's policy on resident rights, which requires treating residents and their possessions with respect and dignity.
A resident with left-sided muscle weakness following a stroke was not accommodated in their preference for an electric Hoyer lift for transfers and a large Geri-chair for seating. Both electric lifts were unavailable due to dead batteries, and the Geri-chair was shared among multiple residents, limiting its availability. This led to the resident refusing showers and being observed in a disheveled state, highlighting a failure to meet the resident's needs and preferences.
A resident diagnosed with atrial fibrillation did not receive timely cardiology follow-up after returning to the facility. Despite requests, the resident was not informed of any cardiology appointments. The facility physician prescribed Eliquis but did not ensure cardiology follow-up, and the facility's policies on timely physician visits and condition changes were not followed.
Two residents in a long-term care facility did not receive their prescribed Augmentin due to medication unavailability. One resident, with COPD, missed three doses, while another, with diabetes and a UTI, missed two doses. The facility's policy requires medications to be administered within one hour of the prescribed time, and the staff should have used the emergency kit while waiting for delivery.
Two residents with type 2 diabetes mellitus were served incorrect desserts during a lunch meal service, contrary to their prescribed diets of low concentrated sweets and no added salt. The dietary supervisor and DON confirmed the errors, acknowledging that the dietary staff failed to follow the physician's orders, which specified lemon pound cake instead of cheesecake with cherry topping.
The facility did not meet the required 80 square feet per resident in multi-resident rooms for 8 out of 18 rooms. Observations and interviews revealed that rooms 5 through 12 provided only 79.6 square feet per resident. Some residents expressed concerns about room size, but staff did not report care provision issues. The Director of Nursing was unaware of the space requirements, and the facility's policy was not followed.
A resident was moved to a new room without receiving the required written notice, despite being cognitively intact and expressing dissatisfaction with the change. The facility's policy mandates advance written notice for room changes, but the DON confirmed that only verbal notifications were given, which was reflected in the resident's medical records.
The facility failed to maintain room temperatures between 71 and 81 degrees Fahrenheit, with some rooms reaching 84.7 degrees, causing discomfort for two residents. One resident with cellulitis and hemiplegia and another with ventricular tachycardia and COPD were affected. The Maintenance Supervisor confirmed the air conditioning was functioning, but the Administrator acknowledged the temperature issue.
Failure to Develop Comprehensive Care Plan for Tobacco and Marijuana Use After Re-Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing tobacco and marijuana use for a resident who was re-admitted with a documented history of marijuana use and multiple medical diagnoses, including heart failure, COPD, and nicotine dependence. Despite the resident's intact cognitive status and previous positive test for THC, the care plan did not include interventions related to marijuana or smoking following re-admission. Both the RN and DON confirmed during interviews and record reviews that no smoking care plan was present in the resident's current records, even though the resident was known to be a smoker and had previously tested positive for THC. The facility's policy requires a comprehensive, person-centered care plan to be developed within seven days of the completion of the required assessment and to be updated upon re-admission from a hospital stay. However, this process was not followed for the resident in question, as no new care plan addressing the resident's tobacco or marijuana use was created after re-admission. This omission was verified by both nursing staff and leadership during the survey.
CNA Worked Without Active Certification and CPR Credentials
Penalty
Summary
A Certified Nursing Assistant (CNA) was found to have provided direct care to residents without maintaining an active State-approved CNA certification and a current CPR certification. Review of the CNA's employee file showed that the CNA's license had expired and there was no documentation of a current CPR certificate. Staffing schedules confirmed that the CNA was assigned and worked shifts on multiple dates while not meeting these requirements. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that both were aware of the requirement for CNAs to have active licenses and CPR certification before providing care. The DSD, responsible for verifying staff credentials, acknowledged that the CNA should not have been scheduled to work. The DON confirmed that the CNA was allowed to work despite the expired license and missing CPR certification, attributing the lapse to an oversight. Facility policies and job descriptions reviewed also specified the necessity of current certification and licensure for employment in these roles.
Failure to Maintain Safe Water Temperatures and Monitoring
Penalty
Summary
The facility failed to maintain a safe water system for 44 residents by not ensuring the proper functioning of the high temperature alarm, which is designed to alert staff when water temperatures exceed 120°F. During interviews, the Maintenance Supervisor confirmed that the high temperature alarm at the nurses station was not working, and the Administrator stated that the Maintenance Supervisor was responsible for daily hot water monitoring and ensuring the alarm was operational. This malfunction meant that staff were not alerted to potentially unsafe water temperatures, as required by facility procedures. Additionally, the facility did not monitor or record hot water temperatures on three separate days in June 2025, as evidenced by blank entries in the Daily Hot Water Temperature Record. The Maintenance Supervisor acknowledged that no checks were performed on those days, which was contrary to the facility's policy requiring daily monitoring to prevent scalding. The facility's policy specifies that water temperatures should be maintained between 105°F and 120°F, and that maintenance staff must conduct and log periodic checks, which was not consistently done.
Failure to Document Vital Signs Prior to Hospital Transfer
Penalty
Summary
The facility failed to assess and document vital signs prior to non-emergent transfers to a general acute care hospital for two residents. For the first resident, who had chronic obstructive pulmonary disease and intact cognition, there was no documentation of vital signs being taken before her transfer to the hospital for increased difficulty breathing and lower leg edema. The last recorded vital signs were from the previous day, and the transfer was conducted without updated assessment. The Director of Nursing (DON) confirmed that it is expected for staff to obtain and document vital signs prior to any transfer, and that unstable vital signs would require ambulance transport rather than the facility van. Similarly, for a second resident with heart failure and moderate cognitive impairment, no vital signs were documented prior to her transfer to the hospital for shortness of breath, increased weakness, and lethargy. The last set of vital signs was recorded the day before the transfer. The DON reiterated that nursing staff are expected to obtain and document vital signs at least one hour before hospital transfer. Facility policy also requires nurses to make detailed observations and record relevant information in the medical record when there is a change in a resident's condition or status, including prior to transfer.
Failure to Complete Abuse Investigation Before Allowing Staff to Return to Work
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse made by a resident against a CNA before allowing the alleged perpetrator to return to work. The resident, who was cognitively intact and had a history of left-sided paralysis following a stroke, reported that the CNA was rough while changing her brief, causing pain and a bump on her left wrist. The incident was reported to the LVN, who assessed the resident and notified the DON and Administrator. The police were also involved and interviewed the resident. The CNA was sent home the evening of the allegation but was allowed to return to work the following morning, before the investigation was completed. The Administrator, who was responsible for the abuse investigation, did not interview the resident or other residents assigned to the CNA prior to allowing the CNA to return to work. The Administrator relied on interviews with staff and the police report, believing there was enough information to permit the CNA's return. The facility's policy required immediate suspension of any employee accused of abuse pending the outcome of a thorough investigation, including interviews with the resident, staff, and other residents cared for by the accused employee. These steps were not completed before the CNA resumed work, resulting in a failure to follow the facility's abuse investigation and reporting procedures.
Improper Food Cooling Process Knowledge in Dietary Staff
Penalty
Summary
The facility failed to ensure that a dietary staff member could accurately verbalize the proper cool down process for cooked foods, which is essential to prevent foodborne illnesses. During an interview, the staff member incorrectly stated that the cooling process from a hot food temperature of 135 degrees Fahrenheit to an ambient temperature of 70 degrees Fahrenheit would take one hour, and from 70 degrees Fahrenheit to a cold temperature of 40 degrees Fahrenheit would take less than an hour. This understanding was inconsistent with the facility's policy, which requires potentially hazardous foods to be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours, and then to 41 degrees Fahrenheit or below within the next 4 hours, not exceeding a total cooling time of 6 hours. This discrepancy in the staff member's knowledge had the potential to expose 44 residents to foodborne illnesses due to improper cooling of food. The staff member mentioned referring to the cool down log when she had questions about the process, indicating a reliance on documentation rather than a clear understanding of the procedure.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices, as observed during a survey. Turkey and bologna were stored at unsafe temperatures, with measurements showing 46.7 F and 46.9 F, respectively, which is above the safe storage temperature of 41 F. This was acknowledged by the Dietary Manager (DM), who stated that storing deli meats above 41 F could lead to foodborne illnesses. Additionally, a dietary aide was observed preparing milk for residents without wearing a beard net, which the DM confirmed was necessary to prevent cross-contamination. Further observations revealed that the air conditioning unit's air outlet grill above the food preparation table was dirty, with a black substance found on it. The DM stated it was the cook's responsibility to clean the unit daily. A lemon juice container intended for cleaning was stored near food items, which the DM acknowledged should be labeled and stored separately to prevent contamination. Lastly, a dietary aide used an expired quaternary sanitizer test kit, which could lead to inaccurate readings and ineffective sanitization, potentially causing foodborne illness.
Expired Medications Administered and Found in E-Kit
Penalty
Summary
The facility failed to ensure that expired medications were not available for use, resulting in a resident receiving an expired medication. During a medication pass observation, an LVN prepared morning doses for a resident, which included an Atrovent inhaler with an expiration date of December 2024. The LVN did not check the expiration date before administering the medication. The resident had been receiving this medication four times a day since February 11, 2025, as per the physician's order for COPD treatment. The LVN confirmed the expiration date and acknowledged that a new inhaler needed to be ordered from the pharmacy. Additionally, during an inspection of a medication cart, an E-Kit containing controlled substances was found to have expired medications, including carisoprodol tablets with an expiration date of December 30, 2024. The facility's policies on expired medications and emergency medications require that expired medications be identified and removed promptly, and that the consultant pharmacist inspects emergency kits monthly. However, these procedures were not followed, leading to the availability of expired medications in the facility.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that multi-resident bedrooms provided the required minimum of 80 square feet per resident in seven out of 17 rooms, specifically Rooms 5, 6, 8, 9, 10, 11, and 12. During an initial tour, it was observed that these rooms contained three beds each, accommodating three residents per room, but only provided approximately 79.6 square feet per resident. The Administrator confirmed that these rooms did not meet the required space per resident and acknowledged the deficiency. Despite the deficiency, there were no complaints from residents or staff regarding insufficient living space, and no negative impacts on the health, safety, and comfort of the residents were observed during the survey. Residents interviewed stated they were comfortable in their rooms. The facility's policy, revised in May 2017, requires that bedrooms measure at least 80 square feet per resident in double rooms, which was not adhered to in the mentioned rooms.
Inconsistent Blood Pressure Medication Management
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a thorough monthly drug regimen review for three residents, which included identifying and making recommendations on non-standardized and inconsistent procedures by nursing staff for holding blood pressure medications. The consultant pharmacist did not address the lack of hold parameters for blood pressure medications ordered by physicians, leading to nursing staff using their clinical judgment to decide when to hold medications. This practice was inconsistent with the facility's policy and procedure for medication regimen reviews. Resident 3 was admitted with diagnoses including hypertensive heart disease with heart failure. The resident had physician orders for lisinopril and carvedilol without hold parameters, and the medication administration record indicated that these medications were administered even when blood pressure readings were low. Similarly, Resident 18 had orders for Lotensin, and the medication was held based on low blood pressure readings without specific hold parameters. Resident 32 also had orders for lisinopril and carvedilol without hold parameters, and the medications were inconsistently held or administered based on nursing judgment. Interviews with nursing staff and the Director of Nursing revealed that the facility relied on nursing clinical judgment to determine whether to hold blood pressure medications, with no clear policies or procedures in place. The consultant pharmacist acknowledged not identifying or making recommendations on these inconsistencies. This lack of standardized procedures and oversight had the potential to affect the effective management of residents' hypertension.
Failure to Attempt Non-Pharmacological Interventions Before Antipsychotic Use
Penalty
Summary
The facility failed to ensure that antipsychotic medications were used only after non-pharmacological interventions were attempted and the resident was assessed to be in significant distress or a danger to themselves or others. This deficiency was identified in the case of a resident with dementia who was administered Seroquel, an antipsychotic medication, without prior attempts at non-pharmacological interventions. The resident's medical record did not show evidence of hallucinations or delusions, and the facility did not conduct a psychiatric consultation to assess the necessity of the medication. The resident was admitted with a diagnosis of unspecified dementia with psychotic disturbance, but there was no history of psychosis or prior use of antipsychotic medication. Despite this, the facility continued the use of Seroquel, which was initially administered as a one-time dose in the hospital for agitation. The Director of Nursing acknowledged that non-pharmacological interventions were not attempted because the resident had received Seroquel in the hospital. The facility's policy requires that psychotropic drugs be used only after alternative methods have been tried unsuccessfully, and informed consent is obtained, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 11.11% during a medication administration observation. Three medication errors were identified out of 27 opportunities, involving two residents. The first error involved a Licensed Vocational Nurse (LVN 1) who administered an Advair inhaler to a resident with chronic obstructive pulmonary disease (COPD). The resident, who preferred communication in Spanish, was instructed in English to spit out water after rinsing the mouth, but instead swallowed it. This was due to a communication barrier, as the resident did not understand English well and LVN 1 did not use a Spanish-speaking staff or interpreter. This error had the potential to increase the risk of oral fungal infection. The second error involved the administration of an expired Atrovent inhaler to the same resident. LVN 1 did not check the expiration date before administering the medication, which had expired in December 2024. The third error involved another resident who was given two tablets of acetaminophen instead of the prescribed one tablet. LVN 1 documented the administration of one tablet, but admitted to giving two tablets. These errors were contrary to the facility's policy and procedure for administering medications, which requires checking expiration dates and administering medications as prescribed.
Failure to Honor Resident's Dietary Preference
Penalty
Summary
The facility failed to honor a resident's dietary preference by serving fish during a meal, despite clear instructions to avoid fish. The resident, who was admitted with diagnoses including muscle weakness and failure to thrive, had a meal ticket indicating a preference for no fish at both lunch and dinner. On February 27, 2025, during a tray line observation, it was noted that a slice of fish was placed on the resident's tray, contrary to the stated preference. The dietary manager acknowledged that serving food against the resident's preferences could upset the resident and potentially lead to reduced food intake. The facility's policy on resident food preferences, dated July 2017, emphasizes the importance of assessing and communicating individual food preferences to ensure resident satisfaction.
Failure to Post EBP Signage for Residents
Penalty
Summary
The facility failed to ensure that the required Personal Protective Equipment (PPE) usage was clearly indicated before entering rooms of residents on Enhanced Barrier Precautions (EBP). This deficiency was identified through observation, interview, and record review, revealing that rooms of residents on EBP did not have the necessary signage posted by the door. Specifically, residents with conditions such as wounds, indwelling devices, or those undergoing dialysis were placed on EBP, but there was no signage to inform staff and visitors of the necessary isolation precautions and protective equipment required to prevent the spread of infection. During interviews, a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN) confirmed that Resident 7, who had a wound on the right foot, was on EBP, yet there was no signage indicating the required PPE or specific precautions. The Infection Preventionist (IP) also acknowledged that EBP signage should have been posted for the rooms of Residents 4, 6, 7, 8, 18, 21, and 37. The facility's policy and procedure on infection control, dated October 2022, indicated that Enhanced Barrier Precautions are designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes, but this protocol was not followed as required.
Failure to Conduct Timely Neuro Checks After Resident Fall
Penalty
Summary
The facility failed to conduct and complete neurological assessments for a resident following an unwitnessed fall. On January 16, 2025, a resident was found lying face down on the floor next to her bed, with a small pinkish discolored area on her right forehead, and she complained of right shoulder discomfort and nausea. Despite the resident's history of muscle weakness and falling, and being on blood-thinning medication, the required neuro checks were not performed as per the facility's protocol. Licensed Vocational Nurse (LVN 1) initially stated that neuro checks would be initiated every 15 minutes for the first hour, every 30 minutes for the second hour, and then every four hours for 24 hours. However, the neurological assessment was not completed as required, with no assessment of the resident's pupil response and other neurological functions after 9:55 a.m. The LVN was observed attending to other duties and did not return to reassess the resident, and the responsibility was later transferred to Registered Nurse (RN 1), who also did not conduct the necessary assessments. The Director of Nursing (DON) confirmed that the facility's protocol for neuro checks was not followed, and there was no written policy specifically for neuro checks. The DON acknowledged the importance of these assessments to ensure residents do not experience an altered level of consciousness or sustain additional injuries after a fall. The failure to conduct timely and complete neuro checks for the resident, who was at increased risk due to blood-thinning medication, was a significant deficiency in the facility's care protocol.
Failure to Develop Care Plans for Marijuana Use
Penalty
Summary
The facility failed to develop care plans addressing the use of marijuana for two residents, which was identified during a survey. Resident 1, who was admitted with diagnoses including embolism and thrombosis, was found outside the facility feeling unwell and reported using marijuana. Despite this incident, no care plan was initiated to address the marijuana use or the resident's reported symptoms. The Director of Nursing confirmed that the charge nurse did not initiate a care plan for Resident 1's marijuana use, which should have included interventions for monitoring the resident's safety. Similarly, Resident 2, admitted with asthma, was found unresponsive in a wheelchair and later confirmed to have used marijuana. Despite a positive drug screen for marijuana at a general acute care hospital, no care plan was initiated to address this new condition. The Director of Nursing acknowledged that a care plan should have been developed to monitor for adverse effects. The facility's policy requires comprehensive, person-centered care plans to be developed and revised as residents' conditions change, which was not adhered to in these cases.
Failure to Monitor Change in Condition
Penalty
Summary
The facility failed to assess and monitor a change in condition for a resident, which had the potential to delay necessary treatment. On October 25, 2024, the Maintenance Supervisor heard the resident expressing feelings of having a stroke and assisted her into the facility, notifying the nursing staff. Despite the resident's cognitive intactness and her history of embolism and thrombosis, there was no follow-up or monitoring conducted by the nursing staff. The resident had also reported using marijuana, which was not documented or addressed in her care plan. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) revealed that the RN did not assess the resident, notify the physician, or update the care plan as required by the facility's policy. The DON was unaware of the incident, indicating a lack of communication and adherence to the facility's Change of Condition policy. The policy mandates prompt notification of the physician and detailed documentation when there is a significant change in a resident's condition, which was not followed in this case.
Medication Order Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents' admission orders included all current medications and correct dosages for two residents. Resident 4's admission order for Sertraline, an anti-depressant medication, had an incorrect dosage. The resident was receiving 100 mg twice per day at the General Acute Care Hospital (GACH) but was ordered 100 mg once per day at the facility. This discrepancy led to Resident 4 receiving an incorrect dose of Sertraline on September 6, 2024. Additionally, Resident 5's admission orders did not include her asthma medications, specifically the Symbicort and albuterol inhalers, which were listed on her GACH Discharge Medications list. The facility's Director of Nursing (DON) confirmed that the admission nurse is responsible for reviewing the GACH discharge medication list and obtaining physician orders for the medications. However, Resident 5 did not receive physician orders for her asthma medications upon admission, which was a failure to adhere to the facility's policy and procedure for medication therapy.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in common areas and resident bedrooms. During an unannounced visit, multiple residents reported and were observed to be affected by the flies. One resident, who had a diagnosis of cerebral infarction and was cognitively intact, mentioned an increase in flies and was seen swatting at them. Another resident, also cognitively intact, reported flies in his bedroom, stating they were everywhere. A third resident, with moderate cognitive impairment and a diagnosis of pituitary gland cancer, was observed with flies hovering around her face, which had a necrotic area. The facility's maintenance supervisor and director of staff development confirmed that fly traps had been removed from the facility approximately one month prior, leading to an increase in flies. The administrator revealed that the facility had not been contracted with a pest control company since April 2024 due to corporate confusion and non-payment. Although the corporate office sent a maintenance crew monthly to treat for other insects, no treatments for interior flies were provided. The facility's pest control policy, revised in May 2008, stated that the facility should maintain an ongoing pest control program to ensure the building is free of insects and rodents, which was not adhered to in this case.
Delayed Reporting of Alleged Abuse and Unauthorized Medication Administration
Penalty
Summary
The facility failed to report alleged abuse involving three residents to the California Department of Public Health (CDPH) immediately or within 24 hours, as required. The incidents involved verbal abuse and unauthorized administration of medication by Certified Nursing Assistants (CNAs). Resident 1 was allegedly verbally abused by a CNA, who shook the resident's bed, antagonized her, and told her to "shut your mouth." Residents 2 and 3 were allegedly given sleeping medicine by a CNA without proper authorization. These allegations were reported to the facility's Administrator, but not to the CDPH or other authorities within the required timeframe. The Administrator received a call on August 28, 2024, regarding the unauthorized administration of medication to Resident 3, but delayed reporting the incident while waiting for a written statement. The written statement, received on August 30, 2024, included allegations involving all three residents and two CNAs. Despite this, the Administrator did not report the allegations to the CDPH until September 4, 2024, believing more proof was needed. This delay in reporting resulted in a delayed investigation and implementation of corrective actions, placing the residents at risk for further abuse.
Improper Storage of Resident's Electric Wheelchair
Penalty
Summary
The facility failed to treat a resident's possessions with respect and dignity, specifically concerning the storage of the resident's electric wheelchair. During an unannounced visit, it was observed that the electric wheelchair was stored in the maintenance/supply office without any protective cover. Additionally, a large roll of silver window insulation, which belonged to the facility, was placed on top of the wheelchair. This improper storage method had the potential to damage the wheelchair. Interviews with the Maintenance Supervisor and the Director of Nursing confirmed the improper storage practices. The Maintenance Supervisor acknowledged that the wheelchair was not covered and that the insulation roll was not the resident's property. The Director of Nursing expressed that she would expect the wheelchair to be protected and free from facility belongings being placed on it, acknowledging that the current state was disrespectful. The facility's policy on resident rights, which emphasizes treating residents with respect and dignity, was not adhered to in this instance.
Failure to Accommodate Resident's Transfer and Seating Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of Resident 2, who relies on staff for transfers using a Hoyer lift and prefers an electric Hoyer lift for safety and comfort. However, both electric Hoyer lifts in the facility were unavailable due to dead batteries, leaving only a manual lift for use. This situation led to Resident 2 refusing showers in the past when the electric lift was not available. Additionally, Resident 2 prefers to sit in a large Geri-chair when out of bed, but the facility only has one such chair, which is shared among multiple residents, making it unavailable for Resident 2's exclusive use. Resident 2, who was admitted with a diagnosis of left-sided muscle weakness following a cerebral infarction, was observed lying in bed with a disheveled appearance, indicating a lack of proper accommodation for his needs. Interviews with facility staff, including the Maintenance Supervisor, CNA, DON, and Administrator, confirmed the unavailability of the electric Hoyer lifts and the shared use of the Geri-chair. The facility's policy on resident rights emphasizes treating residents with dignity and supporting their care preferences, which was not upheld in this case.
Failure to Coordinate Cardiology Care for Resident with Atrial Fibrillation
Penalty
Summary
The facility failed to coordinate cardiology specialty care for a resident who was diagnosed with atrial fibrillation during a hospital admission. After returning to the facility, the resident requested the Director of Nursing (DON) to notify the physician about the need for a cardiology follow-up. Despite reminders, the resident was not informed of any cardiology appointments. A review of the resident's records from May 4, 2024, to July 1, 2024, showed no documentation of a cardiology consultation. Interviews with the DON and the facility physician (FP) revealed that the FP saw the resident two days after hospital discharge and prescribed Eliquis, but there was no follow-up care with cardiology ordered. The FP stated that the licensed nurses should have followed up with him and that the resident should have been seen by cardiology within a month of discharge. The facility's policies on physician visits and changes in a resident's condition emphasize timely physician visits and prompt notification of significant changes, which were not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors when the prescribed antibiotic, Augmentin, was not administered as ordered. Resident 1, who was admitted with chronic obstructive pulmonary disease, did not receive her Augmentin on three occasions due to the medication being unavailable. The medication was supposed to be administered every 8 hours for 7 days, but it was not given on the night of June 6 and twice on June 7. The Licensed Vocational Nurse confirmed that the medication was not administered because it was not available, and the initials on the Medication Administration Record were circled to indicate this. Similarly, Resident 3, who was admitted with diabetes and a urinary tract infection, did not receive Augmentin on two occasions. The medication was ordered to be given three times a day for 10 days, but it was unavailable on June 6 at noon and 10 p.m. The Pharmacist and Registered Nurse indicated that the medication should have been retrieved from the emergency kit while waiting for delivery. The Director of Nursing stated that if the emergency kit does not contain the needed medication, the licensed nurse should notify the physician or obtain a new order. The facility's policy requires medications to be administered within one hour of their prescribed time, and any deviations should be documented in the Medication Administration Record.
Failure to Follow Prescribed Diet Orders for Diabetic Residents
Penalty
Summary
The facility failed to adhere to the prescribed diet orders for two residents, both diagnosed with type 2 diabetes mellitus, during a lunch meal service. On July 1, 2024, Resident 2 was served cheesecake with cherry topping instead of the lemon pound cake specified in their diet order. The resident's physician had ordered a diet of no added salt, low concentrated sweets, and pureed food. The dietary supervisor confirmed that the dessert served was incorrect and did not align with the carbohydrate-restricted diet ordered by the physician. Similarly, Resident 3, who was also on a low concentrated sweets, no added salt, and mechanical soft diet, received the same incorrect dessert of cheesecake with cherry topping. The resident expressed that they regularly received inappropriate desserts and had previously informed the staff. The dietary supervisor acknowledged the error, stating that the dietary staff should have followed the diet spreadsheet and physician's order, which specified lemon pound cake for the resident. Interviews with the Director of Nursing and a review of the facility's policies highlighted that the dietary department failed to follow the physician's orders as required. The facility's policy on therapeutic diets emphasizes the importance of adhering to physician-prescribed diets to support residents' treatment plans. The failure to provide the correct diet had the potential to compromise the nutritional and medical condition of the residents involved.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that the required 80 square feet per resident in multi-resident bedrooms was met for 8 out of 18 rooms. During an unannounced visit, it was observed that rooms 5 through 12 each measured 239 square feet and housed three residents, providing only 79.6 square feet per resident, which is below the required standard. Interviews with residents and staff revealed that while some residents expressed concerns about room size affecting their ability to navigate or store belongings, staff did not report difficulties in providing care due to room size. The Director of Nursing was unaware of the minimum square footage requirements, and the facility's policy stated that rooms should meet federal and state requirements for space per resident. The Administrator confirmed that the rooms in question did not meet the required square footage per resident, as outlined in the facility's policy. Despite this, there were no complaints from residents or staff about inadequate living space or care provision issues due to room size. The facility's policy, revised in May 2017, mandates that bedrooms measure at least 80 square feet per resident in double rooms and 100 square feet in single rooms, which was not adhered to in the identified rooms.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice to a resident regarding a pending room change, which is a violation of the resident's rights. The resident, who was cognitively intact with a Brief Interview of Mental Status score of 15, was informed verbally about the room change to accommodate another admission. The resident expressed dissatisfaction with the change, stating a preference for the previous room and indicating that she does not 'react well' to such changes. The facility's policy requires advance notice and documentation of room changes, including written notice to the resident or their representative. However, the Director of Nursing (DON) confirmed that the facility's practice was to verbally notify residents without providing written notice. This lack of written communication was evident in the resident's medical records, which did not contain any documentation of a written notice for the room change.
Facility Fails to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain room temperatures within the required range of 71 to 81 degrees Fahrenheit, resulting in discomfort for residents and potential health risks. During an unannounced visit, it was observed that three out of six sampled resident rooms had temperatures exceeding the maximum limit, with one room reaching 84.7 degrees Fahrenheit. This deficiency was confirmed through observations, interviews, and temperature checks conducted by the Maintenance Supervisor using a handheld laser thermometer. Two residents were directly affected by the excessive heat. One resident, who was cognitively intact and had a history of cellulitis, hemiplegia, and hemiparesis, was found perspiring in his room with a small fan running. He expressed discomfort due to the heat, particularly in the morning when the sun shone directly into his room. Another resident, also cognitively intact and with a history of ventricular tachycardia, COPD, and heart failure, reported feeling too hot and having difficulty sleeping due to the high temperatures. The facility's Maintenance Supervisor indicated that the air conditioning system was functioning properly and that additional measures, such as sprinklers on the roof and industrial fans in the hallways, were in place to manage the heat. However, the facility's Administrator acknowledged that the temperatures in some rooms and the main hallway exceeded the acceptable range. The facility's policies and procedures emphasized maintaining a homelike environment with comfortable and safe temperatures, but the observed conditions did not align with these standards.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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