Buena Vista Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 1440 S Euclid Avenue, Anaheim, California 92802
- CMS Provider Number
- 055459
- Inspections on file
- 25
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Buena Vista Care Center during CMS and state inspections, most recent first.
A resident reported experiencing verbal and physical abuse from a roommate, but the facility's investigation did not include an interview with the roommate involved. Instead, only the reporting resident and another resident were interviewed, as the SSD was instructed by the Administrator to limit the interviews. This omission resulted in an incomplete investigation of the abuse allegation.
A resident with diabetic ulcers did not receive the prescribed wound care as an LVN used Gentell wound cleanser instead of the ordered normal saline. The DON confirmed that treatments should follow physician orders and any changes should be clarified.
A facility failed to implement a physician's order for bilateral floor mats for a resident at high risk for falls. Observations revealed that only one floor mat was placed, contrary to the care plan. Staff interviews confirmed the oversight, acknowledging the resident's fall risk and the need for proper fall prevention measures.
A facility failed to consistently provide non-pharmacological pain interventions before administering acetaminophen to a resident, as required by their policy. The resident, unable to make decisions, had orders for pain monitoring and non-drug interventions, but the MAR lacked documentation of these interventions on several occasions. The DON confirmed the findings and acknowledged the expectation for nurses to document non-drug interventions before medication administration.
A resident with diabetic foot ulcers did not receive an alternating pressure pad as recommended by the Wound Consultant. The facility lacked a physician's order for the pad, and the resident's medical record did not document its use. Interviews revealed that the facility did not have the pads, and the LVN did not clarify the recommendation. The Wound Consultant expected the facility to follow his recommendations or inform him if the equipment was unavailable.
A facility failed to document attempts to schedule a vascular consult for a resident with Type 2 Diabetes Mellitus, as required by their policy. Despite receiving a physician's order, RN 1 did not record her efforts to secure an appointment or her communication with a Nurse Practitioner about the delay. The DON confirmed the lack of documentation.
A survey revealed multiple food safety and sanitation deficiencies in an LTC facility, including unmonitored cool down processes for TCS foods, unsanitized food preparation surfaces, and unwashed produce. Staff failed to follow proper hygiene practices, such as changing gloves and covering facial hair, and personal items were found in food prep areas. The kitchen environment was unclean, with structural issues and improperly stored cleaning equipment.
The facility failed to address ongoing complaints from the Resident Council about cold meals, despite repeated assurances from the dietary department to monitor food temperatures and discuss tray delivery with nursing. Observations showed that open tray carts were used instead of available enclosed carts, which could have kept meals warm. Interviews revealed a lack of effective communication and follow-up on the concerns, with several staff members not conducting assigned room rounds or asking residents about food temperatures.
The facility failed to follow prescribed menus for residents on pureed and fortified diets, affecting 20 residents on pureed diets and 27 on fortified diets. Issues included not following recipes, incorrect portion sizes, and undocumented menu substitutions. Additionally, fortified diets lacked required items like Super Soup, indicating lapses in dietary guidelines adherence.
The facility failed to follow infection control practices, affecting several residents and areas. A resident's bedside commode was not emptied regularly, causing a strong urine odor. Another resident's flush syringe touched a blanket, and an RN fanned an uncapped IV port with her hand. Infection control logs were inaccurate, and the laundry area had multiple concerns. Staff did not adhere to hand hygiene protocols, and a resident's urinary catheter bag was touching the floor. These failures risked contamination and disease transmission.
The facility failed to maintain the ice machine in safe operating conditions, as it was not cleaned and sanitized per manufacturer's instructions, and lacked an air gap to prevent backflow. The MS used an unauthorized cleaner and did not follow proper cleaning procedures, while the RD was instructed not to inspect the internal components. These deficiencies posed a potential risk to the 84 residents consuming food prepared in the kitchen.
Two residents were found self-administering medications without proper authorization or assessment. One resident, cognitively intact, had Nerve Shield Pro at the bedside without a physician's order. Another resident, with moderate cognitive impairment, had Tums tablets without documented assessment for self-administration. The facility's policy requires an interdisciplinary team assessment and care plan, which were absent in both cases.
A facility failed to develop comprehensive care plans for two residents. One resident's care plan did not address the use of a bedside commode, leading to persistent urine odor issues. Another resident's care plan failed to address psychosocial needs and did not document non-pharmacological interventions for behaviors associated with risperidone use. These deficiencies risked the residents not receiving person-centered services tailored to their needs.
Two residents in a facility were not provided with activities that met their specific needs, risking their psychosocial well-being. One resident, with developmental delay and psychosis, was not engaged in activities aligned with his interests, such as exercising and reading, due to inadequate assessment by the Activities Director. Another resident, who is blind, expressed a desire for more interaction and involvement with the Braille Institute, but the facility did not facilitate this. The activities provided were limited to room visits and listening to music.
The facility failed to securely store razors, posing a risk to two residents with cognitive impairments. An opened pack of razors was found in their bedside drawers, contrary to the facility's policy that sharp objects should be stored in the supply room. Staff interviews confirmed the oversight, and the DON verified the findings.
A facility failed to maintain proper IV access care for a resident by not labeling the IV catheter site with the required date, time, and staff initials. This was observed during a survey, and an RN confirmed the oversight. The facility's policy mandates such labeling, which was not followed in this instance.
The facility failed to follow physician's orders for oxygen therapy for two residents, with one receiving incorrect oxygen flow and another having undated oxygen tubing. These deficiencies were confirmed by nursing staff and acknowledged by the DON.
The facility failed to follow pharmaceutical procedures for two residents. One resident's Percocet was removed but not documented as administered, while another resident had medications at bedside without a physician's order or assessment for self-administration. Interviews confirmed these discrepancies.
The facility failed to document non-pharmacological interventions for a resident on risperidone and did not obtain a baseline valproic acid level for another resident. Additionally, a resident with diabetes had a change in skin condition that was observed but not documented by an LVN. These deficiencies posed a risk of inadequate monitoring.
A facility failed to properly monitor a resident's orthostatic blood pressures as ordered for olanzapine use, resulting in identical readings for lying, sitting, and standing positions. Staff interviews confirmed that blood pressures were copied rather than measured separately, contrary to physician orders and facility policy.
The facility's medication error rate was 7.69%, exceeding the acceptable limit of 5%. An LVN failed to administer medications as ordered to a resident, specifically not providing metformin with meals and omitting cholecalciferol. This was confirmed through observation and interview.
The facility failed to remove expired medications from Medication Cart C and did not store internal and external medications separately. Expired wound care products were found on the cart, and suppositories were stored alongside liquid medications due to space constraints. An LVN and the Central Supply Designee confirmed these findings, which could negatively impact residents' well-being.
The facility failed to ensure the CDM was competent in managing food services and the RD did not provide adequate oversight, potentially jeopardizing the health of 84 residents. During a survey, issues such as improper food handling, unsanitized surfaces, and non-compliance with dietary requirements were found. The RD was unaware of these issues despite performing monthly audits.
The facility failed to preserve the nutritive value of pureed vegetables by preparing them two hours before meal service and holding them on a hot steam table. This was observed when a staff member boiled and blended green beans, then held them at an inappropriate temperature, potentially affecting the nutritional needs of residents on a pureed diet. The RD confirmed that recipes should be followed, highlighting a deviation from the facility's guidelines.
The facility failed to provide 20 residents on mechanically altered diets with the appropriate form of ground meat, serving 1/2 inch chopped chicken instead of the required 1/8 inch ground meat. This discrepancy was observed during a meal service, and the Registered Dietitian confirmed that the facility's dietary protocols were not followed.
The facility failed to maintain accurate medical records for several residents, including incorrect documentation of blood pressure access for a resident on hemodialysis, incomplete treatment administration records for another resident, and an incomplete POLST form for a deceased resident. Additionally, informed consent forms for medications were not properly corrected or updated, leading to potential care issues.
The facility failed to maintain a pest-free kitchen environment, as flies were observed near the lunch meal tray line. Despite a pest control policy and multiple maintenance requests for a screen door, the back kitchen door remained open due to heat, allowing flies to enter. The CDM, DM, and Administrator were aware of the issue, but no effective solution had been implemented.
A resident with a Foley catheter was observed without a dignity bag covering the urinary drainage bag, contrary to the facility's policy on dignity. The resident, who was cognitively intact, had a physician's order for the catheter due to obstructive uropathy. An RN confirmed the lack of a dignity bag, and the DON acknowledged the deficiency.
A resident in a LTC facility was found shivering and wearing a hooded jacket due to a cold room temperature, which was verified to be below the required range by both RN 1 and the Maintenance Director. The facility's policy mandates maintaining ambient temperatures between 71 to 81 degrees Fahrenheit, but the resident's room was recorded at 68.9 degrees Fahrenheit, indicating a failure to provide a comfortable environment.
The facility did not update the care plans for two residents after their Covid-19 symptoms resolved and they were no longer on antibiotics. This oversight was confirmed during a review with an RN, posing a risk of not providing individualized care.
A facility failed to provide a sack lunch to a resident during dialysis days, despite a medical order. The resident, who was cognitively intact, reported not receiving the lunch. RN 2 confirmed the order but lacked documentation that the dietary department was informed, posing a risk for medical complications.
Failure to Interview All Involved Parties in Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving one of five sampled residents. According to the facility's policy, all allegations of abuse are to be thoroughly investigated. In this case, a resident reported experiencing problems with other residents, including verbal abuse and physical altercations, and specifically mentioned issues with a particular roommate. The facility's investigation included interviews with the reporting resident and another resident, but did not include an interview with the roommate who was directly mentioned in the allegation. The Social Services Director (SSD), who was responsible for conducting resident interviews, confirmed that she did not interview the roommate because she was instructed by the Administrator to only interview another resident. The Administrator acknowledged that the omission occurred because they had previously spoken to the roommate about compatibility issues and overlooked the need to include him in the current investigation. As a result, the investigation did not fully address the concerns raised in the abuse allegation.
Failure to Administer Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide the necessary wound care treatments for a resident's left foot wounds as ordered by the physician. The resident, who had a diagnosis of Type 2 Diabetes Mellitus with other diabetic kidney complications, was observed not receiving the prescribed care. The physician's orders specified that the resident's left mid to lateral foot diabetic ulcer and left 5th metatarsal head diabetic ulcer should be cleansed with normal saline, followed by the application of Betadine, an ABD pad, and secured with a kerlix roll of gauze every day during the day shifts for 14 days. However, during a wound care observation, an LVN was seen using Gentell wound cleanser spray instead of the ordered normal saline to cleanse the resident's wounds. The LVN acknowledged the discrepancy and confirmed that the Gentell wound cleanser and normal saline were not the same. The Director of Nursing (DON) also confirmed that the licensed nurses were expected to administer treatments as ordered by the physician and that any deviation should be clarified with the physician. The DON was informed of these findings and acknowledged the issue.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement the physician's order and plan of care for a resident who was at high risk for falls and had a history of falls with injuries. Specifically, the facility did not place bilateral floor mats as ordered by the physician to prevent falls while the resident was in bed. The resident's medical records indicated a physician's order dated 9/12/24, which required the use of bilateral floor mats for fall management. However, during observations on 12/23/24, it was noted that the resident only had a floor mat on the left side of the bed, contrary to the physician's order. Interviews with facility staff, including a CNA and the DSD, confirmed the absence of the floor mat on the right side of the resident's bed. The CNA acknowledged the resident's fall risk and the potential for the resident to attempt to get out of bed unassisted. The DSD verified that the resident should have had bilateral floor mats as per the physician's order to mitigate injuries in the event of a fall. The DON was also informed and acknowledged the findings, confirming the deficiency in implementing the fall prevention plan as ordered.
Inconsistent Pain Management Practices
Penalty
Summary
The facility failed to provide consistent non-pharmacological pain interventions for a resident before administering acetaminophen, as required by their policy. The policy, revised in October 2022, stated that non-pharmacological interventions should be considered either alone or alongside medications to manage pain. However, the medical administration record (MAR) for September 2024 showed that the resident received acetaminophen on several occasions without documented evidence of non-drug interventions being attempted first. The resident, who lacked the capacity to understand and make decisions, had physician orders to monitor pain levels and use non-drug interventions coded from 0 to 10. Despite these orders, the MAR did not reflect any non-pharmacological interventions on specific dates before administering the medication. The Director of Nursing (DON) confirmed these findings during an interview and acknowledged that nurses were expected to document any non-drug interventions attempted prior to administering pain medication.
Failure to Provide Recommended Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of new pressure ulcers and promote the healing of existing pressure injuries for a resident. The resident, who had a diagnosis of Type 2 Diabetes Mellitus and was at risk for developing pressure ulcers, had diabetic foot ulcers and was recommended by the Wound Consultant to use an alternating pressure pad. However, the facility did not provide this equipment, as there was no physician's order for the alternating pressure pad, and the resident's medical record lacked documentation of its use. Interviews with the Central Supply Staff and LVN revealed that the facility did not have the alternating pressure pads, and the LVN did not clarify the recommendation with the Wound Consultant. The Central Supply Staff confirmed that no special mattress was ordered for the resident. The Wound Consultant expected the facility to carry out his recommendations or inform him if the recommended equipment was unavailable. The Director of Nursing was informed and acknowledged the findings.
Incomplete Documentation of Vascular Consult for Resident
Penalty
Summary
The facility failed to ensure the medical record for a resident was complete and accurate, specifically regarding the documentation of attempts to obtain and schedule a vascular consult. The facility's policy and procedure for charting and documentation require that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. However, the medical record for a resident with a diagnosis of Type 2 Diabetes Mellitus did not include documentation of a physician's order for a vascular consultation being carried out. Interviews with the Medical Record Director and the DON revealed that the responsibility for carrying out the physician's order for the vascular consult fell on the nurses, specifically RN 1. RN 1 acknowledged receiving the order and attempting to schedule the consult, but the earliest available appointment was two to three months away. RN 1 informed a Nurse Practitioner of the situation but failed to document these attempts and communications in the resident's medical record. The DON confirmed the absence of documentation, acknowledging the findings.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by multiple deficiencies observed during a survey. The cool down process for time and temperature control for safety (TCS) foods was not monitored, with staff failing to keep a cooling log to ensure proper temperature control. This was confirmed through interviews with kitchen staff and the Certified Dietary Manager (CDM), who acknowledged the absence of a cool down log. Additionally, food preparation surfaces were not sanitized according to the USDA Food Code, with staff using soiled cloths and failing to use the sanitizing spray correctly. The Infection Preventionist (IP) and CDM were unaware of the proper sanitizing procedures, indicating a lack of training and oversight. Further observations revealed that fresh produce, such as lettuce, was not washed before use, contrary to the facility's policy. The CDM confirmed that the lettuce was not pre-washed by the supplier, yet salads were prepared using the unwashed lettuce. Manual dishwashing procedures were also inadequate, with no sanitizing solution or test strips available for use in emergencies. Staff were not trained in the proper manual dishwashing process, and the CDM admitted to a lack of a contingency plan if the dish machine failed. Additional hygiene and safety violations included improper glove use, with staff failing to wash hands or change gloves between tasks, and uncovered facial hair in the kitchen area. Personal items, such as drinking containers, were found in the food preparation area, and staff wore inappropriate jewelry and artificial nails during food preparation. The kitchen environment was not maintained in a clean or functional state, with dirty utensils, equipment, and structural issues such as cracked walls and bulging ceilings. Cleaning equipment was stored unsanitarily, and a food preparation sink lacked backflow prevention, posing further risks to food safety.
Facility Fails to Address Resident Council's Concerns About Cold Meals
Penalty
Summary
The facility failed to effectively address the repeated concerns of cold food raised by the Resident Council over several months. Despite the dietary department's responses to monitor food temperatures and discuss tray delivery with the nursing staff, the issue persisted. The Resident Council minutes from November 2023 to October 2024 consistently documented complaints about cold meals, with the dietary department's responses remaining largely unchanged, focusing on monitoring temperatures and discussing delivery speed with nursing. Observations and interviews revealed that the facility used open tray carts for meal delivery, which did not adequately maintain food temperatures. The Certified Dietary Manager (CDM) acknowledged that enclosed tray carts, which could help keep meals warm, were available but not used due to the time it took to load them. This decision was made despite the ongoing complaints and the availability of the enclosed carts, which were intended to address the temperature issue. Interviews with various staff members, including the Administrator, Director of Nursing (DON), and other department heads, indicated a lack of effective communication and follow-up on the Resident Council's concerns. The Administrator was unaware that open carts were being used, and the DON confirmed that the tool used for room rounds did not include questions about dietary concerns. Additionally, several staff members admitted to not conducting their assigned room rounds or not asking residents about food temperatures, further contributing to the facility's failure to address the issue adequately.
Failure to Follow Prescribed Diets and Menu Documentation
Penalty
Summary
The facility failed to adhere to the prescribed menus for residents requiring pureed and fortified diets, affecting 20 residents on pureed diets and 27 residents on fortified diets. The deficiencies included not following the standardized recipe for pureed green beans, resulting in an incorrect consistency, and not using the correct portion size for pureed meat, which could potentially impact the nutritional intake of the residents. Additionally, mashed potatoes were omitted from the pureed diet menu without proper documentation or approval from the Registered Dietitian (RD). Further issues were identified with menu substitutions that were not documented or approved by the RD. For instance, applesauce was substituted for pureed pound cake without recording the change or obtaining necessary approvals. This lack of adherence to the facility's policy on menu changes and substitutions indicates a failure to ensure that residents' nutritional needs were consistently met. The facility also did not comply with the requirements for fortified diets, as evidenced by the absence of Super Soup in the meals of residents on fortified/high protein diets. The Therapeutic Spreadsheets specified that Super Soup should be included, but it was not prepared or served, which was confirmed by the staff. These failures highlight significant lapses in following dietary guidelines and ensuring the nutritional adequacy of meals provided to residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices, impacting both sampled and nonsampled residents. Resident 41's bedside commode was not regularly emptied, leading to a strong urine odor in the hallway. The commode was found with a plastic bag half-filled with urine, and a towel on the floor was stained with yellow marks. Despite the expectation for staff to empty the commode every two hours, this was not consistently done, and there was no care plan addressing the use of the bedside commode. Additionally, Resident 61's flush syringe came into contact with a blanket, and the RN fanned the uncapped IV port with her hand, both actions contrary to infection control protocols. The facility's infection control surveillance logs were inaccurate, with discrepancies noted in the documentation of infections that met McGeer's criteria. The laundry area presented multiple infection control concerns, including the storage of dirty linens in uncovered bins, lack of an eye wash station, and improper storage of clean items in the dirty laundry area. The decorative fountain was not monitored for Legionella, and the sit-to-stand device had a non-cleanable surface due to duct tape covering a ripped area. Staff failed to follow hand hygiene protocols, as observed with CNAs and LVNs not washing hands before and after medication administration or after removing gloves. Resident 33, on enhanced barrier precautions, did not receive care with the required gloves and gown. Resident 75's urinary catheter bag was observed touching the floor, and Resident 791's water pitcher had a dark yellow buildup and was unlabeled. These failures posed a risk of contamination and transmission of communicable diseases within the facility.
Ice Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain essential equipment, specifically the ice machine, in safe operating conditions. During an observation and interview, it was found that the ice machine was not cleaned and sanitized according to the manufacturer's instructions. The Maintenance Staff (MS) admitted to cleaning the ice machine once a month, but upon inspection, black residue was found on the internal components, indicating inadequate cleaning. The MS also used a non-Manitowoc product, Nu Calgon Cleaner, which was not recommended by the manufacturer, and did not follow the specified cleaning procedure. Additionally, the ice storage bin lacked an air gap to prevent backflow, as the drainage pipe was directly connected to the sewer line. The MS confirmed the absence of an air gap and incorrectly believed it was unnecessary. The Registered Dietitian (RD) also noted that she was instructed by the MS not to inspect the internal components of the ice machine, further indicating a lack of proper oversight and adherence to safety protocols. These deficiencies were observed in a facility where 84 residents consumed food prepared in the kitchen, posing a potential risk of contamination and illness. The facility's policies and procedures, as well as the USDA Food Code, require that equipment and food-contact surfaces be clean to sight and touch, which was not adhered to in this case.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure safe self-administration of medications for two residents. Resident 69, who was cognitively intact with a BIMS score of 15, was found with two bottles of Nerve Shield Pro at the bedside, one of which was empty. The resident admitted to self-administering the supplement, which was brought by a family member, without a physician's order or documented assessment for self-administration. The facility's policy requires an interdisciplinary team assessment and a care plan for residents to self-administer medications, none of which were present in Resident 69's medical record. Similarly, Resident 35, with a BIMS score of 12 indicating moderate cognitive impairment, was observed with Tums tablets on the overbed table. The resident reported taking the medication for stomach pain, but there was no physician's order or documented assessment for self-administration. The nursing staff confirmed the absence of necessary documentation and acknowledged that medications should not be left at the bedside without proper authorization and assessment. These oversights were verified by the Director of Nursing, highlighting a lapse in adherence to the facility's medication administration policies.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 41 and Resident 67. For Resident 41, the care plan did not address the use of a bedside commode, which led to a persistent urine odor in the hallway. Observations revealed that the bedside commode was not emptied regularly, and a towel with yellow stains was used by the resident due to difficulties in self-transferring. The staff, including CNA 1, acknowledged the odor issue but did not have a clear protocol for addressing it. Medical records confirmed that Resident 41 was sometimes continent and sometimes incontinent, yet there was no care plan to address her specific toileting needs. For Resident 67, the care plan failed to address psychosocial needs and did not document non-pharmacological interventions for behaviors associated with risperidone use. Resident 67, who has developmental delay and psychosis, was observed repeatedly expressing a desire to go to the gym, which disturbed his roommate. The medical record showed that risperidone was administered for aggressive behavior, but there was no documentation of non-pharmacological interventions. Interviews with staff, including RN 1 and the DON, confirmed the lack of documentation and the absence of a care plan that included activities such as attending a day program, which was part of Resident 67's routine prior to admission. These deficiencies posed a risk of the residents not receiving person-centered services tailored to their specific needs. The lack of a comprehensive care plan for both residents highlights the facility's failure to address essential aspects of their care, potentially impacting their quality of life and well-being.
Deficiency in Resident Activity Programs
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the specific needs of two residents, which risked not supporting their psychosocial well-being. Resident 67, who has developmental delay and psychosis, expressed a desire to go to the gym and was observed to be in a confused, child-like state. The Activities Director did not assess Resident 67's activity needs adequately, as she did not contact the previous day program where Resident 67 participated in various activities such as reading, writing, and exercising. Instead, Resident 67's activities were limited to staying in his room, looking at family pictures, and family visits, which did not align with his interests and capabilities. Resident 66, who is blind, reported a lack of staff interaction and expressed interest in re-engaging with the Braille Institute, where he was previously involved. The Activities Director did not contact any agencies like the Braille Institute to provide activities suitable for Resident 66. Instead, his activities were limited to listening to music and family visits. This lack of tailored activities for both residents indicates a deficiency in the facility's ability to meet the specific needs of its residents, potentially affecting their psychosocial well-being.
Failure to Securely Store Razors Poses Risk to Residents
Penalty
Summary
The facility failed to ensure that razors were stored securely, leading to a potential accident hazard for two residents. During an observation, an opened pack of razors was found in the bedside drawers of two residents, who were identified as having cognitive impairments. One resident was noted to have no capacity to understand and make decisions, while the other was oriented only to self and exhibited confusion. This oversight was confirmed by a Certified Nursing Assistant (CNA), who acknowledged the presence of the razors and removed them from the bedside. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), revealed that the razors were supposed to be stored in the supply room and not left at the bedside. The Director of Nursing (DON) was informed of the findings and verified the deficiency. The facility's policy and procedure for safety and injury prevention indicated that sharp objects should be put away when not in use, which was not adhered to in this instance.
Failure to Label IV Catheter Site
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the IV access for a resident, identified as Resident 66, who was reviewed for IV care. The deficiency was observed when the IV catheter site for Resident 66 was found unlabeled, lacking the required date, time, and staff initials on the dressing label. This observation was made during a survey on 10/29/24, when Resident 66 was seen in bed with the unlabeled IV site. The facility's policy and procedure for Peripheral Venous Catheter Insertion, dated March 2023, mandates that IV sites should be labeled with the date, time, and initials. An interview with RN 1 confirmed the oversight, as RN 1 verified that the IV site was not labeled as per the facility's policy. Resident 66 was admitted to the facility with a diagnosis including a urinary tract infection (UTI).
Failure to Follow Oxygen Therapy Orders and Equipment Protocols
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen therapy for two residents, leading to potential inadequacies in respiratory care. For Resident 83, the oxygen concentrator was set at 4 liters per minute, contrary to the physician's order of 2 liters per minute via nasal cannula continuously every shift. This discrepancy was confirmed by both LVN 6 and RN 2 during observations and interviews. Resident 83, who has the capacity to understand and make decisions, was observed with the incorrect oxygen setting on two separate occasions. For Resident 1, the facility did not ensure that the oxygen tubing was dated as required by the facility's policy. The oxygen tubing bag was dated 10/21/24, but the tubing itself was not dated, and it should have been changed on 10/28/24. Resident 1, who is moderately cognitively impaired and lacks the capacity to make decisions, was observed receiving oxygen at 2 liters per minute via nasal cannula. RN 2 confirmed the oversight regarding the undated tubing during an interview. The Director of Nursing acknowledged these findings.
Pharmaceutical Procedure Failures in LTC Facility
Penalty
Summary
The facility failed to ensure proper pharmaceutical procedures were followed for two residents. For one resident, Percocet, an opioid-based pain reliever, was removed from the supply on six occasions but was not documented as administered in the Medication Administration Record (MAR). This discrepancy was confirmed during an interview with an LVN, who acknowledged that the medication was signed out from the controlled drug record but not recorded as administered in the MAR. Another resident was observed with medications at their bedside without a physician's order, assessment, or care plan for self-administration. The resident had a BIMS score indicating moderate cognitive impairment and was found with Tums tablets on their overbed table. Interviews with RNs revealed that no medication should be left at the bedside and that the facility had not assessed the resident for self-administration. Additionally, there was no documented physician's order for the Tums, although there was an order for a different medication for upset stomach.
Deficiencies in Medication Monitoring and Documentation
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were documented for a resident receiving risperidone, and there was no clear indication for the use of this medication. The resident, who had developmental delay and psychosis, exhibited behaviors such as yelling and whining, particularly when touched by staff. Despite these behaviors, the medical records lacked documentation of any non-pharmacological interventions attempted to manage these behaviors. Additionally, there was no baseline valproic acid level obtained for the resident, who was also receiving valproic acid for epilepsy. Another resident, who was diagnosed with diabetes and blindness, experienced a change in skin condition, specifically purple discoloration on the left upper abdominal area. This change was observed by an LVN but was not documented in the medical records. The LVN was unable to provide an explanation for the lack of documentation regarding the resident's skin condition. These failures in documentation and monitoring posed a risk of inadequate monitoring for the residents involved.
Failure to Monitor Orthostatic Blood Pressure for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs by not properly monitoring orthostatic blood pressures as ordered by the physician for the use of olanzapine. The facility's policy required monitoring for adverse consequences, including cardiovascular effects, but the medical records showed that the resident's blood pressure readings were identical for lying, sitting, and standing positions on multiple occasions. This indicates that the blood pressure was not measured separately for each position as required. Interviews with facility staff, including an LVN and an RN, confirmed that the blood pressure readings were copied rather than taken separately for each position. The staff acknowledged that the blood pressure should change slightly with position changes and that the physician's order to monitor orthostatic hypotension was not followed. The Director of Nursing was informed and acknowledged these findings.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the actual rate being 7.69%. This deficiency was identified through observation, interview, and medical record review. Specifically, the facility did not ensure that LVN 3 administered medications to Resident 75 as ordered. Resident 75 had physician's orders for cholecalciferol 50 mcg to be taken once daily and metformin HCl 500 mg to be taken twice daily with meals. During a medication administration observation, LVN 3 administered metformin without meals and failed to administer cholecalciferol altogether. LVN 3 confirmed in an interview that the medications were not administered as ordered.
Medication Storage Deficiencies Identified
Penalty
Summary
The facility failed to ensure proper medication storage, as evidenced by the presence of expired medications on Medication Cart C. During an inspection, several expired wound care products, including Cutimed Epiona, Manukahd Superlite honey coated absorbent dressing, Hydrogel saturated gauze, Skintegrity Hydrogel impregnated gauze, and Aquaderm hydrogel sheet wound dressing, were found. These items had expiration dates ranging from 2020 to 2024. An LVN confirmed the findings and acknowledged that expired medications should have been removed from the cart, as per the facility's policy and procedure for medication disposal. Additionally, the facility did not adhere to its policy of storing internal and external medications separately. In the medication room, suppositories and liquid medications were stored side by side on the same shelf due to a lack of space. The Central Supply Designee confirmed this storage issue and stated that orally administered medications and suppositories were supposed to be stored separately, as outlined in the facility's policy. These storage failures had the potential to negatively impact residents' well-being and increase the risk of medication errors.
Inadequate Management and Oversight in Food Services Department
Penalty
Summary
The facility failed to ensure that the Certified Dietary Manager (CDM) was competent in managing the day-to-day functions of the food services department, and the Registered Dietitian (RD) did not provide adequate oversight. This lack of competency and oversight had the potential to jeopardize the health and well-being of the 84 residents who consumed food prepared in the kitchen. The facility's documents indicated that the CDM's job description included organizing, planning, and supervising the dietary department functions, while the RD was responsible for providing management tools to enhance the operation of the dietary department. However, during the annual recertification survey, multiple issues were identified, including improper monitoring of time and temperature during the cool down process for TCS foods, unsanitized food preparation surfaces, and inappropriate use of gloves. Additional deficiencies observed during the survey included raw vegetables not being washed prior to service, lack of sanitizing solution for manual ware washing, kitchen employees drinking in food preparation areas, and improper personal hygiene practices such as wearing artificial nails and jewelry. The kitchen environment was found to be unclean, with food preparation equipment and utensils not properly maintained. Furthermore, meal preparation did not adhere to dietary requirements, with incorrect portion sizes and unapproved menu changes. The RD confirmed performing monthly kitchen audits but was unaware of the extent of the issues found during the survey. The findings were confirmed by the Administrator and other facility staff.
Failure to Preserve Nutritive Value of Pureed Vegetables
Penalty
Summary
The facility failed to ensure the nutritive value of pureed vegetables was preserved, as observed during a survey. The deficiency was identified when pureed green beans were prepared two hours before meal service and held on a hot steam table, which could potentially affect the nutritional needs of residents on a pureed diet. The facility's policy and procedure for food preparation emphasized the importance of preserving the nutritive value of vegetables by cooking them in a small amount of water and only until tender. However, during the preparation of lunch, a staff member boiled frozen green beans with water, vegetable broth, garlic, and pepper, then blended them into a liquid consistency. The mixture was thickened and placed on a steam table, where it was held at a temperature of 129 degrees Fahrenheit until the lunch tray line began, at which point the temperature had risen to 207 degrees Fahrenheit. The Registered Dietitian confirmed that all recipes should be followed, indicating a deviation from the established guidelines.
Failure to Provide Properly Prepared Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that 20 residents on mechanically altered diets received the appropriate form of ground meat, as required by their dietary needs. The facility's Diet Manual, revised in August 2023, specified that the Mechanical Soft (Ground) diet should include meat that is ground or chopped to 1/8 inch or less. However, during an observation of the lunch meal tray line, it was noted that chopped chicken approximately 1/2 inch in size was being served to residents on the Mechanical Soft ground diet. This discrepancy was confirmed by a staff member, who initially stated that the chopped chicken was intended for the Mechanical Soft ground diets. Further investigation revealed that the facility's Therapeutic Spreadsheet indicated that residents on Mechanical Soft diets should receive two ounces of ground chicken, while those on Soft Bite Sized diets should receive two ounces of bite-sized chicken. Despite this, the staff member responsible for meal preparation was unaware of the correct dietary requirements and only ground the meat after being prompted. The Registered Dietitian confirmed that the Therapeutic Spreadsheets should be adhered to for all diets, indicating a lapse in following established dietary protocols.
Incomplete and Inaccurate Medical Records in LTC Facility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to potential care issues. For Resident 33, the facility did not accurately document the blood pressure access site, despite having a care plan that specified no blood pressure checks or blood draws on the left upper extremity due to hemodialysis access. The medical records showed multiple instances where blood pressure readings were taken from the left arm, contrary to the care plan. Additionally, there were discrepancies in the documentation of Resident 33's mental capacity, with two different assessments recorded without proper correction or addendum. Resident 60's Treatment Administration Record (TAR) was incomplete, with two instances where the administration of clotrimazole cream was not documented. The Licensed Vocational Nurse (LVN) responsible for the treatment acknowledged the oversight, indicating that the treatment was completed but not recorded in the TAR as required by the facility's policy. For Resident 90, the Physician Orders for Life-Sustaining Treatment (POLST) form was incomplete, failing to indicate whether the resident had an advanced directive. This was despite the availability of an Advanced Healthcare Directive Acknowledgement Form that showed the resident did not have an advanced directive. Additionally, Resident 30's informed consent documentation for Depakote and Olanzapine was inaccurate, with dosage errors and incorrect indications not properly corrected or updated, as per the facility's policies.
Failure to Maintain Pest-Free Kitchen Environment
Penalty
Summary
The facility failed to ensure the kitchen was free from flies, posing a risk for pest contamination of residents' food. The facility's pest control policy, revised in May 2008, mandates an effective pest control program. However, documentation from a pest elimination company showed treatments for ants, roaches, mice, and rats, but did not address flies. Maintenance requests dated 7/6, 8/31, and 10/11/24, indicated a need for a screen door on the dietary and delivery doors to prevent insect entry, which had not been fulfilled. During an observation on 10/31/24, the back door of the kitchen was found open without a screen, allowing flies to enter. The CDM stated the door was left open due to heat and confirmed multiple requests for a screen door. Interviews with the DM and Administrator revealed awareness of the issue, but no effective solution had been implemented. The back door had an air curtain, but it was not effective in preventing flies from entering the kitchen.
Failure to Provide Dignity Bag for Resident's Foley Catheter
Penalty
Summary
The facility failed to ensure that a dignity bag was used to cover the urinary catheter drainage bag for a resident, identified as Resident 75, who was reviewed for Foley catheter care. This oversight was observed during a survey conducted on 10/29/24, where Resident 75 was found lying in bed with the Foley catheter bag attached to the bed without a dignity bag. The facility's policy and procedure on dignity, revised in February 2021, explicitly states that staff are expected to help residents keep urinary catheter bags covered to promote dignity and respect. Resident 75, who was cognitively intact with a BIMS score of 15, had a physician's order for a Foley catheter due to obstructive uropathy. During an interview conducted on the same day as the observation, RN 1 confirmed that all residents with Foley catheters should have a covering on the urinary bag for dignity purposes and verified that Resident 75's catheter bag was uncovered. The Director of Nursing (DON) was informed of these findings on 11/1/24 and acknowledged the deficiency.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable temperature level for Resident 33, which is a violation of the resident's right to a safe, clean, comfortable, and homelike environment. According to the facility's policy and procedure, the ambient temperature in resident areas should be maintained between 71 to 81 degrees Fahrenheit. However, during an initial tour of the facility, Resident 33 was observed wearing a hooded jacket and shivering, indicating discomfort due to the cold room temperature. The resident, who is cognitively intact with a BIMS score of 15, reported that the room temperature was always cold. Further observations and interviews confirmed the deficiency. On a subsequent visit, Resident 33 continued to express discomfort due to the cold temperature, and the room temperature was verified to be below the required range at 68 degrees Fahrenheit by both RN 1 and the Maintenance Director. The Maintenance Director used a digital thermometer to confirm the room temperature was 68.9 degrees Fahrenheit, which is below the facility's policy requirements, thus failing to provide a comfortable environment for the resident.
Failure to Update Care Plans for Resolved Covid-19 Cases
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were revised to reflect their current care needs and interventions. Resident 67 and Resident 41 both had care plans that included problems related to their Covid-19 diagnoses and the use of antibiotic medication. However, these care plans were not updated after the residents' Covid-19 symptoms resolved and they were no longer on antibiotic medication. This oversight was identified during a medical record review and interview with RN 2, who confirmed that the care plans had not been revised to reflect the changes in the residents' conditions. Resident 67 was admitted to the facility and was noted to lack the capacity to understand and make decisions, as per the history and physical examination dated 9/28/24. Despite the resolution of Covid-19 symptoms and discontinuation of antibiotic medication, Resident 67's care plan still reflected the outdated information. Similarly, Resident 41's care plan continued to list Covid-19 and antibiotic use as current issues, even though these were no longer applicable. The failure to update the care plans posed a risk of not providing individualized and person-centered care to the residents.
Failure to Provide Sack Lunch for Dialysis
Penalty
Summary
The facility failed to provide a sack lunch to a resident during dialysis days, as required by the resident's medical orders. The resident, who was cognitively intact with a BIMS score of 15, reported not receiving any sack lunch during dialysis sessions. A review of the resident's medical records confirmed an order dated January 3, 2024, allowing the resident to bring a sack lunch to the dialysis center. During an interview, RN 2 confirmed the existence of this order but was unable to provide documented evidence that a diet order form was submitted to the dietary department to ensure the resident received a sack lunch on dialysis days. This oversight posed a risk for possible medical complications for the resident.
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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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