Camino Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Hawthorne, California.
- Location
- 13922 Cerise Avenue, Hawthorne, California 90250
- CMS Provider Number
- 056267
- Inspections on file
- 54
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Camino Healthcare during CMS and state inspections, most recent first.
A CNA entered a resident’s room and touched the resident’s forehead without performing hand hygiene, despite facility policy requiring use of alcohol-based hand rub or soap and water before and after direct resident contact. The resident had dementia, Alzheimer’s disease, and dysphagia following a nontraumatic intracerebral hemorrhage and lacked capacity to make decisions, with orders for a fortified puree diet, pain assessments with pain management, and monitoring of both lower extremities for redness, discoloration, swelling, and pain related to immobilizer use. In a concurrent interview, the CNA acknowledged they were supposed to clean their hands before touching residents because failure to do so could cause an infection.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with Alzheimer’s and multiple health issues was discharged to a board and care facility with a large quantity of Norco, a controlled narcotic, without proper documentation or reconciliation of medications as required by facility policy. The discharge plan lacked details on medication names, dosages, and amounts, and the attending physician was not informed about the medications provided. Staff interviews revealed that standard procedures for documenting and verifying controlled substances at discharge were not followed.
A resident with multiple health conditions received Norco, a controlled pain medication, but several administrations were not documented in the e-MAR as required. The medication was removed from inventory and not properly recorded, as confirmed by a nurse and facility records, in violation of facility policy for controlled substances.
A nurse failed to disinfect a wrist blood pressure monitor before and after use on a resident with dementia, COPD, and a wound infection. The device was placed back in the medication cart without cleaning, contrary to facility infection control policy, increasing the risk of infection transmission.
Two residents experienced deficiencies in fall prevention when the facility failed to individualize care plans, conduct timely IDT meetings, accurately assess fall risk, and implement recommended safety interventions such as bed railings and cushion pads. These lapses occurred despite the residents' high risk for falls and the facility's policies requiring such measures.
A resident with nicotine dependence and COPD was found with cigarettes in their possession, contrary to facility policy prohibiting residents from keeping tobacco products. The care plan included outdated interventions, and the required quarterly Smoking Evaluation was not completed or updated, as confirmed by the DON and RN. These failures resulted in a lack of a safe and hazard-free environment.
A resident with a history of stroke, bipolar disorder, and aphasia was found with scratch marks on the left hand. Facility staff did not perform a skin assessment or notify the physician as required by policy, despite the resident's communication difficulties and need for substantial assistance with daily activities. This deficiency was confirmed through staff interviews and record review.
A resident with cognitive impairment and recent aggressive behavior did not receive a physician-ordered urinalysis after a change in condition. Despite facility policy requiring prompt implementation of new orders, the UA was not performed, resulting in a failure to provide timely laboratory services.
The facility failed to maintain a clean environment and adequate room temperatures for its residents. A resident's air vent was covered with dust, and multiple residents reported feeling cold due to room temperatures below the required range. The Maintenance Supervisor confirmed the issues, noting that the thermostat could be adjusted by anyone, affecting multiple rooms.
The facility did not replace sharps containers on Medication Carts #2 and #4 when they reached the Full line, with objects protruding from one container. An LVN confirmed the containers were overfilled and acknowledged the risk of injury.
A facility failed to accurately complete the MDS for a resident with End Stage Renal Disease, heart failure, and cirrhosis. The resident's MDS inaccurately indicated receipt of the Influenza Vaccine, despite no documentation supporting this. The facility's policy requires accurate certification and transmission of MDS data.
A resident with diagnoses of depression, schizophrenia, and anxiety did not receive a required PASRR level II assessment, despite a positive PASRR level I indicating the need for further evaluation. The resident's care plan required adherence to PASRR level II recommendations, but the assessment was not completed, potentially impacting the resident's receipt of necessary mental health services.
A facility failed to implement a comprehensive care plan for a resident with End Stage Renal Disease and heart failure, who was non-compliant with a physician-ordered fluid restriction. Despite the resident's cognitive ability to understand the risks, staff did not inform him about the dangers of excessive fluid intake, and no care plan was in place to address this non-compliance. The DON confirmed the absence of a care plan and the resident's risk for fluid overload.
A resident with diabetes and severe cognitive impairment did not receive necessary nail care, resulting in long, thick nails with debris. The LVN failed to notify the SSD for podiatry services, contrary to the facility's policy requiring podiatrist care for diabetic residents.
A resident with severe cognitive impairment and multiple diagnoses experienced a 10-pound weight loss over 30 days, which was not reported to the physician as required by the facility's policy. The necessary change of condition form was delayed, and an Interdisciplinary Team meeting was not conducted to address the resident's care needs.
A resident with severe cognitive impairment and multiple health issues had an IV line left in place after the completion of antibiotic therapy, contrary to the facility's policy. The IV line, used for administering Meropenem, was not removed after the therapy ended, as observed during a survey. A nurse confirmed the oversight, acknowledging the risk of infection due to the failure to remove the IV line promptly.
A resident with cerebral infarction and heart failure did not have her oxygen saturation levels checked frequently enough to maintain them above 90% as per physician's orders. Despite having an oxygen concentrator and nasal cannula by her bedside, the equipment was not in use. The resident's oxygen saturation was only checked once in October and November, and twice in December, which was insufficient. An LVN confirmed that vital signs should be taken at least once a day, and the staff should have clarified the frequency with the doctor.
The facility failed to implement a resident's fluid restriction order accurately, leading to potential health risks. Additionally, there was a lack of communication with the dialysis center regarding medication management for another resident, and an emergency kit was not available at the bedside for a third resident, posing a risk of complications.
A resident with multiple health conditions, including multiple myeloma and hypertension, did not receive necessary behavioral health care services due to a lack of communication within the facility. Despite a physician's order for a psychiatric evaluation, the Social Service Director was not informed, resulting in the resident not being evaluated by a psychiatrist. This oversight occurred even though the resident exhibited refusal of care behaviors, which could have been addressed with appropriate psychiatric intervention.
A resident with urinary retention and an indwelling catheter did not receive a timely urology follow-up due to the facility's failure to schedule the appointment. Despite a physician order for a consult, the Social Services department did not arrange the necessary referral or appointment, potentially delaying care.
A LTC facility failed to provide appropriate pharmaceutical services for two residents. One resident missed doses of critical medications due to untimely ordering, while another was at risk of receiving a duplicate dose of Carvedilol due to delayed documentation by an LVN. The facility's policies require timely reordering and documentation to prevent such issues.
A resident with diabetes, hypertension, and dementia did not receive her prescribed Jardiance dose due to its unavailability, as observed during a medication administration. The LVN confirmed the missed dose, which could lead to high blood sugar levels. Facility policies require timely medication administration, and the LVN's role includes ensuring medications are given as ordered.
The facility failed to properly label and store medications, as an emergency kit and three bags of ertapenem were found past their discard dates in the medication refrigerator. The ADON confirmed these items should not have been there, and their use could harm a resident. Facility policy requires outdated medications to be immediately removed from inventory.
A resident with severe cognitive impairment and multiple diagnoses did not receive ordered lab tests, including CBC, CMP, HgA1c, TSH, and Lipid panel, as per physician's orders. The facility's failure to conduct these tests was confirmed by an LVN, who could not explain the oversight. This deficiency was contrary to the facility's policy on obtaining and reporting lab results.
A facility failed to ensure hospice services met professional standards by not having a hospice representative participate in the IDT care conference for a resident with severe cognitive impairment and multiple diagnoses. The SSD confirmed the absence of the hospice representative in the October meeting, despite the facility's policy requiring their involvement in care planning.
A resident with a Stage 4 sacral ulcer had their low air loss (LAL) mattress set incorrectly at 350 instead of matching their weight of 141 pounds. This discrepancy was observed during a facility review, and interviews with nursing staff confirmed the importance of setting the mattress to the resident's weight to prevent further skin breakdown. The facility's manual and policy also emphasized the need for correct mattress settings to promote wound healing.
A resident's urinal containing urine was placed on a bedside table next to a meal tray, violating infection control protocols. The resident, diagnosed with schizophrenia, required assistance with daily activities. Staff interviews confirmed the urinal should have been removed and the table cleaned before meal service to prevent contamination.
A resident's telephone order for Hydroxyzine was not entered into the EMR, preventing the medication from being ordered or administered. The resident, who was cognitively intact and had conditions including osteoarthritis and hip pain, had a psychiatric provider's order for Hydroxyzine for anxiety. However, the order was not recorded in the system, contrary to the facility's medication administration policy.
A resident with COPD and pneumonitis did not receive continuous oxygen as ordered by the physician, and their oxygen equipment was not labeled or dated according to facility policy. The resident was observed without the nasal cannula, and staff incorrectly believed the oxygen was to be given as needed. The DON confirmed the oversight and the importance of following physician's orders.
A resident with chronic conditions reported being hit, but the Social Services Director failed to report the abuse allegation to the Administrator or other staff as required. The facility's policy mandates immediate reporting of such allegations, which was not followed, posing a risk of further abuse.
A resident did not receive a prescribed medication, Bethanechol, for urinary muscle spasms in a timely manner due to a staff oversight. The medication order was dated but not administered until a week later, resulting in a delay of care. Interviews with staff confirmed the oversight, and the facility's policy on medication administration was not followed.
Failure to Perform Hand Hygiene Before Direct Resident Contact
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a CNA entered a resident’s room and touched the resident’s forehead without performing hand hygiene. The resident had been admitted on 4/9/2022 and had diagnoses including dementia, Alzheimer’s disease, and dysphagia following a nontraumatic intracerebral hemorrhage, and a history and physical dated 1/2/2025 documented that the resident did not have the capacity to understand and make decisions. The resident’s orders included a fortified puree diet, pain assessments with pain management, and monitoring of both lower extremities every shift for redness, discoloration, swelling, and pain related to immobilizer use. During observation on 2/17/2026 at 11:19 a.m., the CNA touched the resident’s forehead without first cleaning their hands, and in a concurrent interview acknowledged they were supposed to perform hand hygiene before touching residents because not doing so could cause an infection. The facility’s hand hygiene policy dated 12/2023 required use of alcohol-based hand rub or soap and water before and after direct contact with residents. This failure to perform hand hygiene before direct contact with the resident constituted noncompliance with the facility’s infection prevention and control program and its written hand hygiene policy.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt notification and communication regarding an incident that required reporting, as well as the failure to provide investigation outcomes to the appropriate external agencies as required.
Failure to Document and Reconcile Discharge Medications
Penalty
Summary
The facility failed to ensure that the Post Discharge Plan of Care for a resident discharged to a board and care facility was completed according to its own policy and professional standards. The discharge documentation did not include the names, dosages, or amounts of post-discharge medications, specifically omitting details about a controlled substance, Norco, which was dispensed in significant quantity. The medication section of the discharge plan was left blank, and there was no indication of the interdisciplinary team member responsible for completing the document, nor was there a signature from the party accepting the plan. The resident in question had a history of Alzheimer’s disease, cardiomegaly, difficulty walking, and a history of falls, and required supervision or assistance with daily activities. The resident was discharged with a large quantity of Norco, a narcotic pain medication, but the physician order did not specify which medications or amounts were to be provided upon discharge. The discharge summary and transfer/discharge report also failed to document the specific medications and quantities given to the resident or their family. Interviews with facility staff revealed that the normal process for discharging a resident with narcotics was not followed, and the documentation was incomplete due to the nurse being in a hurry. Further, the attending physician was not informed about the medications being sent with the resident and stated that he would not have approved the discharge of Norco due to its risks. The facility’s policy required a reconciliation of all pre-discharge and post-discharge medications, but this was not completed. The lack of proper documentation and communication regarding the controlled medication placed the resident at risk, as noted in the report.
Failure to Document Controlled Medication Administration in e-MAR
Penalty
Summary
The facility failed to ensure that the administration of Norco, a controlled pain medication, was properly documented in the electronic Medication Administration Record (e-MAR) for a resident. Specifically, the Controlled Medication Count Sheet indicated that Norco tablets were removed from inventory on several occasions, but these administrations were not recorded in the e-MAR. This discrepancy was confirmed during a review of both the count sheet and the e-MAR, as well as through an interview with a Licensed Vocational Nurse, who acknowledged that the e-MAR was not signed to reflect the removal and administration of the medication. The resident involved had a history of Alzheimer’s disease, cardiomegaly, difficulty walking, and a history of falls, and was under a physician’s order to receive Norco as needed for pain management. Facility policy required that all administrations of controlled medications be immediately documented with the date, time, amount administered, and the nurse’s signature. The failure to document these administrations in the e-MAR constituted a breach of this policy and created a risk of miscommunication among healthcare personnel regarding the resident’s medication administration.
Failure to Disinfect Blood Pressure Monitor Between Uses
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to disinfect a wrist blood pressure monitor before and after use on a resident. The LVN was observed attempting to take the resident's blood pressure multiple times without success, then placing the monitor back into the medication cart drawer without cleaning it. The LVN acknowledged not disinfecting the device, and another LVN confirmed that this failure could spread germs and increase infection risk. The Infection Preventionist Nurse also stated that not cleaning the monitor before and after use increases the risk of spreading communicable diseases among residents. The resident involved had a history of dementia, chronic obstructive pulmonary disease (COPD), and muscle weakness, and was dependent on staff for assistance with daily activities. The resident's care plan included interventions to prevent skin injury and infection, as the resident had an actual impairment to skin integrity related to a left hip wound infection. The facility's infection control policy required that supplies and equipment be cleaned immediately after use, but this procedure was not followed in this instance.
Failure to Individualize Care Plans and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents. For one resident with muscle weakness and cognitive communication deficits, the care plan was not individualized after a witnessed fall. The care plan, revised after the fall, only included checking range of motion and reporting mental changes, but did not address the specific cause of the fall, such as sliding from the wheelchair. Additionally, there was no Interdisciplinary Team (IDT) meeting conducted to discuss safety interventions following the incident. For another resident with difficulty walking and low back pain, the facility did not conduct an accurate fall risk assessment after a fall, as the assessment did not reflect the incident or the resident's poor balance and medication use, which could increase fall risk. The resident was incorrectly assessed as medium risk instead of high risk. Furthermore, after a subsequent fall, recommendations from rehabilitation services to apply bed railings and cushion pads along the bedside were not implemented. There was also no care plan created to address the new fall risk factors. Observations confirmed that recommended safety interventions, such as bed railings and cushion pads, were not present in the resident's room. The facility's own policies required appropriate assessments and interventions to prevent and minimize falls, as well as IDT review and care plan updates, but these procedures were not followed for the residents involved.
Failure to Enforce Smoking Policy and Update Resident Smoking Evaluation
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment for a resident by not implementing its own Smoking Policy, which prohibits residents from keeping cigarette or tobacco products in their possession. During an observation, a pack of approximately 18 cigarettes was found at the resident's bedside, and there was no metal lock box present. The Registered Nurse confirmed that the resident should not have had cigarettes in their possession, as it was against facility policy and could jeopardize safety. The resident's care plan included an outdated intervention to provide a lock box for smoking materials, which conflicted with the current facility policy. Additionally, the facility did not review, update, or document the resident's Smoking Evaluation at least quarterly, as required by policy. The last documented Smoking Evaluation was several months prior, and the Director of Nursing acknowledged that the evaluation should have been completed quarterly to assess the resident's safety to smoke. The resident had a history of nicotine dependence, COPD, and chest pain, and was assessed as requiring partial/moderate assistance with dressing but was independent with eating and able to understand and express needs. The lack of updated assessments and conflicting care plan interventions contributed to the deficiency.
Failure to Notify Physician of Resident's Skin Condition Change
Penalty
Summary
The facility failed to notify a resident's physician regarding the presence of scratch marks on the resident's left hand. The resident, who had a history of cerebral infarction, bipolar disorder, and aphasia, was observed to have two scratch marks during a room observation. Documentation indicated that the resident had difficulty communicating but was able to comprehend most conversations with prompting. The resident required substantial assistance with activities of daily living such as toileting hygiene, showering, and dressing. Interviews with facility staff, including the Director of Staff Development (DSD), Director of Nursing (DON), and Administrator (ADM), confirmed that a skin assessment had not been performed and the physician had not been notified about the scratches. The facility's policy required that all changes in a resident's condition be communicated to the physician, but this protocol was not followed in this instance. The deficiency was identified through observation, interview, and record review.
Failure to Complete Physician-Ordered Urinalysis Following Change in Condition
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis (UA) with culture and sensitivity was completed and sent to the laboratory for one resident. The resident, who had a history of cerebral infarction, bipolar disorder, and aphasia, was admitted with cognitive impairment and required substantial assistance with activities of daily living. On a documented change of condition, the resident exhibited physical aggressive behavior and confusion, prompting the physician to order a UA to check for a possible urinary tract infection (UTI). Despite the physician's order and the facility's policy requiring prompt implementation of new orders following a change in condition, the UA was not performed. The Director of Staff Development confirmed that the test was not completed, acknowledging that the resident's symptoms could have indicated a UTI. The facility's policy emphasized the need for timely response to changes in resident condition, but the failure to carry out the ordered laboratory test constituted a deficiency in providing timely and quality laboratory services.
Facility Fails to Maintain Cleanliness and Adequate Room Temperatures
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the presence of dust on the air vent above a resident's bed and inadequate room temperatures. During an initial tour, it was observed that the air vent above the head of a resident's bed was covered with dust. The resident, who had been admitted with diagnoses including breast cancer, muscle weakness, and difficulty walking, reported that the dust appeared to be moving like bugs. The Maintenance Supervisor confirmed that the vent was dirty despite a log indicating that vents were clean. The supervisor explained that the vent was a return vent meant to recycle air and should not affect the resident. Additionally, the facility failed to maintain room temperatures within the required range of 71 to 81 degrees Fahrenheit. One resident was observed under multiple blankets and expressed feeling cold, while another resident reported being freezing at night despite using an extra blanket. A third resident, who preferred to keep her window open, had a room temperature of 69 degrees Fahrenheit, which was confirmed by the Maintenance Supervisor. The thermostat controlling multiple rooms was set to maintain 76 degrees, but it could be adjusted by anyone, affecting the temperature in several rooms. The facility's policy required a safe and comfortable environment, which was not upheld in these instances.
Failure to Replace Full Sharps Containers
Penalty
Summary
The facility failed to ensure that two sharps containers on Medication Cart #2 and Medication Cart #4 were replaced when they reached the Full line, posing a potential risk of injury to staff or residents. During an observation, it was noted that the sharps container on Medication Cart #4 was full, with objects protruding from the lid. Similarly, the sharps container on Medication Cart #2 contained objects past the Full line. During a concurrent observation and interview, an LVN confirmed that both containers were overfilled and acknowledged that they should have been replaced once the Full line was reached. The LVN also recognized the potential for injury due to the overfilled sharps containers.
Inaccurate MDS Completion for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for a resident, which had the potential to negatively affect the plan of care and delivery of services. The resident was admitted with diagnoses including End Stage Renal Disease, heart failure, and cirrhosis of the liver. The resident's cognitive skills for daily decision-making were intact, and they required set-up assistance for Activities of Daily Living such as oral and personal hygiene. During a review of the resident's MDS assessment, it was found that the section regarding the Influenza Vaccine was inaccurately completed. The MDS was coded to indicate that the resident had received the vaccine, but there was no documentation to support this, as the resident last received the vaccine the previous year. The facility's policy requires that each individual who completes a portion of the assessment certifies its accuracy, and that accurate MDS data is transmitted to the CMS system.
Failure to Complete PASRR Level II Assessment for Resident
Penalty
Summary
The facility failed to ensure that a resident received a Pre-Admission Screening and Resident Review (PASRR) level II assessment, which is a federal requirement for individuals with mental disorders or intellectual disabilities. The resident in question was admitted with diagnoses of depression, schizophrenia, and anxiety, and the care plan indicated that staff should follow PASRR level II recommendations. However, the PASRR level II assessment was not completed, despite the resident's PASRR level I being positive, indicating the need for further evaluation. During a review of the resident's records, it was found that the resident had fluctuating capacity to understand and make decisions, and was dependent on staff for activities of daily living. The MDS nurse confirmed that the PASRR level II assessment was necessary to determine the appropriate mental health services and care for the resident, but it was not conducted. This oversight had the potential to result in the resident not receiving the required services for their mental health condition, as per the facility's policy and procedure on PASRR.
Failure to Implement Care Plan for Fluid Restriction
Penalty
Summary
The facility failed to initiate a comprehensive care plan for a resident who was non-compliant with a physician-ordered fluid restriction. The resident, diagnosed with End Stage Renal Disease, heart failure, and dependent on renal dialysis, was observed with large quantities of fluids in his room, including soda, water, and orange juice. Despite having the cognitive ability to understand and make decisions, the resident stated that staff had not informed him about the risks of excessive fluid intake. The Licensed Vocational Nurse was unaware of the specific fluid restriction amounts, and the Director of Nursing confirmed that no care plan was in place to address the resident's non-compliance. The facility's policy required the interdisciplinary team to develop a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes to meet their needs. However, the resident's electronic clinical records did not indicate any care plan addressing the non-compliance with fluid restriction. The Director of Nursing acknowledged the resident's risk for fluid overload due to non-compliance and the importance of developing a comprehensive care plan for continuity of care.
Failure to Provide Nail Care for Resident with Diabetes
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 16, received proper grooming for his long fingernails. Resident 16 was admitted with diagnoses including diabetes, hypertension, and dementia, and was noted to have severe cognitive impairment, making him dependent on staff for all activities of daily living. The care plan for Resident 16 indicated that staff should refer him to podiatry if he had thick nails. However, during an observation, it was noted that Resident 16 had long, thick nails with debris underneath, which had not been addressed. Licensed Vocational Nurse (LVN) 1 acknowledged the need for nail cutting for infection control but admitted to not notifying the Social Services Director (SSD) about the resident's condition. The SSD confirmed that she had not been informed of the need for podiatry services for Resident 16. The facility's policy and procedure documents indicated that residents should be well-groomed and that a podiatrist should provide nail care for residents with diabetes, but these procedures were not followed in this case.
Failure to Report Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, who experienced a significant weight loss of 10 pounds within 30 days, was reported to the physician in a timely manner. The resident, who was admitted with diagnoses including diabetes, hypertension, and dementia, was dependent on staff for all activities of daily living and had severe cognitive impairment. Despite the facility's policy requiring physician notification for weight changes exceeding 5% or 5 pounds in 30 days, the necessary communication and intervention were delayed. The deficiency was identified during a review of the resident's clinical records, which showed a weight drop from 147 pounds to 137 pounds over a month. The Licensed Vocational Nurse acknowledged that a change of condition form should have been completed earlier, and the physician should have been notified to obtain new care orders. Additionally, the Director of Staff Development confirmed that an Interdisciplinary Team meeting, crucial for planning the resident's care, was not conducted as required by the facility's policy.
Failure to Remove IV Line After Completion of Antibiotic Therapy
Penalty
Summary
The facility failed to ensure the timely removal of a peripheral intravenous (IV) line for a resident after the completion of IV antibiotic therapy. Resident 75, who was admitted with diagnoses including End Stage Renal Disease, sepsis, and anemia, had an IV line inserted for the administration of Meropenem, an antibiotic, which was scheduled to be discontinued on December 14, 2024. However, during an observation on December 17, 2024, it was noted that the IV line was still in place, with the dressing dated November 26, 2024, indicating that the line had not been removed as per the facility's policy once the therapy was completed. The resident's cognitive skills were severely impaired, and they were dependent on staff for daily activities, including medical decision-making. During an interview, a registered nurse confirmed that the IV antibiotic treatment had been completed the previous week and acknowledged that the nursing staff should have removed the IV line immediately to prevent potential infection at the insertion site. The facility's policy, dated May 2022, clearly stated that the IV line should be removed when the therapy is discontinued, which was not adhered to in this instance.
Inadequate Monitoring of Oxygen Saturation Levels
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 39, had her oxygen saturation levels checked frequently enough to maintain them above 90% as per the physician's orders and care plan. During an observation, it was noted that Resident 39 had an oxygen concentrator and nasal cannula by her bedside, but the equipment was not in use. The resident was admitted with diagnoses including cerebral infarction and heart failure, conditions that necessitate careful monitoring of oxygen levels. The physician's orders from October and November 2024 specified that oxygen should be applied via nasal cannula at 2 liters per minute to keep oxygen saturation at or above 90% as needed for shortness of breath. However, a review of the resident's Weights and Vitals Summary revealed that her oxygen saturation was only checked once in October and November, and twice in December, which was insufficient to ensure compliance with the physician's orders. During an interview, an LVN confirmed that vital signs, including oxygen saturation, should be taken at least once a day or as ordered. The LVN acknowledged that the staff should have clarified with the doctor how frequently the oxygen saturation should be checked, as the current practice did not allow them to determine when to administer oxygen to maintain the required saturation levels.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to implement Resident 20's fluid restriction order accurately, which placed the resident at risk for swelling, discomfort, and shortness of breath. Despite having a fluid restriction order of 1200 cc per 24 hours, the resident's meal ticket did not indicate this restriction, and the care plan lacked details on managing and monitoring fluid intake. Observations revealed that Resident 20 had a significant amount of fluids, such as water bottles and orange juice, in his room, and staff were unaware of the fluid restriction. The Director of Nursing acknowledged the lack of consistent monitoring of the resident's fluid intake. The facility also failed to collaborate and communicate with the dialysis center regarding which hypertensive medications were to be held for Resident 20 before dialysis treatment. The resident was scheduled for hemodialysis three times a week, and certain medications were held on dialysis days without documentation of coordination with the dialysis center. The Minimum Data Set Nurse confirmed the absence of documentation indicating whether the hypertensive medications should be administered, adjusted, or withheld prior to dialysis. Additionally, the facility did not ensure that Resident 75's dialysis emergency kit was readily available at the bedside. The absence of the emergency kit, which should contain essential supplies to manage excessive bleeding from the dialysis site, was confirmed by both a Registered Nurse and the Director of Nursing. The lack of an accessible emergency kit posed a risk of complications in the event of excessive bleeding, as the facility's policy indicated that any problems with a resident's access should be addressed immediately.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 60, received necessary behavioral health care services. Despite having a physician order for a psychiatric evaluation dated 11/11/2024, the facility did not notify a psychiatrist when Resident 60 exhibited episodes of refusal of care, such as showering, bathing, and changing clothes. The Social Service Director (SSD) was responsible for referring residents to a psychiatrist but was not informed by the licensed nursing staff about the physician's order for Resident 60's psychiatric referral. This lack of communication resulted in the resident not being evaluated by a psychiatrist, which could have addressed his refusal of care behavior. Resident 60 was admitted to the facility with diagnoses including multiple myeloma, anemia, and hypertension. The resident had the capacity to understand and make decisions, as indicated in the Minimum Data Set (MDS) dated 9/28/2024. The Director of Nursing (DON) confirmed that the psychiatric referral was not followed through by the facility staff, acknowledging that a psychiatrist could have helped manage the resident's behavior and develop a treatment plan. The facility's policy and procedure on Behavioral Health Services emphasized the importance of providing necessary behavioral health care to maintain residents' well-being, but this was not adhered to in Resident 60's case.
Failure to Schedule Urology Follow-Up for Resident
Penalty
Summary
The facility failed to ensure a follow-up appointment for a urology evaluation was completed for a resident diagnosed with urinary retention, obstructive uropathy, and acute cystitis. The resident, who had an indwelling urinary catheter, expressed a desire to see a medical doctor to address his condition and remove the catheter due to recurring urine infections. Despite having a physician order for a urology consult, there was no documentation indicating that the facility staff scheduled the necessary appointment. The Director of Nursing confirmed that Social Services was responsible for arranging transportation and medical appointments, but acknowledged the absence of documentation for the urology consult. The Social Service Director admitted to not following up with the resident's primary physician for the referral and failing to schedule the appointment. The facility's policy required Social Services to provide medically related social services, including scheduling appointments, to maintain the residents' well-being. This oversight had the potential to delay necessary care and services for the resident.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for two residents, leading to deficiencies in medication management. For one resident, several critical medications, including Jardiance, Apixiban, Breo Ellipta, Metoprolol Tartrate, and Sitagliptin, were not ordered in a timely manner, resulting in missed doses. This resident, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was at risk due to the unavailability of these medications. The Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD) acknowledged that medications should be reordered when there are three remaining to prevent outages, as per the facility's policy. Another resident was at risk of receiving a duplicate dose of Carvedilol due to the LVN's failure to document the administration of the medication immediately after it was given. This resident, who has intact cognition and requires moderate assistance with activities of daily living, was administered Carvedilol without timely documentation, which could lead to confusion and potential medication errors. The Assistant Director of Nursing (ADON) confirmed that medications should be documented as soon as they are administered to ensure safety and accuracy, in line with the facility's policy.
Missed Medication Dose for Resident with Diabetes
Penalty
Summary
The facility failed to ensure that a resident received her prescribed dose of Jardiance, a medication used to control high blood sugar. The resident, who was admitted with diagnoses including diabetes, hypertension, and dementia, was dependent on staff for all activities of daily living due to severe cognitive impairment. The care plan for the resident indicated that staff were responsible for administering diabetes medication as ordered by the doctor. During a medication administration observation, an LVN stated that the resident's Jardiance was not available and confirmed that the resident had missed a dose the previous day. The facility's policy on medication administration required that medications be administered within prescribed time frames, and the policy on medication errors defined a medication error as doses that are ordered but not administered. The LVN's job description also required administering medications as ordered by the physician. This oversight put the resident's health at risk due to the potential for elevated blood sugar levels.
Expired Medications Found in Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed in the medication storage room. During an observation and interview with the Assistant Director of Nursing (ADON), it was found that the medication refrigerator contained an emergency kit and three bags of ertapenem, all of which were past their discard dates. The emergency kit was labeled to be discarded after September 2024, while the ertapenem bags were to be discarded on 12/13/2024, 12/14/2024, and 12/16/2024. The ADON acknowledged that these items should not have been present and stated that their use could potentially harm a resident. A review of the facility's policy and procedure titled 'Medication Storage in the Facility,' dated May 2022, indicated that outdated medications should be immediately removed from inventory. This oversight in medication management had the potential to result in harm to residents if the expired medications were administered.
Failure to Conduct Ordered Laboratory Tests for a Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary laboratory tests as ordered by a physician. The resident, who was admitted with diagnoses including diabetes, hypertension, and dementia, was supposed to have a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Hemoglobin A1C (HgA1c), Thyroid Synthesizing Hormone (TSH), and Lipid panel completed on a specified date. However, these tests were not conducted as per the physician's order, which was confirmed during an interview with a Licensed Vocational Nurse (LVN). The LVN acknowledged that the tests were not completed and could not provide a reason for the oversight. The resident's medical records indicated severe cognitive impairment and dependency on staff for all activities of daily living. The care plan for the resident included obtaining and monitoring lab work as ordered, with results to be reported to the physician. Despite this, the facility did not adhere to its policy and procedure for obtaining laboratory services and notifying providers of test results, as outlined in their policy titled 'Diagnostic Test Results Notification.' This failure had the potential to result in a lack of required monitoring of the resident's health conditions.
Failure to Include Hospice in Care Planning
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for a resident by not having a hospice representative participate in the interdisciplinary team (IDT) care conference meeting. Resident 71, who was admitted with diagnoses including protein calorie malnutrition, chronic obstructive pulmonary disease, and adult failure to thrive, was on hospice care. The Minimum Data Set indicated that the resident's cognitive skills for daily decision-making were severely impaired. Despite the requirement for hospice staff to be actively involved in the care plan meetings, the Social Service Director (SSD) confirmed that no hospice representative attended the IDT care plan meeting in October 2024. The SSD acknowledged the responsibility of coordinating with the hospice representative for the IDT care plan meeting and stated that the absence of documentation indicated the meeting did not occur. The facility's policy and procedure on End of Life, Hospice, and/or Palliative Care emphasized the integration of hospice services into the individualized care plan and required collaboration with hospice staff. The SSD confirmed that IDT care plan meetings should be conducted every three months per state and federal requirements, and the hospice representative's participation was mandatory to ensure continuity in the care provided to the resident.
Improper LAL Mattress Setting for Resident with Stage 4 Ulcer
Penalty
Summary
The facility failed to ensure that a resident's low air loss (LAL) mattress was set to the appropriate setting, which is crucial for the management of a Stage 4 sacral ulcer. The resident, who was admitted with a diagnosis of schizophrenia and had no cognitive impairment, required assistance with activities of daily living and had a documented weight of 141 pounds. However, during an observation, the LAL mattress was found to be set at a firm setting of 350, rather than matching the resident's weight of 141 pounds as required. Interviews with the nursing staff, including Licensed Vocational Nurses (LVN) and the Director of Nursing (DON), confirmed that the mattress setting should correspond to the resident's weight to prevent further skin breakdown and promote wound healing. The facility's manual and policy on skin and wound management also indicated the importance of setting the mattress to the appropriate weight setting. The incorrect setting of the LAL mattress had the potential to delay the wound healing process and increase the risk of further skin breakdown for the resident.
Infection Control Breach: Urinal Placement Next to Meal Tray
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed when a urinal containing urine was placed on a resident's bedside table alongside a meal tray. This incident involved a resident who was admitted with a diagnosis of schizophrenia and required assistance with activities of daily living, including toileting hygiene. The resident's care plan noted a preference for placing the urinal on the bedside table, with an intervention to monitor its placement every shift. During an observation, a CNA placed a meal tray on the bedside table next to the urinal containing urine, which was acknowledged as inappropriate by the CNA. Interviews with the CNA, an LVN, and the DON confirmed that the urinal should have been removed and the table cleaned before placing the meal tray to prevent potential food cross-contamination. The facility's infection prevention and control policy emphasized minimizing the spread of infection, which was not adhered to in this instance.
Failure to Enter Medication Order in EMR
Penalty
Summary
The facility failed to ensure that a resident had telephone orders for Hydroxyzine entered into the electronic medical record (EMR). This oversight was identified during a review of the resident's admission record and Minimum Data Set (MDS), which indicated the resident was cognitively intact and had diagnoses including osteoarthritis, muscle weakness, and hip pain. The resident was admitted to the facility with these conditions, and the deficiency was noted when a registered nurse (RN) reviewed the resident's EMR and Order Summary Report. During an interview and record review, the RN revealed that a text message from the resident's psychiatric provider had ordered Hydroxyzine for anxiety, but this order was not entered into the system. As a result, the medication could not be ordered or administered if requested by the resident. The facility's policy and procedure for medication administration require that all medications be recorded on the resident's medication administration record (MAR), which was not adhered to in this case.
Failure to Administer Continuous Oxygen and Label Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not administering continuous oxygen as per the physician's orders. The resident, who had diagnoses including pneumonitis and chronic obstructive pulmonary disease (COPD), was observed without the nasal cannula and oxygen turned off, contrary to the physician's order for continuous oxygen at 2 liters per minute. Licensed Vocational Nurse (LVN) 2 incorrectly stated that the oxygen was to be given as needed, which was not in line with the physician's continuous oxygen order. This oversight was confirmed by both LVN 2 and Registered Nurse (RN) 1 during interviews and record reviews. Additionally, the facility did not ensure that the resident's oxygen equipment was labeled and dated according to the facility's policy and procedure. The nasal cannula tubing was found unlabeled and placed on top of the oxygen concentrator. The Director of Nursing (DON) acknowledged that the continuous oxygen order was not followed and emphasized the importance of adhering to physician's orders. The facility's policy required oxygen equipment to be labeled and dated, which was not adhered to in this case.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation involving a resident in a timely manner to the State Survey Agency. The resident, who was admitted with chronic kidney disease, urinary tract infection, osteoarthritis, and Type 2 diabetes, reported to the Social Services Director (SSD) that someone had hit her arm. The SSD documented the resident's statement but did not report the allegation to any facility staff or the Administrator, who is the abuse coordinator. The SSD later re-interviewed the resident, who then denied being struck, but the initial allegation was not communicated as required by the facility's policy. The Director of Nursing (DON) and the Administrator both confirmed that any abuse allegation should be reported within two hours, and the failure to do so could result in further abuse or the resident not feeling safe. The facility's policy, revised in April 2019, mandates that all allegations of abuse, neglect, misappropriation of resident property, or exploitation be reported to the Administrator immediately. The lack of timely reporting of the abuse allegation was identified as a deficiency with the potential to result in further abuse to the resident.
Failure to Administer Bethanechol Timely
Penalty
Summary
The facility failed to ensure that a new prescription order for Bethanechol, a medication used to relieve urinary muscle spasms, was carried out for a resident. The resident was admitted with diagnoses including osteoarthritis, benign prostatic hyperplasia, alcohol dependence, and anemia. The physician's order for Bethanechol was dated 6/21/2024, but the medication was not administered until 6/28/2024. This delay was due to a licensed staff member not carrying out the physician's order, resulting in a delay of care. Interviews with the Licensed Vocational Nurse (LVN), Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) confirmed the oversight. The ADON discovered the incomplete order after the resident complained about not receiving the medication. The ADON then ensured the order was carried out on 6/28/2024. The facility's policy requires medications to be administered according to the physician's written orders, which was not followed in this case, leading to a delay in care and potential complications for the resident.
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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