Century Villa, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Inglewood, California.
- Location
- 301 Centinela Ave, Inglewood, California 90302
- CMS Provider Number
- 555368
- Inspections on file
- 24
- Latest survey
- August 8, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Century Villa, Inc during CMS and state inspections, most recent first.
The facility failed to ensure that a resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
A resident with multiple psychiatric diagnoses was prescribed Depakote, an anticonvulsant, which was not properly coded as such in the MDS assessment under high-risk drug classes. The MDS nurse confirmed the medication should have been classified based on its pharmacological category, but this was not done, resulting in inaccurate data being reported to CMS.
A resident with significant medical needs and a POA had their personal funds retained by the facility after discharge due to the facility's failure to respond to a request for the account balance. The Business Office Manager did not provide the required information to the resident's representative, despite facility policy mandating timely written statements upon request.
The facility failed to implement care plan interventions for two residents, leading to deficiencies in their care. One resident with an ankle monitor lacked a care plan for skin care, while another resident had no care plan for temporary leave with family, despite having orders for such absences. The absence of these care plans was acknowledged by staff, highlighting a failure to follow facility policies.
The facility failed to adhere to infection control protocols for two residents, leading to potential infection risks. One resident's nasal cannula and humidifier were not changed as per policy, and another resident's enteral nutrition container was not replaced within the recommended timeframe. These oversights could lead to microbial growth and respiratory or gastrointestinal infections.
A resident with COPD, depression, and schizophrenia had their call light placed out of reach, potentially delaying necessary care. Staff confirmed the call light should be within reach, as per facility policy.
A resident's privacy was compromised when a sign disclosing the need to keep a law enforcement device charged was posted above their bed. The resident, with conditions including COPD, epilepsy, and schizophrenia, was unable to express or understand ideas and was fully dependent on staff. Facility staff acknowledged the privacy breach, which violated the policy requiring discreet display of confidential information.
A facility failed to revise a resident's care plan to include specific instructions for oxygen therapy, despite the resident's diagnoses of COPD, respiratory failure, and chronic heart failure. The care plan lacked details on the frequency, route, and conditions for administering oxygen, which was necessary for managing the resident's shortness of breath. The MDS Nurse acknowledged the oversight, noting that the care plan should have been updated to guide staff on when to administer oxygen and change equipment.
The facility failed to correctly obtain orthostatic blood pressure readings for two residents, potentially delaying interventions for orthostatic hypotension. Blood pressure readings were taken in the wrong order and without sufficient time between position changes, contrary to facility policy.
A resident with a history of cerebrovascular accident, schizophrenia, and bipolar disorder was not properly supervised or equipped with a smoking apron during a smoking break, contrary to her care plan and smoking assessment. The resident was observed on the smoking patio without the required protective gear and with her back to the supervising staff, posing a safety hazard. Facility staff acknowledged the oversight, which was inconsistent with the facility's smoking policy.
A resident with cervicalgia and neuropathy did not receive prescribed tramadol for severe pain on two occasions, despite the medication being removed from the narcotic cart. The discrepancy between the controlled drug record and the eMAR was confirmed by staff, leading to increased pain and frustration for the resident.
A facility failed to assess and obtain a physician's order for siderail use for a resident with diagnoses of failure to thrive and encephalopathy. The resident was observed with siderails up, but no assessment or order was documented. Staff interviews confirmed the lack of an Interdisciplinary Team meeting to determine the appropriateness of siderail use, contrary to facility policy.
The facility failed to manage medications properly, as an expired cranberry extract and an unlabeled docusate sodium liquid were found in a medication cart. The Treatment Nurse confirmed the expired extract should have been disposed of, and the lack of an open date on the docusate liquid could lead to uncertainty about its effectiveness. This was contrary to the facility's policy on medication storage.
A facility failed to date and label food items stored in a resident's room, as required by their policy. Observations revealed that a liter of Coca-Cola, a bag of Ruffles potato chips, and a jar of Cheez Whiz were not dated or labeled. Staff interviews confirmed that the policy mandates dating and labeling of food items, which should be consumed within three days to prevent potential health issues. The resident involved was independent and had the capacity to make decisions.
A facility failed to maintain accurate medical records for a resident during a transfer to another facility. The transfer form contained outdated vital signs and incorrect transfer details, which were not updated to reflect the resident's condition on the day of transfer. The resident had chronic kidney disease, schizophrenia, and anxiety disorder. Staff acknowledged the error, and the importance of accurate documentation was emphasized by the DON.
The facility failed to meet the minimum room size requirement of 80 square feet per resident in six rooms, each occupied by three residents. Despite having a waiver, the limited space potentially affected resident safety and environment, as confirmed by the Maintenance Supervisor and Administrator.
A facility failed to document medication administration within the ordered time for four residents with conditions like bipolar disorder and schizophrenia. Medications scheduled for 9:00 am were administered late by an LVN, who cited issues with a new electronic record system. Despite training, the LVN needed more support, which was not communicated to management. The facility's policy requires timely medication administration, which was not followed, potentially affecting therapeutic outcomes.
The facility did not complete annual competency checklists for the IP, two LVNs, and a CNA, as required by their policy. This was discovered during a review of employee files by the DSD, who could not provide evidence of completed evaluations. The DON confirmed that these evaluations are necessary to ensure staff competency and identify training needs.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Accurately Code Anticonvulsant Medication in MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident by not properly coding Depakote, an anticonvulsant medication, under Section N0415 (High-Risk Drug Classes) as required. The resident in question had diagnoses including paranoid schizophrenia, bipolar disorder, and anxiety disorder, and was prescribed Depakote for bipolar disorder. Despite the medication's pharmacological classification as an anticonvulsant, it was not marked as such in the MDS assessment. The Minimum Data Set Nurse (MDSN) acknowledged during interview and record review that Depakote should have been coded as an anticonvulsant regardless of the reason for its prescription, as per the Resident Assessment Instrument (RAI) manual. The MDSN admitted to not coding Depakote as an anticonvulsant in previous assessments and stated that this error was not previously flagged. The facility's policy and procedure on conducting accurate resident assessments requires that all assessments reflect the resident's status at the time and be completed by qualified staff. The inaccurate MDS assessment resulted in incorrect data being transmitted to CMS, specifically related to medication classification and care screening.
Failure to Respond to Request for Resident Personal Funds Account Balance
Penalty
Summary
The facility failed to respond to a request for the account balance of personal funds for one resident after discharge, resulting in the facility retaining the resident's funds. The resident in question had a Durable Unlimited Power of Attorney (POA) appointing her son to act on her behalf for financial matters. The resident was admitted with multiple diagnoses, including anemia, chronic kidney disease, and gastrostomy status, and was dependent on staff for all activities of daily living. The Minimum Data Set (MDS) indicated the resident rarely had the ability to make herself understood or understand others. The POA requested the account balance while the Business Office Manager (BOM) was away from the facility, but as of the survey date, the BOM had not responded to the request. A review of the resident's Trust Transaction History showed a closing balance of $1,504.04. The facility's policy and procedures require that quarterly statements be provided in writing to the resident or their representative within 30 days after the end of the quarter and upon request. Despite this policy, the BOM confirmed that no response had been given to the POA regarding the resident's personal funds account balance, resulting in the facility retaining the funds after the resident's discharge.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plan interventions for two residents, leading to deficiencies in their care. Resident 44, who was admitted with an ankle monitor, did not have a care plan addressing skin care related to the device. Observations revealed that the ankle monitor was not properly managed, as there was no material between the device and the skin to prevent breakdown. The Director of Nursing acknowledged the absence of a care plan and the need for one to prevent skin issues, although no skin problems had been reported at the time. Resident 90, who had orders allowing temporary leave with family, also lacked a care plan addressing safety and documentation for such absences. The LVN and MDS Nurse confirmed the absence of a care plan for temporary leave, which would typically include goals and interventions to ensure the resident's safety while outside the facility. The facility's policy on temporary passes was not followed, as it required proper documentation and safety measures, which were not in place for Resident 90.
Infection Control Deficiencies in Oxygen and Enteral Nutrition Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for two residents, leading to potential risks of infection. For one resident, the nasal cannula and humidifier used for oxygen therapy were not dated or labeled correctly. The humidifier was observed to be dated over a month prior, and the nasal cannula lacked any date or label. According to the facility's policy, these items should be changed weekly to prevent respiratory infections. Interviews with staff revealed inconsistencies in the understanding of the required frequency for changing these items, with some staff indicating a two-week interval and others stating a weekly change was necessary. Another resident was observed with an enteral nutrition container that had been hanging for more than 24 hours, contrary to the manufacturer's guidelines and the facility's policy, which require the formula to be changed daily. The container was dated two days prior, and there was no nurse's signature or initials to confirm it had been changed as per the physician's orders. This oversight in changing the enteral nutrition could lead to microbial growth, posing a risk of gastrointestinal issues for the resident. The facility's policies and procedures for oxygen administration and enteral nutrition were found to be lacking in specific infection control guidelines. The failure to adhere to these policies and ensure proper labeling and timely changes of medical equipment and nutrition containers could potentially lead to the transmission of infectious microorganisms and increase the risk of infection among residents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light device was placed within reach for a resident, identified as Resident 56, which could result in a delay or inability to obtain necessary care and services. Resident 56 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), depression, and schizophrenia, and had fluctuating capacity to understand and make decisions. The Minimum Data Set (MDS) assessment indicated that Resident 56 required supervision or assistance for activities of daily living. During an observation, the call light was found hanging on the overhead light above the resident's bed, out of reach, which was confirmed by Certified Nursing Assistant (CNA) 1. Interviews with facility staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), confirmed that the call light should always be within reach of the resident to ensure they can call for help in an emergency. The facility's policy and procedure on answering the call light also indicated that the call light should be within easy reach when the resident is in bed or confined to a chair. The failure to adhere to this policy was identified as a deficiency during the survey.
Violation of Resident Privacy Due to Inappropriate Signage
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information by posting a sign above the resident's bed. The sign disclosed that a law enforcement device needed to be plugged in, which was visible to anyone entering the room. This action violated the resident's right to privacy, as the sign contained sensitive information indicating the resident's involvement with law enforcement. The resident, who was admitted to the facility with chronic obstructive pulmonary disease, epilepsy, and schizophrenia, was dependent on staff for all functional abilities and had limited ability to express ideas or understand others. During observations and interviews, staff members, including a CNA and an LVN, acknowledged the inappropriate placement of the sign and its implications for the resident's privacy. The Director of Nursing also recognized the privacy violation but noted that the sign had been in place since before her tenure and was believed to be court-ordered. The facility's policy on posting signs requires that confidential information be displayed discreetly or in restricted areas, which was not adhered to in this case.
Failure to Revise Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to include specific instructions for oxygen therapy. The resident, who was diagnosed with chronic obstructive pulmonary disease, respiratory failure, and chronic heart failure, required continuous oxygen at two liters per minute for shortness of breath and wheezing. However, the care plan, dated several months prior, only indicated that oxygen should be available if ordered or as needed, without specifying the frequency, route, or conditions under which the oxygen should be administered. This lack of detailed instructions placed the resident at risk of not meeting the care plan goal of avoiding shortness of breath. During an interview and record review, the MDS Nurse acknowledged that the care plan should have been updated to include specific interventions such as when to administer oxygen based on the resident's oxygen saturation levels, and when to change the nasal cannula and humidifier. The facility's policy on reviewing and revising care plans stated that care plans should be updated with new or modified interventions when a resident experiences a status change. The failure to revise the care plan with complete interventions could affect the resident's ability to meet their care plan goals.
Improper Orthostatic Blood Pressure Monitoring
Penalty
Summary
The facility failed to properly obtain orthostatic blood pressure readings for two residents, which could potentially delay necessary interventions for orthostatic hypotension. Resident 3, who has a history of bipolar disorder, schizophrenia, and hypertension, had an order to monitor orthostatic blood pressure weekly. However, the blood pressure readings were not taken correctly, as the times recorded were only one minute apart, and the readings were taken in the wrong order, with sitting measurements taken before lying measurements. This incorrect method of obtaining orthostatic blood pressure readings was confirmed during an interview with a registered nurse. Similarly, Resident 52, who also has a diagnosis of schizophrenia and hypertension, had an order to monitor orthostatic blood pressure weekly. The blood pressure documentation for Resident 52 showed similar issues, with readings taken only one minute apart and in the incorrect order. The facility's policy on orthostatic hypotension requires blood pressure to be measured in three positions: lying, sitting, and standing, with adequate time between position changes. The failure to adhere to this policy and the incorrect method of obtaining readings were identified as deficiencies during the survey.
Failure to Supervise Resident During Smoking Break
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 32, was adequately supervised and wore a smoking apron during a smoking break. Resident 32, who has a history of cerebrovascular accident, schizophrenia, and bipolar disorder, was observed sitting in a wheelchair on the smoking patio without a smoking apron and with her back to the sliding glass door, contrary to her care plan and smoking assessment requirements. The Assistant Activities Director (AAD) and Activities Director (AD) both acknowledged that Resident 32 needed supervision and a smoking apron for safety, and that the resident's positioning and lack of protective gear posed a safety hazard. Interviews with the Director of Nursing (DON) and a review of the facility's policy on resident smoking confirmed that the facility's procedures were not followed. The DON stated that smoking assessments are used to determine if residents require supervision and protective gear while smoking. The facility's policy mandates supervision and the use of smoking aprons for residents who need them, as indicated in their care plans. The failure to adhere to these protocols resulted in a potential safety risk for Resident 32, as she was not properly supervised and did not have the necessary protective equipment while smoking.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to administer pain medication as needed to one of the sampled residents, identified as Resident 84. Resident 84 was admitted with diagnoses including cervicalgia, idiopathic neuropathy, and anxiety, and was capable of understanding and making decisions. The Minimum Data Set (MDS) assessment indicated that Resident 84 experienced significant pain, rated seven out of ten, which had the potential to interfere with daily activities. Despite the physician's order to administer tramadol 50mg every six hours for severe pain, the medication was not given at the scheduled times on two occasions, as documented in the Electronic Medication Administration Record (eMAR). Interviews with Resident 84 and facility staff revealed that the medication was removed from the narcotic cart but not administered, leading to increased pain and frustration for the resident. The Licensed Vocational Nurse (LVN) and the Minimum Data Set (MDS) Nurse confirmed the discrepancy between the controlled drug record and the eMAR, indicating a failure to follow the facility's medication administration policy. This oversight resulted in Resident 84 experiencing worsened pain and emotional distress due to the delay in receiving her prescribed pain medication.
Failure to Assess and Order Siderails for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 39, had an assessment and physician's order for the use of siderails. During an observation, it was noted that Resident 39 was resting in bed with one siderail up on each side, yet there was no documented order for their use in the resident's records. The resident had been admitted with diagnoses including failure to thrive and encephalopathy, conditions that could affect their ability to safely use siderails. Interviews with facility staff, including a Registered Nurse and the Minimum Data Set Nurse, revealed that an Interdisciplinary Team (IDT) meeting is required to assess the appropriateness of siderail use for residents. It was confirmed that Resident 39 did not undergo such an assessment, nor was there an order for siderails. The facility's policy mandates an assessment and documentation of the need for siderails before their use, which was not adhered to in this case.
Medication Management Deficiency
Penalty
Summary
The facility failed to properly manage medications in accordance with accepted professional principles, as observed during a survey. Specifically, a bottle of expired cranberry extract was found in medication cart #3 at nurses station #3, and a bottle of opened docusate sodium liquid lacked an open date label. During an interview, the Treatment Nurse acknowledged that the expired cranberry extract should have been disposed of to prevent residents from receiving ineffective medication. Additionally, the absence of an open date on the docusate liquid could lead to uncertainty about its effectiveness. The facility's policy on medication storage, which requires the disposal of outdated drugs and maintaining medication areas in a clean and safe manner, was not adhered to, contributing to this deficiency.
Failure to Date and Label Food Items in Resident's Room
Penalty
Summary
The facility failed to ensure that food items stored in a resident's room were properly dated and labeled, as required by their policy. During an observation, it was noted that a liter of Coca-Cola, a large bag of opened Ruffles potato chips, and an open jar of Cheez Whiz in the resident's room were not dated or labeled. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), confirmed that the facility's policy mandates that all food items brought in by family or visitors must be dated and labeled, and consumed within three days. The staff acknowledged that failing to adhere to this policy could potentially lead to stomach issues for the resident. The resident involved, identified as Resident 84, was admitted to the facility with diagnoses including cervicalgia, idiopathic neuropathy, and anxiety. The resident was assessed to have the capacity to understand and make decisions, and was independent with personal hygiene, dressing, and eating. The facility's policy on the use and storage of food brought in by family or visitors emphasizes the importance of labeling and dating food items to ensure resident safety. However, the failure to comply with this policy in the case of Resident 84 represents a deficiency in the facility's adherence to its own procedures.
Inaccurate Documentation During Resident Transfer
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident 22, which is not in accordance with accepted professional standards. Specifically, the facility did not document the correct information regarding the resident's transfer to a different facility. The transfer form for Resident 22, dated 2/3/25, contained outdated vital signs and incorrect transfer details, which were not updated to reflect the resident's condition on the day of transfer. This discrepancy was acknowledged by the Director of Staff Development (DSD) and Registered Nurse (RN) 2, who admitted to not updating the transfer form with the correct information. Resident 22, who had diagnoses including chronic kidney disease, schizophrenia, and anxiety disorder, was transferred to another facility on 2/3/25. The Director of Nursing (DON) emphasized the importance of accurate documentation to ensure the resident's condition is known and to facilitate proper care during transfers. The facility's policy on charting and documentation requires that all services and changes in a resident's condition be documented in the medical record, which was not adhered to in this case.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that six out of forty-seven rooms met the minimum requirement of 80 square feet per resident in multiple occupancy rooms. During observations and interviews, it was confirmed that rooms 22, 24, 26, 27, 28, and 29 did not meet this requirement, as they were each occupied by three residents but only provided approximately 225 to 229 square feet in total. This deficiency was acknowledged by the Maintenance Supervisor and the Administrator, who confirmed the room measurements and the occupancy levels. The Administrator stated that the facility had a room waiver for these rooms, which allowed for the variance in square footage. However, the waiver did not negate the fact that the residents in these rooms had less space, potentially affecting their safety and environment. The facility's policy and procedure indicated that shared rooms must provide at least 80 square feet per resident, which was not adhered to in these cases. The Administrator acknowledged that the limited space could increase the risk of accidents for the residents occupying these rooms.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to document medication administration within the ordered time for four sampled residents. Each resident had specific diagnoses, including bipolar disorder, schizophrenia, dementia, epilepsy, and neuropathy, which required timely medication administration to manage their conditions effectively. The medications for these residents were scheduled for 9:00 am on November 22, 2024, but were administered and documented at varying times outside the prescribed window by LVN 3. LVN 3, responsible for administering the medications, stated that the facility had recently transitioned to an electronic medical record system on October 8, 2024. Despite receiving training, LVN 3 admitted to being slow in documenting medication times and expressed a need for additional training, which was not communicated to management. The facility's policy requires medication to be administered within 60 minutes before or after the scheduled time, a guideline that was not adhered to in these instances. The Director of Nursing (DON) confirmed the transition to the electronic system and mentioned that staff had access to training resources. However, the DON could not provide documentation of these training sessions. The facility's documentation policy emphasizes timely entries after care is provided, which was not followed, leading to potential risks in therapeutic outcomes for the residents involved.
Failure to Complete Annual Competency Checklists for Nursing Staff
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP), two Licensed Vocational Nurses (LVN1 and LVN2), and one Certified Nursing Assistant (CNA2) had their annual competency checklists completed. This deficiency was identified during a review of employee files conducted by the Director of Staff Development (DSD) on August 13, 2024. The DSD was unable to provide evidence that the required annual competencies were completed for these staff members. The purpose of these annual competencies is to assess the nursing skills of the staff and ensure they are capable of performing their duties effectively. The Director of Nursing (DON) confirmed that the facility's policy requires staff to complete a competency checklist upon hire and annually thereafter. These checklists are intended to verify staff competency and identify any need for additional training. The facility's policy and procedure document, titled 'Competency Evaluation,' outlines that these evaluations are necessary to ensure staff have the appropriate skills to meet the needs of the residents. The failure to complete these evaluations could potentially result in staff providing substandard care due to a lack of verified competencies.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
