Cerritos Vista Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellflower, California.
- Location
- 17836 Woodruff Avenue, Bellflower, California 90706
- CMS Provider Number
- 056405
- Inspections on file
- 38
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at Cerritos Vista Healthcare Center during CMS and state inspections, most recent first.
A resident with depression, anxiety, insomnia, and moderately impaired cognition was started on quetiapine 50 mg at bedtime for depression with hopelessness and agitation, but staff did not obtain informed consent before administering the psychotropic medication. During interview and record review, an RN confirmed that informed consent was not obtained prior to starting the drug, and the DON acknowledged that consent should be secured before administering psychotropic medications. Facility policy requires that residents or their representatives be fully informed of benefits, risks, duration, side effects, and alternatives before initiating psychotherapeutic drugs, but this was not followed in this case.
A resident with depression, anxiety disorder, insomnia, moderately impaired cognition, and ADL assistance needs had physician orders for a psychological evaluation, follow-up treatment, and a psych consultation for depression and anxiety. Record review and interviews with an RN and the DON confirmed that the psych consultation was never completed despite the active orders and a facility policy requiring provision of needed behavioral health services.
A resident with depression, anxiety, insomnia, homelessness, and moderately impaired cognition had a physician’s order for a one-time Permethrin/nit remover kit for head lice. The order was placed, but the medication was not dispensed and administered until three days later, despite facility policies and the DON’s expectation that medication orders be implemented within 24 hours. An RN acknowledged that the treatment should have been carried out right away, and the delay resulted in the resident not being treated for head lice in a timely manner, with the report noting potential for uncomfortable itching and loss of sleep.
The facility failed to prevent a cockroach infestation, resulting in the closure of the kitchen and sightings of cockroaches in the rooms of two residents with COPD. Despite pest control treatments and recommendations for repairs, the infestation persisted, and documentation of completed repairs was lacking. The issue was confirmed by city inspection, resident reports, and staff interviews.
A resident with cognitive impairment and high care needs reported being struck and was observed with facial bruising and redness. Multiple staff members witnessed or were informed of the resident's allegations and visible injuries, but failed to take protective action or initiate an abuse investigation, leaving the resident unprotected and at risk for further harm.
A resident with cognitive impairment and significant care needs was found with facial bruising and made statements indicating possible abuse. Multiple staff observed or were informed of the injuries and allegations, but failed to promptly report the suspected abuse to the DON and authorities as required by policy, resulting in delayed investigation.
A resident with significant cognitive and physical impairments was found with multiple facial bruises and alleged being hurt by an RN. Although a CNA submitted a statement regarding the allegation, the DSD did not review it and the DON did not interview the CNA or obtain her statement, resulting in an incomplete abuse investigation and failure to follow facility policy.
A resident with Alzheimer's disease and severe cognitive impairment was transferred to a GACH for behavioral evaluation and, after being cleared for discharge, was not allowed to return to the facility despite available beds. Facility staff, following direction from the psychiatrist and Administrator, declined readmission, citing behavioral concerns, and did not provide proper discharge notice or allow the resident a chance to improve. The resident remained in the hospital for 21 days before being transferred to another SNF.
A resident who required maximal assistance did not receive timely care during an overnight shift, with staff delaying rounds for several hours and providing care in a darkened room. As a result, staff were unable to properly assess the resident, who was later found with significant facial bruising. Facility policy required rounds and adequate lighting, but these procedures were not followed.
A resident with severe cognitive impairment and Alzheimer's disease was found with a discoloration on the left jaw by a CNA, who reported it to the charge nurse. Despite facility policy requiring reporting of injuries of unknown origin, the DON and Administrator did not report the incident to authorities, assuming it was due to the resident's behavior. This resulted in a delayed investigation and potential loss of information.
A resident admitted with pneumonia and moderate cognitive impairment did not have physician or NP progress notes readily accessible in the medical record. The DON confirmed that these notes, which are required for documenting prognosis and care plans, were missing despite facility policy requiring their inclusion.
A deficiency was identified when staff and signage at the facility enforced a two-person visitor limit per resident, despite the facility's policy supporting unlimited visitation. Interviews with staff, a family member, and a resident confirmed that this restriction was communicated and sometimes inconsistently enforced. Leadership acknowledged the error and noted that alternative spaces could be used for larger groups, but the practice of limiting visitors was not in line with residents' rights.
A resident with multiple medical conditions and cognitive impairment was placed in an abdominal binder restraint without documented attempts at alternative interventions, a complete informed consent, required 30-minute monitoring, or a care plan addressing the restraint. Nursing staff confirmed that facility policy was not followed regarding restraint use, monitoring, and documentation.
A resident with COPD and dysphagia who was dependent in multiple activities of daily living was placed in an abdominal binder restraint, but this was not documented as a restraint on the MDS. One RN did not consider the binder a restraint and omitted it from the MDS, while other staff and facility policy confirmed it should have been documented. This resulted in inaccurate assessment documentation.
A resident with diabetes and on anticoagulant therapy experienced a bleeding toenail detachment that was not comprehensively assessed or monitored for several days. Despite physician notification and facility policy requiring ongoing documentation, there was no follow-up assessment or treatment documentation by nursing staff, resulting in a lack of monitoring of the resident's condition.
Two residents with significant medical conditions and existing pressure ulcers were not consistently turned and repositioned every two hours or as needed, as required by facility policy and national guidelines. Documentation and staff interviews confirmed that these care tasks were not performed on several shifts, and neither resident was on a formal turning and repositioning program despite being at high risk for pressure injuries.
A resident with multiple complex medical conditions, including diabetes and heart failure, vomited and did not receive a comprehensive assessment or documentation of vital signs such as blood pressure, heart rate, temperature, or blood glucose. Staff interviews and record review confirmed that the required post-incident assessments were not completed or documented, contrary to facility policy.
A resident with multiple complex medical conditions and severe cognitive impairment experienced an episode of vomiting and was administered Ondansetron by an RN, but the administration was not documented in the MAR as required by facility policy. Both the RN and DON acknowledged that all medication administration must be recorded.
A resident dependent on staff for all ADLs was left in a soiled gown with dry blood on her nostril for an extended period due to staff workload and lack of timely communication between CNA and LVN. Both CNA and LVN observed the hygiene issue but did not address it promptly, resulting in the resident remaining unclean and uncomfortable.
A resident with significant medical needs did not receive prescribed pain medication or a pain assessment prior to wound care, resulting in unrelieved pain during treatment. The responsible LVN failed to follow physician orders and facility policy, and the resident was observed to be in distress during care.
A resident with muscle weakness and a pressure ulcer reported a broken bed with a burning smell, but maintenance did not promptly assess or document the issue, and staff lacked clear procedures for urgent equipment failures. Another resident with morbid obesity and skin issues was not provided with properly fitting adult briefs, leading to discomfort, skin irritation, and missed therapy sessions, despite her requests and facility policies requiring accommodation of individual needs.
The facility failed to ensure accurate completion and documentation of resident assessments in the MDS for two residents. One resident's discharge status was incorrectly coded, and another resident's bowel and bladder continence status was inconsistently documented, with assessments not reflecting the resident's actual condition or care plan. These inaccuracies had the potential to negatively impact care planning and service delivery.
Two residents with documented serious mental illnesses, including depressive disorder, bipolar disorder, and schizophrenia, were not accurately identified on their PASRR Level 1 screenings, resulting in the screenings being marked negative and not triggering required Level 2 assessments. Nursing staff confirmed that the screenings should have indicated the presence of serious mental disorders based on the residents' diagnoses and medication histories.
Two residents did not receive appropriate respiratory care: one did not have required emergency tracheostomy supplies at the bedside, and another received oxygen therapy without a physician order or monitoring instructions, contrary to facility policy and care plans.
A nurse failed to remain with a resident during two nebulizer breathing treatments and did not instruct the resident to rinse her mouth after one of the treatments, resulting in a medication error rate above 5%. The resident, who was cognitively intact and had a history of acute respiratory failure, was left unattended, leading to issues such as the nebulizer mask slipping off. Facility policy and physician orders requiring supervision and mouth rinsing were not followed.
A resident with COPD and asthma was given three doses of expired Advair Diskus by three different nurses after the medication's expiration date had passed. The expired inhaler remained in the medication cart and was not removed as required, and staff did not check the expiration date before administration, despite facility policy and manufacturer instructions.
Surveyors identified deficiencies in food storage, temperature control, and hand hygiene. Multiple food items in dry storage and refrigeration were found undated, unlabeled, or improperly sealed. During meal service, ground beef patties were served below the required temperature, and a dietary aid failed to perform hand hygiene and change gloves between tasks, increasing the risk of cross contamination.
The facility failed to ensure proper infection control by not disinfecting padded bedrails wrapped in foam and paper tape for a resident with seizure disorder, and by staff not performing hand hygiene during meal service and medication administration. These lapses were observed when a nurse handled multiple lunch trays and touched her mask without sanitizing hands, and when another nurse prepared and administered medications without hand hygiene, contrary to facility policies.
A resident with intellectual disabilities and dysphagia was fed by a staff member who stood over her instead of sitting at eye level, contrary to facility policy and care plan requirements. The staff member only adjusted his position after noticing a state surveyor, and both the staff member and DON confirmed that proper feeding assistance should be provided at eye level to ensure resident comfort and dignity.
A resident with documented PTSD and depression was not accurately identified as having a serious mental illness on the Level I PASRR screening, despite clear evidence in the admission record and MDS. The screening was marked negative, and the required follow-up evaluation was not initiated, contrary to facility policy.
A resident with a history of respiratory conditions was observed receiving different oxygen flow rates without corresponding physician orders or care plan updates. The care plan did not specify the oxygen rate and was not revised upon the resident's readmission with oxygen therapy, contrary to facility policy. Nursing staff and the DON confirmed the care plan should have been updated to reflect the resident's current needs.
A resident was found storing TUMS at bedside without a physician's order or self-administration assessment, despite staff awareness, and an expired inhaler was administered to another resident with COPD and asthma after its expiration date was clearly marked, with multiple LPNs involved. Facility policies requiring removal of unauthorized bedside medications and checking expiration dates before administration were not followed.
A resident with significant medical needs and no natural teeth did not receive timely replacement of missing dentures, and there was no documented follow-up by social services after a dental visit. The resident reported discomfort while eating and embarrassment due to missing dentures, and staff interviews confirmed that required follow-up and documentation were not completed according to facility policy.
The facility failed to securely store discontinued controlled substances and maintain accurate documentation for two residents. Narcotics were not properly accounted for, with discrepancies in the narcotic count sheet and missing documentation. The DON acknowledged the importance of accurate records to prevent medication errors.
A resident with intact cognition and capacity to make medical decisions was prescribed Lidocaine patches for pain management in her left knee and shoulder, but the facility failed to develop a care plan. Despite receiving the patches since admission, there was no documented care plan, as confirmed by interviews with an LVN and the DON. This oversight hindered the facility's ability to effectively assess and adjust the resident's pain management regimen.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent prior to initiating a psychotropic medication for a resident. The resident was admitted with diagnoses including depression, anxiety disorder, insomnia, and homelessness. An MDS assessment dated 12/30/2025 documented moderately impaired cognition, with the resident needing setup assistance for eating and partial assistance for other ADLs. The physician’s orders, covering 12/24/2025 to 12/31/2026, included a new order starting 12/25/2025 for quetiapine fumarate 50 mg by mouth at bedtime for depression manifested by verbalized feelings of hopelessness and agitation. During a concurrent interview and record review, RN 1 confirmed that staff did not obtain informed consent before administering the quetiapine, and that administration began on 12/25/2025. In a separate interview, the DON stated that informed consent should be obtained prior to the administration of psychotropic medications. Review of the facility’s policy titled “Psychotherapeutic drug informed consent,” revised 1/2026, showed that the facility policy requires residents and/or their representatives to be fully informed of the benefits, risks, frequency/duration, possible side effects, and alternative approaches before starting psychotherapeutic drugs. Despite this policy, informed consent was not obtained for this resident before the psychotropic medication was administered.
Failure to Complete Ordered Psychological Consultation for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with diagnosed mental health conditions received a psychologist consultation as ordered by the physician. The resident was admitted with diagnoses of depression, anxiety disorder, and insomnia. An MDS assessment dated 12/30/2025 documented moderately impaired cognition and a need for setup assistance with eating and partial assistance with other ADLs such as bathing, dressing, and toileting. Physician orders dated 12/24/2025 and 12/26/2025 directed that the resident receive a psychological evaluation, follow-up treatment as indicated, and a psych consultation for depression and anxiety. Record review and staff interviews confirmed that the ordered psychological services were not completed. During an interview and concurrent record review, an RN acknowledged that a psych consultation had been ordered for the resident but was not carried out, and stated that the order should have been completed as written. The DON similarly stated that a psych consult should be completed if ordered by the physician. The facility’s Behavioral Assessment, Intervention, and Monitoring policy, revised 3/2019, indicated that the facility will provide behavioral health services as needed for residents to attain or maintain their highest practicable mental, physical, and psychosocial well-being, but this was not followed for this resident.
Delay in Dispensing and Administering Ordered Lice Treatment
Penalty
Summary
The facility failed to ensure timely dispensing and administration of a prescribed medication for head lice for one resident. The resident was admitted with diagnoses including depression, anxiety disorder, insomnia, and homelessness, and had a Minimum Data Set indicating moderately impaired cognition, requiring setup assistance with eating and partial assistance with other ADLs. A physician’s order dated 12/26/2025 directed the use of a Permethrin/Nit Remover combination kit to be applied to the scalp one time for head lice, with instructions to reorder after seven days. Facility policies on administering medications and on ordering and receiving medications from the pharmacy both indicated that medications would be administered and received in a timely manner. During an interview and record review, an RN confirmed that although the lice medication was ordered on 12/26/2025, it was not administered until 12/29/2025, three days later. The RN stated that not administering the Permethrin as soon as it was ordered was unacceptable and that it should have been carried out right away. The DON stated that medication orders with instructions need to be implemented within 24 hours. As a result of this delay, the resident was not treated for head lice until three days after the infestation was identified, which the report states has the potential to cause uncomfortable itching and loss of sleep for the resident.
Cockroach Infestation Leads to Kitchen Closure and Resident Exposure
Penalty
Summary
The facility failed to maintain sanitary conditions by not preventing a cockroach infestation, resulting in the closure of the kitchen and sightings of cockroaches in resident rooms. Multiple reports and interviews documented that at least two residents observed cockroaches in their rooms on several occasions, with one resident noting repeated sightings over a period of months. Both residents had chronic obstructive pulmonary disease (COPD), a condition that can be exacerbated by environmental contaminants. The facility's Concern Records and Resident Council Departmental Response forms confirmed these observations, and the Ombudsman also witnessed cockroaches in resident rooms and reported them to facility leadership. A city inspection of the facility's kitchen found live adult German cockroaches near the handwashing area and on the wall, leading to the suspension of the facility's public health permit and the closure of the kitchen. The Environmental Health Specialist (EHS) had previously instructed the facility to eradicate the pests by a set deadline, but upon re-inspection, the infestation persisted. The EHS explained that cockroaches can carry germs from garbage and sewage, contaminating food and surfaces, particularly in kitchen and food storage areas. Interviews with facility staff revealed that pest control services were provided monthly and more frequently as needed, with treatments occurring at least three times in the past month. The pest control company gave recommendations for repairs to prevent pest entry, which the Maintenance/Housekeeping Director claimed to have completed, but no documentation was maintained to verify these repairs. The DON acknowledged being informed of the infestation and noted that residents keeping food in their rooms could contribute to the problem. The facility's policy required an effective pest control program to keep the building free of insects and rodents.
Failure to Protect Resident Following Allegation and Signs of Abuse
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for assistance with daily activities and lacked capacity to make decisions, reported being struck to a CNA after bruising was observed on her face. The CNA relayed the resident's statement to an RN, but there was no evidence that immediate protective measures or a thorough investigation were initiated at that time. Later, another CNA witnessed an RN roughly handling the resident and observed redness on both cheeks. Despite reporting the resident's allegations and observed rough handling to another RN, no action was taken to protect the resident or escalate the concern, as the RN did not perceive the resident's behavior as a concern and did not seek translation or further assessment. The facility's failure to act on the resident's allegations and visible injuries resulted in the resident being left unprotected after making an abuse allegation. The staff did not follow the facility's policy to report and investigate suspected abuse, and the resident remained at risk for continued abuse. The deficiency was identified through interviews, record reviews, and direct observations of the resident's injuries and staff interactions.
Failure to Timely Report Suspected Abuse and Facial Injuries
Penalty
Summary
Facility staff failed to report suspected abuse involving a resident who was found with multiple facial bruises. The resident, who had diagnoses including anemia, generalized muscle weakness, depression, and lacked decision-making capacity, required substantial assistance with daily activities. On the morning of the incident, a CNA discovered the resident with red and purple bruises on her face and reported that the resident stated in Spanish that she had been hit. The CNA relayed this information to an RN. Earlier, another CNA had witnessed the resident expressing fear and alleging that a male staff member had hurt her, and later observed the same staff member handling the resident roughly and covering her face with a sheet. Despite these observations and allegations, the initial reports to nursing staff did not result in immediate action or escalation as required by facility policy. Interviews with staff revealed confusion and lack of follow-through regarding mandated reporting procedures. One CNA admitted uncertainty about what to do after her initial report was not acted upon, and the RN on duty did not seek translation services to better understand the resident's statements. The facility's policy requires immediate reporting of suspected abuse to the DON and appropriate authorities, but this process was not followed, resulting in a delay that hindered the ability of regulatory authorities to conduct a timely and effective investigation.
Failure to Thoroughly Investigate Allegation of Abuse and Unexplained Bruising
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was found with multiple facial bruises. The resident, who had diagnoses of generalized muscle weakness and depression and lacked decision-making capacity, was discovered with significant discoloration on both cheeks, jawline, temple, and orbital area. A CNA reported that the resident alleged being hurt by an RN and submitted a written statement to the Director of Staff Development (DSD). However, the DSD did not review the statements and only passed them to the Director of Nursing (DON). The DON acknowledged that the investigation into the resident's bruises was incomplete. Although statements were collected from staff assigned to the resident, the DON did not interview the CNA who reported the allegation and did not have her statement. The facility's policy required extensive efforts in investigating unusual occurrences or injuries of unknown origin, but these procedures were not fully followed in this case.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to ensure that a resident with Alzheimer's disease and severe cognitive impairment, who was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of uncontrollable singing and refusal of activities of daily living, was allowed to return to the facility after being cleared for discharge by the hospital. The resident's records indicated that she was admitted to the facility with significant cognitive decline and behavioral disturbances. Upon transfer to the GACH, the facility provided a bed hold notice and a Notice of Proposed Transfer and Discharge, but the discharge notice was not properly signed by the resident or her family member, and did not specify the required advance notice period. After the resident was stabilized and ready for discharge from the GACH, the hospital's social worker contacted the facility to arrange for her return. The facility's Admissions Coordinator, following direction from the facility's psychiatrist and Administrator, declined to readmit the resident, stating that she required placement in a facility better equipped to handle behavioral issues. This decision was made without giving the resident an opportunity to demonstrate improvement. Despite available beds at the facility, the resident remained in the hospital for 21 days while alternative placement was sought. Facility policy indicated that residents seeking to return after hospitalization should be allowed to return to their previous room or the first available bed, provided they still required the facility's services and met eligibility criteria. However, the facility did not follow this policy in the resident's case, as documented in interviews with facility staff and the GACH social worker. The resident was ultimately transferred to another skilled nursing facility after an extended hospital stay.
Delayed and Inadequate Night Shift Care Due to Improper Rounding and Lighting
Penalty
Summary
Staff failed to provide timely and appropriate care to a resident who required substantial assistance with daily activities, including eating, personal hygiene, and transfers. On the overnight shift, rounds were not completed and care was not provided to the resident until approximately four hours after the shift began. When care was eventually given at around 3 a.m., it was performed with the lights off or dimmed, preventing staff from adequately assessing the resident's condition. Multiple staff members, including a CNA and an RN, reported not seeing the resident's face during their rounds due to the darkened room. The resident, who had diagnoses of generalized muscle weakness and depression and lacked decision-making capacity, was later found to have multiple facial bruises and discolorations. Facility policy required staff to make rounds at the beginning of each shift to ensure residents' safety and to provide care under appropriate conditions, including turning on lights to properly assess residents. The failure to follow these procedures resulted in delayed care and an inability to recognize changes in the resident's condition.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with severe cognitive impairment and Alzheimer's disease. A Certified Nursing Assistant (CNA) discovered a discoloration on the resident's left lower jaw while providing care and reported it to the charge nurse. The Change of Condition form documented the injury, and both the Administrator and Director of Nursing (DON) were notified. Despite this, the injury was not reported to the California Department of Public Health (CDPH) as required by facility policy and regulations. Interviews revealed that the DON and Administrator assumed the discoloration was due to the resident's agitated behavior and therefore did not consider it necessary to report the incident to CDPH. The facility's policy clearly states that all injuries of unknown origin must be reported to appropriate authorities and thoroughly investigated. The failure to report resulted in a delayed investigation by CDPH and created the potential for important information or facts to be lost or forgotten.
Physician Progress Notes Not Accessible in Medical Record
Penalty
Summary
The facility failed to ensure that physician progress notes for one resident were readily accessible in the medical record. During a review of the resident's admission record and Minimum Data Set, it was found that the resident had been admitted with pneumonia and had moderately impaired cognition, requiring full assistance with activities of daily living. When the Director of Nursing (DON) was interviewed and the resident's medical record was reviewed, the DON was unable to locate completed copies of the physician or nurse practitioner visit notes for the resident. The DON confirmed that these notes should have been present in the medical record, as they are essential for documenting the resident's prognosis, plan of care, and treatment. The facility's policy and procedure on physician services indicated that physician orders and progress notes are to be maintained in accordance with regulatory requirements and facility policy. However, the absence of these notes in the resident's record demonstrated noncompliance with the requirement to maintain complete and readily accessible medical records. This deficiency was identified through direct observation and interview, with no evidence provided that the required documentation was available at the time of the survey.
Plan Of Correction
F 842 Immediate Corrective Action The Medical Records Director immediately contacted the physician's office to request the progress notes for Resident 1. Identification of Others at Risk The Medical Records designee audited all resident charts on 7/24/25 to ensure the physicians' progress notes were in the chart. No other residents were identified with the same deficiency. Process to Prevent Recurrence On 8/1/25, the Medical Records Consultant gave an in-service to the Medical Records staff regarding the policy for physicians' visits, specifically ensuring that the physicians' progress notes are readily accessible to prevent a delay in the delivery of care and necessary services. The Medical Records Designee will audit physicians' progress notes several times a week for six weeks to ensure they are readily available and monthly thereafter for 3 months. All findings will be reported to the Administrator. Monitoring Performance The Medical Records consultant will visit monthly for three months and quarterly thereafter for six months to ensure physicians' progress notes are readily accessible. All findings will be reported to the Administrator. Findings will be reported to the QA committee for further review and recommendations, monthly, for 3 months or until substantial compliance is achieved.
Deficiency in Resident Visitation Rights Due to Visitor Limitation Policy
Penalty
Summary
Surveyors identified a deficiency related to the facility's failure to respect residents' rights to receive visitors without limitation. Reception staff reported and signage indicated a policy limiting visitors to two per resident per visit, a practice that had been in place for several years. Observations confirmed the presence of this signage at the receptionist's desk, and interviews with staff and family members corroborated that this visitor limit was communicated and enforced, despite the facility's own policy encouraging visiting by family and friends. A family member reported awareness of the two-visitor guideline but noted that the facility did not consistently enforce it, as evidenced by a group celebration for a resident's birthday. On another occasion, the visitor limit sign was not posted at the receptionist's desk, and staff could not account for its absence. A resident also stated that their family had been informed of the two-person visitor limit, indicating that the restriction was communicated to residents and their families. Interviews with the Social Service Director and the Administrator revealed that both were aware residents have the right to unlimited visitors and acknowledged that the signage was incorrect. They stated that alternative spaces, such as the patio or activity room, could be used if resident rooms became overcrowded, rather than limiting visitor numbers. The facility's written policy supported the right to visitation and the provision of comfortable visiting areas, but the observed and reported practices did not align with this policy.
Plan Of Correction
F 550 Immediate Corrective Action The signage at the receptionist desk was immediately removed. On 7/9/25, the Administrator gave a 1-1 in-service to Receptionist 1 and Receptionist 2 regarding the policy for resident rights, specifically regarding visitation. Identification of Others at Risk Social Services Director visited with residents on 7/10/25 to ensure they are able to have visitors with no restrictions. No other residents were identified with the same deficient. Process to Prevent Recurrence On 7/9/25, the DSD gave an in-service to staff regarding the policy for resident rights, specifically regarding visitation. The Social Service designee will visit residents randomly weekly for six weeks to discuss whether they had any concerns with visitation. All findings will be reported to the Administrator. Monitoring Performance The Activity Designee will discuss monthly at resident council for three months whether residents had any concerns with visitation. All findings will be reported to the Administrator. Findings will be reported to the QA committee for further review and recommendations, monthly, for 3 months or until substantial compliance is achieved. The Social Service designee will visit residents randomly weekly for six weeks to discuss whether they had any concerns with visitation. All findings will be reported to the Administrator. Monitoring Performance The Activity Designee will discuss monthly at resident council for three months whether residents had any concerns with visitation. All findings will be reported to the Administrator. Findings will be reported to the QA committee for further review and recommendations, monthly, for 3 months or until substantial compliance is achieved.
Failure to Follow Restraint Policy for Resident Using Abdominal Binder
Penalty
Summary
A deficiency occurred when the facility failed to follow its own restraint policy for a resident who was using an abdominal binder as a physical restraint. The facility did not attempt alternative interventions prior to the application of the abdominal binder, as indicated in the restraint-physical initial evaluation. Additionally, the required informed consent for the restraint was incomplete, lacking a physician's signature and date. The resident's medical records also did not include a care plan addressing the use of the abdominal binder as a restraint. The resident involved had multiple medical diagnoses, including chronic obstructive pulmonary disease (COPD), dysphagia, type 2 diabetes mellitus, and a gastrostomy. The resident was cognitively impaired and dependent on staff for all activities of daily living. Despite these complex needs, staff did not document monitoring of the resident every 30 minutes while the abdominal binder was in use, as required by facility policy. Observations confirmed that the resident was wearing the abdominal binder, and interviews with nursing staff revealed that monitoring and assessment for comfort, tolerance, and breathing difficulties were not performed or documented. Interviews with facility staff, including an LVN, RN, and the Assistant Director of Nursing, confirmed that the facility's procedures were not followed. Staff acknowledged that alternatives to restraint were not tried, informed consent was not properly obtained, and ongoing monitoring and care planning for the restraint were not completed. The facility's policy required that restraints only be used after unsuccessful alternatives, with ongoing documentation, physician orders, and care plans reflecting the use and need for restraints, none of which were fully implemented in this case.
Plan Of Correction
Corrective action: On 7/11/25, the physician's order for the use of abdominal binder for Resident 2 was discontinued and carried out. An individualized care plan to address the use of the abdominal binder was developed on 07/10/2025 for Resident #2. An in-service to the MDS nurses was done by the Regional MDS nurse on 07/9/2025 to discuss the completion of care plans for residents with abdominal binder orders, individualized to address resident needs, clinical conditions, and medical necessity for use. **Identification of others:** On 7/11/25, the DON/ADON conducted a chart audit and reviewed residents with current orders for abdominal binders/physical restraints to ensure that less restrictive interventions were attempted or tried prior to applying a physical restraint. No other residents were identified with the same deficient practice. The Medical Records designee conducted a health records audit on 7/11/25 to ensure residents with an abdominal binder/physical restraint have a complete informed restraint consent. No other residents were identified with the same deficient practice. On 7/11/25, the DON/ADON and Medical Records designee reviewed MAR/TAR records on residents with current orders for abdominal binders/physical restraints to ensure that residents are monitored every 30 minutes while the abdominal binder is in use. No other residents were identified with the same deficient practice. The Lead MDS nurse completed an audit on residents who currently have an abdominal binder/physical restraint order and reviewed to ensure an individualized care plan for abdominal binder/physical restraint use is addressed/updated. No other residents were identified for this deficient practice. **Process to prevent recurrence:** An in-service to all licensed nurses was conducted by the DON on 7/11/25 to discuss trying alternatives prior to the use of an abdominal binder/physical restraint. An in-service to all licensed nurses was conducted by the DON on 7/10/25 to discuss the completion of informed restraint consent when a resident has an order for an abdominal binder/physical restraint. Also, staff must monitor every 30 minutes. An in-service to all licensed nurses was conducted by the DON on 7/9/25 to discuss the completion of care plans for residents with abdominal binder orders, individualized to address resident needs, clinical conditions, and medical necessity for use. The Medical Records designee will conduct a weekly audit for six weeks and monthly thereafter for three months to ensure there is an informed restraint consent completed for residents with an abdominal binder/physical restraint. She will also check the MARS/TARS to ensure the residents are being monitored every 30 minutes. All findings will be reported to the DON. The DON/ADON will ensure care plans for abdominal binder use are addressed for all residents with current abdominal binder orders/physical restraints. Furthermore, the MDS nurses will review/update restraint care plans quarterly and as needed, per protocol. **Monitoring performance:** The DON/ADON will review residents with current orders for abdominal binder application several times a week for six weeks and weekly thereafter for 3 months to ensure that less restrictive interventions were attempted and/or other alternative options prior to abdominal binder/physical restraint. The Director of Nursing will discuss findings at the Quality Assurance and Improvement Committee monthly for evaluation and further action. The DON/ADON and Medical Records designee will check resident records MAR/TAR weekly for six weeks and monthly thereafter for 3 months to ensure residents are being monitored every 30 minutes. An in-service to all licensed nurses was conducted by the DON on 7/9/25 to discuss the completion of care plans for residents with abdominal binder orders, individualized to address resident needs, clinical conditions, and medical necessity for use. The Medical Records designee will conduct a weekly audit for six weeks and monthly thereafter for three months to ensure there is an informed restraint consent completed for residents with an abdominal binder/physical restraint. She will also check the MARS/TARS to ensure the residents are being monitored every 30 minutes. All findings will be reported to the DON. The DON/ADON will ensure care plans for abdominal binder use are addressed for all residents with current abdominal binder orders/physical restraints. Furthermore, the MDS nurses will review/update restraint care plans quarterly and as needed, per protocol. **Monitoring performance:** The DON/ADON will review residents with current orders for abdominal binder application several times a week for six weeks and weekly thereafter for 3 months to ensure that less restrictive interventions were attempted and/or other alternative options prior to abdominal binder/physical restraint. The Director of Nursing will discuss findings at the Quality Assurance and Improvement Committee monthly for evaluation and further action. The DON/ADON and Medical Records designee will check resident records MAR/TAR weekly for six weeks and monthly thereafter for 3 months to ensure residents are being monitored every 30 minutes. The Director of Nursing will discuss findings at the Quality Assurance and Improvement Committee monthly for evaluation and further action. The Regional MDS nurse shall conduct chart audits monthly for 3 months with a focus on care plans for residents with current restraint orders and will provide a report of findings to the Administrator/QA committee for review and further recommendations.
Inaccurate MDS Documentation of Restraint Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment entries accurately reflected a resident's use of restraints. Specifically, for a resident admitted with chronic obstructive pulmonary disease and dysphagia with a gastrostomy, the MDS dated 5/15/2025 indicated that the resident did not have any restraints. However, a review of the resident's physical restraint evaluation dated 5/10/2025 showed that staff had initiated an abdominal binder restraint for the resident. During interviews and record reviews, one registered nurse stated that she did not mark the abdominal binder as a restraint on the MDS because she did not consider it to be a restraint. Another registered nurse and the Assistant Director of Nursing both confirmed that the abdominal binder used for the resident was considered a restraint and should have been documented as such on the MDS. The staff acknowledged the importance of accurate MDS entries, as they reflect the care provided and are essential for identifying the correct status of the patient. Facility policy and procedure documents reviewed indicated that any person completing any portion of the MDS assessment is required to sign and certify the accuracy of that portion. The failure to accurately document the use of a restraint on the MDS for this resident resulted in a deficiency related to the accuracy of assessments, as required by federal regulations.
Plan Of Correction
F 641 Corrective action: A. Resident #2's Admission/Medicare 5-day assessment with an Assessment Reference Date (ARD) of 05/15/2025 has been modified on 07/10/2025 to correct coding for Section P0100D. Other Restraint, to code use of the abdominal binder. This assessment was transmitted and accepted on 07/11/2025 accordingly. B. In-service was done by the Regional MDS consultant re: Section P coding accuracy on 07/9/2025. Identification of Others at Risk: The Lead MDS nurse did a chart audit on 7/10/25 and reviewed residents with current order for abdominal binder use to check if they were correctly coded on the MDS assessment/s: Section P. A copy of this audit was provided to the DON/Administrator for review. One other resident was identified for this deficient practice and MDS assessment was modified accordingly. Measures to prevent recurrence: The Lead MDS nurse will ensure all residents with (new) abdominal binder order that meet the definition of restraint are coded accurately. The Regional MDS consultant shall perform random chart audits, focusing on coding Section P accurately, monthly for three months and present inaccuracy findings to the DON and the Administrator for corrective actions. Monitoring Performance: The Director of Nursing will present a recapitulation of findings of the random monthly audits at the Monthly Quality Assessment and Assurance Committee meeting for review with corrective actions, as indicated. Measures to prevent recurrence: The Lead MDS nurse will ensure all residents with (new) abdominal binder order that meet the definition of restraint are coded accurately. The Regional MDS consultant shall perform random chart audits, focusing on coding Section P accurately, monthly for three months and present inaccuracy findings to the DON and the Administrator for corrective actions. Monitoring Performance: The Director of Nursing will present a recapitulation of findings of the random monthly audits at the Monthly Quality Assessment and Assurance Committee meeting for review with corrective actions, as indicated.
Failure to Assess and Monitor Toenail Detachment in High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a resident's toenail detachment after it began bleeding for five days. The resident, who had multiple diagnoses including diabetes, chronic obstructive pulmonary disease, dysphagia, and was on long-term anticoagulant therapy, was dependent on staff for all activities of daily living and had impaired cognitive skills. The resident's daughter reported bleeding from the resident's toe, and an RN noted dried blood under the left fifth toe. The RN notified the physician, who ordered the treatment nurse to assess and evaluate the situation. Despite this order, there was no documentation of ongoing assessment or monitoring of the toe's condition in the days following the initial report. The RN who first assessed the resident was not present for six days, and upon return, found the toenail had completely detached. The treatment nurse only assessed the resident after the toenail was fully removed, and there was no follow-up treatment documentation regarding the bleeding or the status of the toe during the intervening period. The Director of Nursing confirmed that there was no documentation regarding the status of the toenail's detachment after the initial change of condition assessment. Interviews with nursing staff, including the LVN and Assistant Director of Nursing, confirmed that the resident's condition warranted close monitoring and documentation due to the risk factors of diabetes and anticoagulant use. Facility policies required documentation of changes in condition for at least 72 hours or longer if warranted, including objective, complete, and accurate records of assessments and treatments. However, these policies were not followed, as there was no documentation of the source of bleeding, circulation, signs of infection, or the progress of the toenail detachment for several days.
Plan Of Correction
Immediate Corrective Action Upon notification, the RN Supervisor immediately assessed the toenail of Resident 2 and notified the Physician and family. The treatment nurse was informed and assessed the resident. On 7/9/25, the DON gave a 1-1 in-service to RN 1 regarding ensuring to assess and monitor residents after they have a change of condition and ensure not to delay necessary medical intervention, pain, or further injury. On 7/9/25, the DON gave a 1-1 in-service to LVN 1 regarding ensuring to assess and monitor residents after they have a change of condition and ensure not to delay necessary medical intervention, pain, or further injury. Identification of Others at Risk The Director of Nursing and Medical Records conducted a health records review on 7/9/2025 to ensure all residents with a change of condition were assessed and monitored and follow-up was completed. No other residents were identified with the same deficient. Process to Prevent Recurrence On 7/9/25, the DON gave an in-service to Licensed nurses regarding ensuring to assess and monitor residents after they have a change of condition and ensure not to delay necessary medical intervention, pain, or further injury. Medical Records will audit change of condition assessments daily for six weeks and weekly thereafter for three months to ensure compliance. All findings will be reported to the DON. Monitoring Performance The DON or designee will randomly check residents' change of condition assessments several times a week for six weeks and weekly thereafter for three months to ensure licensed nurses have assessed and monitored after the residents' change of condition.
Failure to Consistently Turn and Reposition Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care by not consistently turning and repositioning two residents with existing pressure ulcers every two hours or as needed. Both residents had significant medical conditions that increased their risk for pressure injuries, including functional quadriplegia, diabetes, muscle weakness, and end stage renal disease for one resident, and acute kidney failure, diabetes, muscle weakness, and a Stage IV pressure ulcer for the other. Documentation and interviews confirmed that the required turning and repositioning tasks were left blank on several shifts, indicating the care was not performed as required. Resident records and assessments showed that both individuals were dependent on staff for mobility and at high risk for developing or worsening pressure ulcers. One resident had multiple pressure ulcers, including an unstageable ulcer on the sacrum and deep tissue injuries on the right gluteus and left heel. The other resident had a Stage IV pressure ulcer on the sacral region. Despite these conditions, neither resident was on a formal turning and repositioning program according to their Minimum Data Set assessments. Interviews with facility staff, including an LVN and the DON, confirmed that the lack of documentation meant the turning and repositioning was not done. Facility policy and national guidelines both require regular repositioning of residents at risk for pressure injuries, but this was not followed for these two residents, as evidenced by incomplete documentation and staff statements.
Failure to Assess and Document After Resident Vomiting Episode
Penalty
Summary
The facility failed to complete and document a comprehensive assessment, including a head-to-toe physical evaluation, blood pressure, heart rate, temperature, and blood glucose measurements, after a resident experienced vomiting. The resident in question had multiple significant diagnoses, including pneumonia, diabetes, gastrostomy status, dependence on supplemental oxygen, and heart failure, and was noted to have severely impaired cognition and total dependence on all activities of daily living. Despite these complex medical needs, after the resident vomited, the responsible nurse did not perform or document the required assessments and vital sign checks. Interviews with facility staff confirmed that the expected protocol following a change in condition, such as vomiting, was not followed. The Director of Nursing stated that staff should conduct a head-to-toe assessment and check vital signs after such events to identify and address potential problems early. Review of facility policy also indicated that a detailed observation and collection of pertinent information should occur after a significant change in a resident's condition. However, documentation and staff statements confirmed that these steps were not taken in this instance.
Failure to Document Medication Administration in MAR
Penalty
Summary
A deficiency occurred when the facility failed to ensure that medication administration was properly documented in the Medication Administration Record (MAR) for a resident. The resident, who was admitted with multiple diagnoses including pneumonia, diabetes, gastrostomy status, dependence on supplemental oxygen, and heart failure, had severely impaired cognition and was dependent on staff for all activities of daily living. The resident had an active order for Ondansetron 4 mg via G-tube every eight hours as needed for nausea and vomiting. On a day when the resident experienced vomiting, a registered nurse stated that Ondansetron was administered but this administration was not documented in the MAR for that month. Both the registered nurse and the Director of Nursing confirmed that medication administration should always be documented according to facility policy. Review of the facility's policy confirmed that licensed personnel are required to document all medication administration.
Failure to Provide Timely Personal Hygiene and ADL Assistance
Penalty
Summary
A resident with significant physical and cognitive impairments, including muscle wasting, multiple pelvic fractures, contractures, and memory problems, was observed in bed with a soiled gown and dry blood on her right nostril for an extended period. The resident was dependent on staff for all activities of daily living (ADLs), including bed mobility, eating, oral hygiene, and personal hygiene. During the observation, the resident appeared uncomfortable, contracted in both lower extremities, and expressed that she was waiting to be cleaned and was in pain. The assigned CNA reported a heavy workload, stating that she was responsible for multiple residents requiring showers and was unable to perform ADLs for the resident in a timely manner. The CNA noticed the dry blood but did not immediately notify the charge nurse, believing it was outside her scope and due to being busy. The LVN also observed the dry blood but did not clean it, assuming it would be addressed during the resident's scheduled shower. The DON confirmed that both CNAs and licensed staff are responsible for ensuring residents are clean and comfortable, and that delays in care can occur when residents require more time for ADLs. Facility policy requires staff to provide appropriate support and assistance with hygiene for residents unable to perform ADLs independently.
Failure to Provide Timely Pain Management Prior to Wound Care
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including muscle wasting, pelvic fractures, and contractures, did not receive appropriate pain management prior to wound care treatment. The resident was dependent on staff for all activities of daily living and had documented memory problems. Despite physician orders for scheduled and as-needed pain medications, including Tramadol and Tylenol, the resident did not receive Tramadol prior to wound care as ordered, and there was no evidence of pain assessment or administration of pain medication before the procedure. The resident was observed to be in significant discomfort, reporting pain throughout her body and stating she had not received pain medication that morning. During wound care, the resident exhibited clear signs of pain, including screaming when touched and turned, leading the treatment nurse to stop the procedure. The responsible LVN admitted to not assessing the resident's pain or administering pain medication as required, citing an intention to wait until just before wound care, but ultimately failing to do so. The facility's policy required pain assessment and timely administration of analgesics, but these steps were not followed, resulting in the resident experiencing unrelieved pain during wound treatment and personal care.
Failure to Timely Address Malfunctioning Equipment and Provide Properly Fitting ADL Supplies
Penalty
Summary
The facility failed to assess and repair a malfunctioning bed in a timely manner for a resident who was admitted with muscle weakness and a sacral pressure ulcer. The resident reported to nursing staff that her bed was broken and emitted a smoke odor, but no maintenance staff evaluated the bed until several days later. The maintenance request log did not specify who checked the bed or when, and there was no immediate response to the report of a burning smell. Interviews with staff revealed that there was no clear process or training for handling malfunctioning equipment, and the bed was not prioritized for immediate inspection despite the potential risk. Additionally, the facility did not provide properly fitting adult briefs for another resident with morbid obesity, muscle weakness, and heart failure. The resident reported discomfort and skin irritation due to being supplied with briefs that were too small, despite her requests for a larger size. She also refused therapy sessions out of concern for exposure due to the ill-fitting briefs. The social service director was unaware of the complaint and stated that no authorization was needed to order the correct size, while the DON acknowledged that staff should have assessed and accommodated the resident's needs promptly. Review of facility policies indicated that maintenance is responsible for keeping equipment safe and operable, and that staff are expected to accommodate residents' individual needs and preferences, including adaptive devices and modifications. The policies also require ongoing assessment and intervention to support residents' activities of daily living and well-being, but these were not followed in the cases described.
Inaccurate Resident Assessments and MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments and that assessment statuses were properly reflected in the medical records for two of three sampled residents. For one resident, the Minimum Data Set (MDS) assessment was inaccurately coded regarding the resident's discharge status. The MDS indicated the resident was discharged to a short-term general hospital, while the discharge summary and staff interviews confirmed the resident was actually discharged to home with family and home health services. Both the Registered Nurse Supervisor and the Director of Nursing acknowledged that the MDS should have been coded to reflect the actual discharge destination, as this information is essential for accurate reporting and follow-up by CMS. For another resident, the facility failed to ensure that bowel and bladder assessment entries on the MDS were accurately documented. The resident's care plan included a scheduled toileting program, and physician orders required monitoring and documentation of bowel elimination. However, the MDS and related documentation contained conflicting information regarding the resident's continence status. The resident reported being continent and able to sense the need to use the bathroom, but the MDS and Bowel and Bladder Program Screener reflected varying levels of incontinence. The MDS Coordinator admitted that the assessments were based on CNA documentation and that resident interviews were not conducted, leading to inaccurate coding. Facility policies and procedures require that MDS assessments be completed accurately, using information from multiple sources including resident interviews, record reviews, and communication with staff and family. The failure to accurately code and document resident assessments in the MDS had the potential to negatively affect the residents' plans of care and the delivery of necessary services, care, and treatment.
Failure to Accurately Complete PASRR Screenings for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that two out of five sampled residents had their Level 1 Preadmission Screening and Resident Review (PASRR) completed accurately. For both residents, the PASRR Level 1 screenings were marked as negative, indicating no serious mental illness, and therefore did not trigger a Level 2 screening. However, both residents had documented diagnoses of serious mental illnesses, including depressive disorder, bipolar disorder, and schizophrenia, as well as histories of psychotropic medication use. For one resident, the admission record and medical documentation showed diagnoses of depressive disorder, bipolar disorder, and schizophrenia, with significant cognitive and functional impairments. Despite these diagnoses, the PASRR Level 1 screening indicated 'no' to the presence of a serious mental disorder, which was inconsistent with the resident's medical history. The Registered Nurse Supervisor confirmed during interview and record review that the PASRR should have been marked 'yes' to trigger a Level 2 screening based on the resident's diagnoses and medication regimen. Similarly, another resident with diagnoses of depressive disorder, bipolar disorder, and dementia was also marked as negative for serious mental illness on the PASRR Level 1 screening. The Registered Nurse Supervisor acknowledged that, given the resident's medical diagnoses and history of psychotropic medication use, the screening should have indicated the presence of a serious mental disorder. The Director of Nursing emphasized the importance of accurate PASRR screenings to ensure appropriate assessment and care planning for residents with mental health needs. The facility's policy requires a new Level 1 PASRR if there is a significant change in condition or any error in previous screenings.
Failure to Provide Required Respiratory Care and Adhere to Physician Orders
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents. For one resident with a tracheostomy, required emergency supplies—including a replacement tracheostomy tube, inner cannula, and obturator—were not available at the bedside as mandated by the resident's care plan and facility policy. Observations confirmed the absence of these supplies, and both the treatment nurse and DON acknowledged that these items should have been present at the bedside for emergency situations such as accidental decannulation or tube blockage. For another resident receiving oxygen therapy via nasal cannula, there was no physician order in place for the administration of oxygen or for oxygen saturation monitoring, despite the resident being observed with an oxygen concentrator set at 5L/min. Nursing staff confirmed that the resident had been receiving oxygen without a physician's order, and the DON stated that such an order is required, including details on the amount of oxygen, monitoring parameters, and tubing changes. Review of facility policies confirmed that a replacement tracheostomy tube and related supplies must be available at the bedside at all times, and that oxygen administration requires a physician's order. The lack of adherence to these policies resulted in the identified deficiencies for both residents.
Medication Error Rate Exceeds 5% Due to Improper Nebulizer Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 26 observed opportunities, resulting in a 7.69% error rate. Specifically, a nurse did not remain with a resident during two separate nebulizer breathing treatments, contrary to facility policy and physician orders. The nurse set a timer and left the resident unattended during the administration of Ipratropium-Albuterol and Budesonide inhalation solutions, only returning after the treatments were completed. During this time, the resident's nebulizer mask was observed to have slipped off, and the resident reported having to reposition the mask herself when left alone. Additionally, the nurse failed to instruct the resident to rinse her mouth after the administration of Ipratropium-Albuterol via nebulizer, as required by the physician's order and documented in the Medication Administration Record. The nurse only provided mouth rinsing instructions after the Budesonide treatment, not after the Ipratropium-Albuterol treatment. The nurse acknowledged not being aware that the mask sometimes fell off and admitted to not staying with the resident during the treatments, despite knowing it was required. The resident involved was admitted with acute respiratory failure with hypoxia and was cognitively intact. Interviews with the resident and staff confirmed that the resident was often left alone during nebulizer treatments and sometimes had to adjust the mask herself. Facility policy and the Director of Nursing both confirmed that staff are required to remain with residents during nebulizer treatments and to instruct them to rinse their mouths after administration, which was not followed in these instances.
Expired Medication Administered to Resident with Respiratory Conditions
Penalty
Summary
A deficiency occurred when a resident with a history of COPD, asthma, and recent respiratory infections was administered three doses of expired Advair Diskus (fluticasone and salmeterol) by three different licensed nurses. The medication, which is used to treat breathing difficulties, was found to have been opened and labeled with an expiration date, but was not removed from the medication cart after it expired. The facility's records and interviews confirmed that the expired inhaler was administered on three separate occasions after the expiration date had passed. The resident's care plan included interventions to assess for respiratory distress and to administer medications as ordered. However, the expired inhaler remained accessible in the medication cart, and the nurses did not check the expiration date before administration. The manufacturer's label on the inhaler specified that it should be discarded one month after opening, but this instruction was not followed, resulting in the use of an expired medication. Interviews with nursing staff and the Director of Nursing confirmed that the expired medication was administered and that the process for checking expiration dates was not followed. The facility's policy required that expiration dates be checked prior to administration, but this was not done, leading to the resident receiving potentially ineffective medication for their respiratory condition.
Food Storage, Temperature Control, and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner, as observed during multiple inspections of the dry storage area, walk-in refrigerator, and seasoning shelf. Several food items, including breadcrumbs, grits, split peas, barley, beans, bread, chicken salad, dressings, mustard, sour cream, cheese, fruit plates, paprika, and onion powder, were found to be either undated, unlabeled, or not properly sealed. The Dietary Supervisor confirmed that all food items should be labeled with receiving, open, and use-by dates, and that all opened items should be tightly closed to prevent contamination. Facility policies reviewed also required proper dating, labeling, and storage of all food items, but these procedures were not consistently followed by staff. During meal service, the temperature of ground beef patties in the steam tray was found to be 138°F, which is below the facility's required minimum of 155°F for ground meat. The cook stated that the temperature had dropped unexpectedly, and the Dietary Supervisor indicated that meat temperatures should be above 165°F for safety. Facility policy required that food temperatures be checked and recorded to ensure hot foods are served at proper temperatures, but this was not adhered to in this instance. Additionally, a Dietary Aid was observed failing to perform proper hand hygiene and glove changes between tasks during trayline. The staff member touched a juice cup with bare hands, put on gloves without washing hands, handled a lunch cart, and then touched clean plate lids without changing gloves or washing hands. The Dietary Aid acknowledged the lapse, and the DON confirmed that hand hygiene should be performed between tasks to prevent cross contamination. Facility policy required hand washing before donning gloves and after handling soiled items, but these procedures were not followed.
Failure to Implement Infection Control Measures and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in several instances involving both environmental cleaning and staff hand hygiene. In one case, a resident with a history of seizures, liver transplant, and peritonitis had bed side rails wrapped with foam and paper tape for safety. Observations revealed that these materials were porous and not suitable for disinfection with the bleach germicidal wipes used by housekeeping staff, as these wipes are intended for nonporous, hard surfaces. The Infection Preventionist Nurse confirmed that the use of foam and paper tape on bedrails was inappropriate, as it could not be properly sanitized and posed a risk for cross contamination, contrary to the facility's policy requiring cleaning and disinfection of resident-care equipment according to CDC recommendations. Another deficiency was observed during a dining service, where a Treatment Nurse failed to perform hand hygiene while checking lunch trays. The nurse touched multiple trays, a diet listing document, her mask, and the lunch cart door without washing or sanitizing her hands between tasks. The nurse acknowledged the lapse, and both the Infection Preventionist Nurse and Director of Nursing confirmed that hand hygiene should be performed between tasks and after touching high-touch surfaces, as outlined in the facility's hand hygiene policy. A further incident involved a Licensed Vocational Nurse who did not perform hand hygiene after preparing medications and before administering them to a resident with hemiplegia and prostate cancer. The nurse was observed holding a straw for the resident to drink water without having washed or sanitized her hands after medication preparation. The nurse admitted to not following hand hygiene protocols, which is required by the facility's policies for both hand hygiene and medication administration.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
A deficiency occurred when a staff member failed to treat a resident with dignity and respect during feeding assistance. The resident, who had intellectual disabilities and dysphagia, required help with eating and was enrolled in a restorative nursing feeding program. During an observation, the staff member was seen standing over the resident while feeding her, rather than sitting at eye level as required by the facility's policy and the resident's care plan. The staff member only corrected this after noticing the presence of a state surveyor, at which point he retrieved a stool and sat next to the resident to continue feeding. Interviews with the staff member and the Director of Nursing confirmed that the expectation was for staff to sit at eye level with residents during feeding to ensure comfort, dignity, and to avoid making residents feel rushed. The facility's policy on meal assistance also specified that residents should not be fed while staff are standing over them. The failure to follow these procedures resulted in the resident potentially feeling rushed, uncomfortable, and disrespected during mealtime.
Failure to Accurately Complete PASRR Screening for Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately complete a Level I Pre-Admission Screening and Resident Review (PASRR) for one resident who had documented diagnoses of post-traumatic stress disorder (PTSD) and depression. The resident's admission record and Minimum Data Set (MDS) both indicated the presence of these mental health conditions. However, the Level I PASRR screening marked the question regarding serious mental illness as 'No,' despite the resident's diagnoses. This resulted in a negative Level I PASRR, which did not trigger a Level II evaluation for serious mental illness. During an interview and record review, the DON acknowledged that the Level I PASRR screening was inaccurate and should have reflected the resident's mental health diagnoses. The facility's policy required submission of a new Level I PASRR if discrepancies were found between the screening and the resident's records, but this was not done. As a result, the resident was not properly screened for mental disorders or intellectual disabilities as required by federal regulations.
Failure to Update Care Plan for Oxygen Therapy Changes
Penalty
Summary
The facility failed to update the care plan for a resident when their oxygen requirements changed. The resident, who had a history of pneumonia, acute respiratory failure, and COPD, was observed receiving varying amounts of supplemental oxygen via nasal cannula, with the oxygen concentrator set at 5 L/min during one observation and 2 L/min during another. Despite these changes, there were no physician orders for oxygen therapy or oxygen saturation monitoring, and the care plan did not specify the oxygen rate. The care plan had been initiated and revised previously but was not updated upon the resident's readmission to the facility with oxygen therapy. Interviews with nursing staff and review of facility policy confirmed that the care plan should have been reviewed and revised when the resident was readmitted and when there was a change in condition. The facility's policy required the interdisciplinary team to update care plans after significant changes, unmet outcomes, readmissions, or at least quarterly. The Director of Nursing acknowledged that the care plan should have been updated to reflect the resident's current oxygen therapy needs.
Improper Medication Storage and Administration Practices
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly labeled and stored according to professional standards, resulting in two specific deficiencies. In the first instance, a resident was found to have a bottle of TUMS, an over-the-counter antacid, stored at their bedside without a physician's order for self-administration. The resident, who had diagnoses including cholangitis, muscle weakness, and a pressure ulcer, was assessed as not being able to safely self-administer medications. Despite this, the resident reported that staff were aware of the medication at the bedside and had advised hiding it during the survey. Facility policy required that medications not authorized for self-administration be removed from the bedside and returned to the nurse in charge. In the second instance, an expired inhaler containing fluticasone and salmeterol was found on a medication cart and had been administered to a resident with COPD and asthma. The inhaler, which was labeled with an open date, had expired according to manufacturer instructions but was still used for three doses by different licensed nurses. The facility's policies required checking expiration dates before administration and removing expired medications from storage, but these procedures were not followed, resulting in the administration of expired medication. Both deficiencies were identified through observation, interview, and record review. Staff interviews confirmed awareness of the improper storage and administration practices, and facility policies were reviewed that outlined the correct procedures, which were not adhered to in these cases.
Failure to Replace Missing Dentures and Follow Up on Dental Care
Penalty
Summary
The facility failed to implement its policy and procedure for dental services by not ensuring the replacement of missing dentures and not following up after a dental visit for a resident with significant medical needs. The resident, who was edentulous and required maximal assistance for daily activities, had an order for dental consult and treatment as needed. Despite this, there was no documentation of follow-up regarding the resident's missing dentures in the social service notes, and the care plan only indicated observation for chewing or swallowing difficulties and a dental consult if needed. During interviews and observations, the resident reported not knowing the whereabouts of her dentures, experiencing discomfort while eating, and feeling embarrassed due to the lack of teeth. She stated that the first set of dentures did not fit properly, the second set was missing, and although she requested new dentures from the Social Service Director (SSD), she had not received any updates. The dental notes indicated the resident had lost her dentures months prior and allegedly declined new ones, but the SSD did not follow up to confirm the reason for refusal or to reassess the resident's wishes. The facility's policy required referral for dental services within three days of lost or damaged dentures and documentation if this was not possible, as well as assistance from social services in arranging appointments and follow-up. The SSD acknowledged not following up with the resident after the dental visit, and the Director of Nursing confirmed the importance of timely denture provision. The lack of follow-up and failure to replace the dentures constituted a deficiency in meeting the resident's oral health needs as outlined in the facility's own policies.
Deficiencies in Controlled Substance Management
Penalty
Summary
The facility failed to securely store discontinued orders for controlled substances for two residents, as required by its policy and procedure. During an observation and interview, it was revealed that narcotics, once expired or no longer prescribed, were supposed to be brought to the Director of Nursing (DON) and stored under double lock. However, a clear plastic bin in the DON's office contained a box of fentanyl patches without a resident name label and two bubble packs of hydrocodone-acetaminophen tablets prescribed to one resident, with discrepancies in the narcotic count sheet indicating missing tablets. Additionally, the facility did not maintain accurate documentation for the controlled drug record of one resident. The narcotic control book, which should be updated after every administration, was not accurately maintained, leading to an incorrect count of medications. The DON acknowledged the absence of documentation for another resident, emphasizing the importance of accurate records to prevent residents from missing medications or receiving unprescribed ones. The facility's policy required discontinued or expired controlled medications to be stored under double lock and destroyed by the DON and consultant pharmacist, with routine monitoring during quarterly inspections.
Failure to Develop Care Plan for Pain Management
Penalty
Summary
The facility failed to develop a care plan for a resident who was prescribed Lidocaine patches for pain management in her left knee and left shoulder. Despite the resident's intact cognition and capacity to make medical decisions, as indicated in her Minimum Data Set and History and Physical, there was no care plan documented for the use of Lidocaine patches. The resident had been receiving these patches since her admission, as confirmed by her Medication Administration Record and her own statement during an interview. The absence of a care plan was confirmed during interviews with a Licensed Vocational Nurse and the Director of Nursing, who both acknowledged that a care plan should have been developed to monitor the resident's pain management. The facility's policy requires that care plans be implemented within seven days of admission or after a professional's initial contact with the resident. The lack of a care plan resulted in the facility's inability to assess and adjust the resident's pain management regimen effectively.
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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