Cheviot Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3533 Motor Avenue, Los Angeles, California 90034
- CMS Provider Number
- 056451
- Inspections on file
- 58
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Cheviot Hills Post Acute during CMS and state inspections, most recent first.
A resident admitted with sequelae of cerebral infarction, DM, and heart failure was assessed on admission as having excessive dry skin to the face and BLE, but no individualized care plan was developed to address this skin abnormality. The ADON acknowledged that dry skin is a skin abnormality that must be care planned and confirmed that no such care plan existed. The DON stated that not accurately assessing the dry skin could have resulted in broken skin or infection. Review of facility P&P showed that the IDT is required to develop a comprehensive person-centered care plan with measurable objectives and timeframes for all identified needs, including skin problems, but this was not done for this resident’s dry skin.
A resident with a history of stroke, DM, and heart failure was admitted with excessive dry skin on the face and bilateral lower extremities, but nursing staff did not obtain treatment orders or develop a care plan for this condition. Although the admission assessment documented dry skin, subsequent weekly head‑to‑toe assessments by CNs and LVNs failed to record it, and the ADON later confirmed these assessments were inaccurate. Staff interviews showed that CNs are expected to report skin abnormalities to charge nurses, LVNs typically obtain A + D ointment orders for dry skin, and RNs are responsible for comprehensive assessments and care plans, yet these processes did not result in an accurate assessment or care plan for the resident’s dry skin, contrary to facility policy and scope‑of‑practice requirements.
A resident with significant medical needs was found to have excessive dry skin on the face and overgrown toenails, despite requiring substantial assistance with ADLs. Staff observations and interviews confirmed the hygiene issues, and the care plan did not address the resident's specific skin care needs. Facility policy required support for hygiene and grooming, but this was not consistently provided.
A resident with multiple complex medical conditions, including OSA and use of BiPAP, was not accurately assessed in the MDS, as both the diagnosis of OSA and the BiPAP treatment were omitted. The ADON confirmed these omissions during review, despite facility policy requiring comprehensive and consistent documentation.
A resident with multiple diagnoses, including OSA and a history of hypercapnic respiratory failure treated with BiPAP, did not have a care plan developed for OSA or BiPAP use. The absence of this care plan was confirmed during record review and interview with the ADON, despite facility policy requiring comprehensive care planning for all identified needs.
A resident with multiple chronic conditions and at risk for pressure injuries was admitted with a physician's order for left foot treatment, but the facility did not develop a care plan to address this need. The DON confirmed that interventions for the left foot were not care planned, despite facility policy requiring comprehensive care planning and regular updates based on resident condition.
A resident with multiple risk factors for pressure injuries did not receive consistent skin monitoring or timely reporting of changes, as required by physician orders and facility policy. Staff failed to apply prescribed ointment and did not report redness and a developing wound on the resident's left heel, despite the resident voicing concerns and preventive measures being in place.
The facility did not ensure dietary cooks followed the menu and used a recipe for lunch, leading to potential food preparation errors. Observations revealed missing or incorrectly dated food items and a lack of a written recipe for the meal being prepared. Interviews confirmed that cooks were memorizing recipes, contrary to facility policy requiring standardized recipes.
The facility failed to maintain safe food storage and preparation practices, risking foodborne illness for 89 residents. Observations revealed improperly labeled food in the refrigerator and a lack of recipes for meal preparation. Interviews indicated inadequate staff training and improper cooling methods for leftovers, contrary to facility policies.
A facility failed to promote dignity during meal assistance when a CNA was observed feeding a resident while standing, contrary to the policy requiring staff to be seated at eye level. The resident, with a history of metabolic encephalopathy and other conditions, was dependent on assistance for eating. The facility's policy emphasizes maintaining resident dignity and ensuring safe eating practices.
A facility failed to complete and submit the annual MDS assessment within the required timeframe for a resident with multiple diagnoses, including epilepsy and bipolar disorder. The resident was totally dependent on staff for all ADLs and had severely impaired cognition. The last MDS assessment was completed months before the due date, and the facility's policies and job descriptions required timely completion and submission of assessments.
A facility failed to conduct a PASRR Level 1 assessment for a resident with schizophrenia and major depression, leading to potential inappropriate placement and management. The resident was admitted with these diagnoses, and the PASRR letter indicated no need for Level II screening. However, the facility did not follow up on the necessary PASRR Level II evaluation. Interviews revealed staff lacked experience and training in PASRR procedures, contributing to the oversight.
The facility failed to complete and maintain PASRR Level I evaluations for three residents, impacting their psychiatric care. A resident with bipolar disorder and another with schizophrenia did not have their mental illnesses indicated in their PASRR Level I, preventing necessary Level II evaluations. Another resident qualified for a Level II evaluation, which was not conducted. The Admission Director admitted to errors due to insufficient training.
The facility failed to maintain proper narcotic disposal procedures, as the DON did not keep records of medications collected for disposal, potentially leading to diversion. Additionally, an incorrect PASRR Level 1 screening was submitted for a resident with schizophrenia and major depression due to inadequate training of the Admission Director. These deficiencies highlight issues in the facility's adherence to policies, impacting resident care.
A resident with multiple health issues, including fractures and mobility problems, missed a crucial orthopedic follow-up appointment due to the facility's failure to coordinate transportation and appointment scheduling. The case manager, responsible for these tasks, was absent, leading to the oversight. The facility's policy requires social services to manage such referrals and transportation, which was not followed.
The DON failed to properly store and discard medications, leaving them accessible in an unlocked container in his office. The medications were not dissolved as required, posing a risk for diversion. The facility's policy mandates secure storage and proper disposal methods, which were not followed.
A resident experienced a delay in receiving a substitute meal after expressing dissatisfaction with the breakfast served. Despite requesting an alternative at 7:15 am, the resident waited over two hours before receiving a substitute meal. Staff interviews indicated a delay in the kitchen's preparation of the substitute, contrary to the facility's policy on accommodating food preferences.
A resident was bitten by a spider due to the facility's failure to maintain a pest-free environment. Despite recent pest control measures, a CNA observed a spider near the resident's room. The Maintenance Supervisor confirmed scheduled fumigation, but the incident indicates a lapse in the pest control program's effectiveness.
A resident with a history of falls and cognitive impairments was left unattended by a CNA while sitting on the side of the bed, resulting in a fall and multiple rib fractures. The resident required substantial assistance with daily activities and was identified as a fall risk. Despite this, the CNA left the resident unsupervised, leading to the incident and subsequent hospital transfer.
A resident with a history of sepsis and diabetes, and an indwelling catheter, exhibited chills on two occasions, but the facility failed to notify the physician as required by the care plan. This led to the resident developing altered mental status and being transferred to a hospital, where she was diagnosed with sepsis and a UTI.
A resident with intact cognitive skills refused assistance from a specific CNA due to negative past interactions. Despite this, another CNA brought the refused CNA into the resident's room to assist with care, violating the resident's right to choose their caregiver. The facility's policies, which emphasize resident participation in care planning, were not followed.
The facility failed to protect a resident from abuse, resulting in one resident punching another, causing a cut to the lip. The incident involved a resident with dementia and another with major depressive disorder and anxiety. The investigation revealed a lack of behavioral monitoring and documentation for the resident with dementia, contributing to the incident.
The facility failed to obtain a physician's order for behavior monitoring and implement behavior monitoring for a resident with dementia, leading to an altercation where another resident punched the first resident in the face. The lack of monitoring and documentation contributed to the incident, despite the facility's policy on behavior management.
Failure to Care Plan for Resident with Documented Dry Skin
Penalty
Summary
Surveyors identified that the facility failed to develop and implement an individualized, person-centered care plan for a resident who was admitted with documented dry skin to the face and bilateral lower extremities. The resident’s admission assessment, completed in the evening on the date of admission, recorded excessive dry skin under the body check section. Despite this documented skin abnormality, a review of the resident’s care plans showed there was no care plan addressing dry skin. The facility’s Assistant Director of Nursing (ADON) stated in interview that dry skin is considered a skin abnormality that must be care planned and confirmed that the resident was admitted with dry skin to the face and both legs but had no corresponding care plan. The resident’s medical record indicated admission with diagnoses including sequelae of cerebral infarction, diabetes mellitus, and heart failure. The Director of Nursing (DON) stated that not accurately assessing the resident’s dry skin could have resulted in broken skin or infection. Review of the facility’s policy and procedure titled “CARE PLAN COMPREHENSIVE” showed that the Interdisciplinary Team, in coordination with the resident and/or representative, is required to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified needs from the comprehensive assessment, including incorporation of identified problem areas and associated risk factors. The failure to create a care plan for the resident’s dry skin was inconsistent with this policy and represented the cited deficiency.
Failure to Assess and Care Plan Dry Skin for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with documented dry skin was properly assessed and care planned by nursing staff with the appropriate competencies and within their scope of practice. On admission, Resident 2’s initial assessment documented excessive dry skin on the face and bilateral lower extremities. The resident had significant medical diagnoses including sequelae of cerebral infarction, diabetes mellitus, and heart failure, and the MDS later documented mild cognitive impairment and a need for assistance with multiple ADLs. Despite the documented dry skin at admission, there were no physician orders for skin ointments or protectants for dry skin in the resident’s record over several months. Review of Resident 2’s care plans showed there was no care plan addressing dry skin, even though the ADON stated that dry skin is considered a skin abnormality that must be care planned. The ADON confirmed that Resident 2 was admitted with dry skin to the face and both legs but that this condition was not reflected in the care plan. Additionally, weekly head‑to‑toe assessments completed by night shift charge nurses on multiple dates did not indicate the presence of dry skin, which the ADON acknowledged was inaccurate. This demonstrated that the ongoing assessments did not accurately capture the resident’s skin condition. Interviews with staff further clarified the facility’s assessment and reporting processes. An LVN stated that A + D ointment is typically ordered for residents with dry skin and that CNs report skin abnormalities to charge nurses, who then assess residents and report changes in condition to the RN Supervisor. The RN Supervisor stated that full body assessments are completed on admission, readmission, or change of condition. Facility job descriptions for LVNs and RNs emphasized providing nursing care within the scope of practice and ensuring baseline and periodic comprehensive assessments and care plans are completed. The facility’s care plan policy required that identified problem areas and risk factors be incorporated into comprehensive care plans and that assessments be ongoing with care plans reviewed and revised as new information emerges. The Board of Vocational Nursing and Psychiatric Technicians guidance indicated that LVNs cannot perform certain types of assessment, underscoring that a licensed nurse with the appropriate skill set did not complete or document an accurate assessment and care plan for Resident 2’s dry skin.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene and grooming for one resident with multiple medical conditions, including Type 2 Diabetes Mellitus, sequelae of cerebral infarction, and dysphagia. Upon admission, the resident was noted to have excessive dry skin on the face and both lower legs, and required substantial to maximal assistance with showers and baths. The resident's care plan addressed self-care performance deficits related to impaired balance and limited mobility, but did not include interventions for the excessive dry skin. Observations revealed the resident had visible dry, white/gray flakes of skin on the face and overgrown toenails. Staff interviews confirmed these findings, with a nurse acknowledging the condition was unacceptable and a CNA admitting the toenails should have been reported to the charge nurse. Further review indicated that although the resident was scheduled for a shower and had reportedly received one, the issues with dry skin and overgrown toenails persisted. The facility's policy required that residents unable to perform activities of daily living independently receive appropriate support for hygiene and grooming, but this was not consistently implemented for the resident in question. The lack of timely intervention and communication among staff contributed to the ongoing issues with the resident's personal hygiene and grooming.
Failure to Accurately Document Diagnoses and Treatments in MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment in the Minimum Data Set (MDS) for one resident. The resident was admitted with multiple diagnoses, including heart failure, cellulitis, muscle weakness, morbid obesity, hypertension, and obstructive sleep apnea (OSA). The resident's hospital history and physical also documented hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome and OSA, which was treated with BiPAP therapy. However, upon review of the resident's MDS, it was found that the diagnosis of OSA was not included in Section I - Active Diagnoses, and the use of BiPAP was not documented in Section O - Special Treatments, Procedures, and Programs. During an interview and record review, the Assistant Director of Nursing (ADON) confirmed that both the OSA diagnosis and BiPAP treatment were missed in the MDS assessment. The facility's policy and procedures require that comprehensive assessments reflect information from progress notes, care plans, and resident observations/interviews, but this was not followed in this case. This omission had the potential to affect the resident's plan of care and delivery of services.
Failure to Develop Care Plan for OSA and BiPAP Use
Penalty
Summary
The facility failed to develop a care plan addressing obstructive sleep apnea (OSA) for a resident who was admitted with multiple diagnoses, including OSA, heart failure, cellulitis, muscle weakness, morbid obesity, and hypertension. The resident's hospital history indicated she experienced hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome and OSA, which was treated with BiPAP therapy, resulting in improvement. Despite these significant medical issues, a review of the resident's care plans confirmed that no care plan was created for OSA or the use of BiPAP. The resident was assessed as having intact cognition but required staff assistance for bed mobility, bathing, dressing, personal hygiene, and supervision for eating and oral hygiene. During an interview and record review, the ADON verified the absence of a care plan for OSA or BiPAP and acknowledged that this could impact the resident's overall health. The facility's own policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes to address all identified needs, but this was not done for the resident's OSA.
Failure to Develop Care Plan for Left Foot Treatment
Penalty
Summary
The facility failed to develop a care plan addressing left foot treatments for a male resident admitted with multiple diagnoses, including peripheral vascular disease, Type 2 diabetes mellitus, atherosclerosis, and other chronic conditions. The resident was identified as being at risk for developing a pressure injury and was dependent on staff for activities such as toileting, personal hygiene, and transfers. Despite a physician's order to apply A&D ointment to the resident's left foot and toes for excessive dryness and to monitor for skin breakdown, no care plan was created to address these specific needs. During an interview and record review, the DON confirmed that the left foot treatment order should have been care planned, especially given the resident's risk factors for pressure injuries. The facility's own policies required comprehensive, interdisciplinary care planning for prevention and wound treatments, as well as regular review and updates to care plans based on changes in resident condition. However, the care plan for this resident did not include interventions for the left foot, and the omission was acknowledged by facility leadership.
Failure to Monitor and Report Skin Changes Leading to Pressure Injury Risk
Penalty
Summary
A deficiency occurred when staff failed to monitor and report changes in a resident's skin condition, specifically redness on the left heel, to the attending physician. The resident, an older male with significant medical history including peripheral vascular disease, diabetes, atherosclerosis, and a partial foot amputation, was identified as being at risk for pressure injuries and was dependent on staff for most activities of daily living. Despite physician orders to apply A&D ointment to the left foot for excessive dryness and to monitor for skin breakdown every shift, staff inconsistently applied the ointment and did not consistently monitor or report changes in the skin condition. The resident reported concerns about developing a pressure ulcer on the heels to both facility staff and the physician, but felt these concerns were not addressed. Observations revealed that heel protector boots, intended as a preventive measure, were not consistently used as ordered. Staff interviews confirmed that the ointment was not applied on the day of observation and that the CNA did not notice or report any redness. When the LVN finally assessed the left heel, a reddened area with a black scab was found, and the resident exhibited pain upon palpation. Facility policy required staff to observe for signs of potential or active pressure injury daily and to notify the physician of any significant changes. However, the lack of timely reporting and intervention for the observed skin changes on the resident's left heel constituted a failure to follow these protocols, resulting in a deficiency related to pressure ulcer prevention and care.
Failure to Follow Menu and Recipe in Food Preparation
Penalty
Summary
The facility failed to ensure that dietary cooks followed the menu and used a recipe for lunch on a specific date. During an initial kitchen observation, it was noted that several food items in the walk-in refrigerator were either not labeled with a date or were dated incorrectly. Additionally, during an observation of the food recipe binder, it was found that there was no recipe for the lunch being prepared, which was chicken noodle casserole. The Dietary Supervisor admitted that the menu was in their office and that the cooks were memorizing the recipe instead of following a written one. Interviews with the Dietary Supervisor and a dietary cook revealed that the lack of a written recipe could lead to food being prepared incorrectly, potentially making residents sick. The facility's policy and procedures, reviewed prior to the incident, stated that menus should meet the nutritional needs of residents and that standardized recipes should be developed and used in food preparation. However, these policies were not followed, as evidenced by the absence of a recipe for the meal being prepared.
Deficiency in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, which had the potential to result in harmful bacteria growth and foodborne illness for all 89 medically compromised residents. During an initial kitchen observation, several containers of cooked food in the walk-in refrigerator were noted to be improperly labeled or unlabeled, with some items not having a date. Additionally, the food recipe binder lacked a recipe for the chicken noodle casserole being prepared, and the Dietary Supervisor admitted that the menu was not available to the cooks, who were instead relying on memorization. Interviews with dietary staff revealed further issues, including a lack of recent skills competency assessments for the cooks and improper cooling methods for leftover food. The night shift cook did not follow the cooling down method for food cooked the previous day, and the leftover food was already stored in the refrigerator without proper cooling. The Registered Dietician confirmed that storing leftover cooked foods improperly could lead to foodborne illnesses. The facility's policy and procedures emphasized the importance of adhering to safe food handling practices, including rapid cooling of potentially hazardous foods, which was not followed in this instance.
Failure to Promote Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that staff promoted dignity while assisting a resident during meals. Specifically, a Certified Nursing Assistant (CNA) was observed feeding a resident while standing, rather than sitting at eye level as required by the facility's policy. This practice was noted during a meal observation, where the CNA was standing to the right side of the resident while feeding them. The CNA acknowledged that she was supposed to be seated beside the resident to assist with feeding, which is in line with the facility's policy to maintain resident dignity and ensure safe eating practices. The resident involved had a medical history that included metabolic encephalopathy, paralytic syndrome following cerebral infarction, hypertension, and contractures of both knees. The resident was dependent on assistance for eating, oral hygiene, and dressing, among other personal care needs. The facility's policy on dignity emphasizes caring for residents in a manner that promotes their well-being and self-esteem. The Assistant Director of Nursing confirmed that CNAs are required to be seated at eye level when assisting residents with eating to ensure proper chewing and swallowing, as well as to uphold the resident's dignity.
Failure to Complete Annual MDS Assessment on Time
Penalty
Summary
The facility failed to complete and submit the annual comprehensive Minimum Data Set (MDS) assessment within the regulatory timeframe for a resident. The resident was originally admitted on November 3, 2023, and readmitted on May 17, 2024, with diagnoses including epilepsy, bipolar disorder, hemiplegia, and hemiparesis. The resident was totally dependent on staff for all activities of daily living and had severely impaired cognition. The last MDS assessment for the resident was completed on July 30, 2024, and the annual assessment was overdue as it should have been completed by November 1, 2024. During a review with the MDS Coordinator, it was confirmed that the annual MDS assessment was overdue, and the coordinator acknowledged that the MDS is a complete record of the resident's care. The Director of Nursing also stated that the MDS should be completed and submitted according to CMS timeframes. The facility's policy and procedures, as well as the MDS/RAI Coordinator's job description, indicated that assessments should be completed and transmitted within required timeframes, which was not adhered to in this case.
Failure to Conduct PASRR Level 1 Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to conduct a Preadmission Screening and Resident Review (PASRR) Level 1 assessment for a resident diagnosed with mental illness, specifically schizophrenia and major depression. The resident was admitted with these diagnoses, and the PASRR letter indicated a negative result for Level I screening, suggesting no need for Level II screening. However, the facility did not follow up on the PASRR Level II for the resident, which was necessary given the resident's mental health conditions and medication regimen, including Trazadone, Risperdal, Aripiprazole, and Clozaril. Interviews with facility staff revealed a lack of experience and training in PASRR procedures. The Admission Director, who was responsible for ensuring PASRR Level 1 was received upon admission, had minimal training and relied on licensed nurses to review the PASRR Level 1. The Assistant Director of Nursing and the Director of Nursing acknowledged the oversight and the need for a PASRR Level II evaluation, which was not conducted. This oversight was attributed to a failure in the facility's process to ensure proper PASRR assessments were completed, potentially leading to inappropriate placement and management of the resident's mental health condition.
Failure to Complete PASRR Evaluations
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening Resident Review (PASRR) Level I was obtained and maintained in the residents' charts for three sampled residents. Resident 1 was readmitted with diagnoses including bipolar disorder, anxiety, and depression, yet the PASRR Level I did not indicate a diagnosis of mental illness, leading to a lack of a Level II evaluation. Similarly, Resident 2, who was readmitted with schizophrenia and major depression, also did not have a PASRR Level I indicating a mental illness, resulting in no Level II evaluation. Resident 74, admitted with schizophrenia and depression, qualified for a PASRR Level II evaluation, but it was not conducted upon admission. The Admission Director admitted to submitting incorrect PASRRs due to a lack of training, which was only received after the errors occurred. The Assistant Director of Nursing acknowledged that Resident 74 should have been rescreened for PASRR Level II upon admission. The Director of Nursing confirmed that incorrect completion of PASRRs could affect psychiatric treatment for residents. The facility's policy stated that the Admissions Director or Social Worker should ensure PASRR completion for all potential residents, but this was not adhered to, leading to the deficiency.
Deficiencies in Narcotic Disposal and PASRR Screening
Penalty
Summary
The facility failed to maintain proper procedures for the disposal of narcotics, as the Director of Nursing (DON) did not keep a log or records of medications collected for disposal by a medication waste management company. During an interview, the DON admitted to not knowing the process of preventing diversion once the medications are picked up, nor did he have an answer for preventing theft of narcotics from an unlocked bucket in his office. This lack of knowledge and procedure could potentially lead to the diversion of medications. Additionally, the facility submitted an incorrect Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident who was admitted with diagnoses including schizophrenia and major depression. The Admission Director (AD) acknowledged submitting the incorrect PASRR and admitted to not receiving adequate training on completing and submitting PASRR Level 1 or Level 2. This error in the PASRR process could affect the necessary and required treatment for the resident. The facility's policies and procedures require the Director of Nursing to be knowledgeable and competent in their duties, including overseeing nursing practices and developing staff training programs. However, the DON's lack of knowledge regarding narcotic disposal and the AD's insufficient training on PASRR processes highlight deficiencies in the facility's adherence to these policies, potentially impacting the quality of care provided to residents.
Failure to Coordinate Orthopedic Follow-Up for Resident
Penalty
Summary
The facility failed to provide necessary social services to Resident 244 by not following up on an orthopedic evaluation appointment. Resident 244, who was admitted with multiple diagnoses including fractures, gout, hyperlipidemia, prostate cancer, and mobility issues, had an intact cognition and required varying levels of assistance with daily activities. Despite having a scheduled orthopedic follow-up appointment, it was canceled without informing the resident of the reason or who canceled it. This oversight was identified during an initial tour when the resident mentioned the missed appointment. The case manager, responsible for coordinating referrals and appointments, acknowledged the missed appointment, citing her absence as the reason. She explained her usual process of arranging transportation and negotiating costs for private pay residents like Resident 244, who lacked transportation insurance. The Director of Nursing emphasized the importance of follow-up appointments for assessing treatment progress and adjusting care plans. The facility's policy indicated that social services should coordinate referrals and transportation for medical services based on physician evaluations and orders, which was not adhered to in this case.
Improper Storage and Disposal of Medications
Penalty
Summary
The Director of Nursing (DON) failed to store and discard controlled and non-controlled medications according to the facility's policy and procedures. During an observation and interview, it was noted that medications were stored in a large blue and white bucket with an unlocked screw-on top in the DON's office, which was shared with the Assistant Director of Nursing (ADON). The medications were whole, intact, and retrievable, and were not mixed in any solution to dissolve them, making them easily accessible. The DON stated that the narcotics are disposed of with the pharmacist once a month, but there was no log for the medication waste management company to sign upon pickup, and the DON was unaware of the process to prevent diversion once the medications were picked up. The facility pharmacist confirmed that the medications should be destroyed by adding a solution called drug buster to dissolve them, but he never witnessed the DON using this solution. The pharmacist emphasized that the container should be closed and locked to prevent drug diversion. The facility's policy requires that all unused controlled substances be retained in a securely locked area until disposal, and staff should contact the provider pharmacy if unsure of proper disposal methods. The failure to follow these procedures posed a risk for medication diversion and potential harm to residents.
Failure to Provide Timely Meal Substitutes
Penalty
Summary
The facility failed to provide food that accommodates a resident's preferences, resulting in a significant delay in meal service. Resident 294, who was admitted with medical diagnoses including hypertension and muscle weakness, was observed on the morning of December 9, 2024, with a breakfast tray containing oatmeal that appeared watery and unappetizing. The resident, whose cognition was intact and could make decisions regarding medical care, expressed dissatisfaction with the meal, stating it was not hot and tasted bad. After requesting a substitute meal at 7:15 am, the resident waited over two hours before receiving an alternative meal of two sausage patties at 9:15 am. Interviews with staff revealed that the delay was due to the kitchen not promptly preparing the substitute meal. A Certified Nursing Assistant confirmed the resident's request for a substitute and noted the prolonged wait time. The Dietary Supervisor acknowledged the delay and stated that typically, substitutes do not take two hours to prepare. The facility's policy requires the Dietary Manager to discuss food preferences with residents and provide suitable substitutes if preferred items are unavailable, which was not adhered to in this instance.
Pest Control Deficiency Leads to Resident Spider Bite
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in a spider bite incident involving Resident 294. The resident, who was admitted with medical diagnoses including hypertension and muscle weakness, was bitten by a spider, highlighting the facility's inability to ensure a homelike environment free of pests. During an observation, a Certified Nursing Assistant (CNA) reported seeing a spider on the wall near the resident's room, although she mentioned not having seen other insects except for occasional gnats. The Maintenance Supervisor stated that the facility's pest control company was scheduled to fumigate soon and that the facility had been treated two weeks prior. Despite these measures, the presence of spiders persisted, indicating a lapse in the effectiveness of the pest control program. The facility's policy mandates an ongoing pest control program to keep the building free of insects and rodents, yet the incident with Resident 294 suggests a failure in implementation. The Administrator acknowledged the expectation of a pest-free environment and indicated that immediate action would be taken upon spotting pests.
Resident Left Unattended Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with a known history of falls and cognitive impairments. On 11/5/2024, a Certified Nursing Assistant (CNA) left the resident unattended while sitting on the side of the bed, which led to the resident falling and sustaining multiple rib fractures. The resident was subsequently transferred to a General Acute Care Hospital for further evaluation and treatment. The resident had been identified as a fall risk due to impaired mobility and cognitive decline, requiring substantial assistance with activities of daily living. Despite these known risks, the CNA left the resident unsupervised, contrary to the facility's fall management policy, which mandates appropriate interventions for residents at risk of falls. Interviews with staff and family members confirmed the resident's fall risk status and the inappropriate action of leaving the resident unattended, which directly contributed to the incident.
Failure to Notify Physician of Resident's Condition
Penalty
Summary
The facility failed to implement its policy and procedure by not ensuring prompt physician notification for a resident who exhibited symptoms of chills on two separate occasions. The resident, who had a history of sepsis and diabetes mellitus, was admitted with an indwelling catheter and a care plan that required monitoring and reporting of signs and symptoms of urinary infection, including chills. Despite this, the resident's physician was not notified when the resident was observed shaking and was only provided with blankets and hot packs. As a result of this oversight, the resident later developed altered mental status and was found to be hypotensive with low oxygen saturation. The resident was subsequently transferred to a General Acute Care Hospital, where she was diagnosed with sepsis and a urinary tract infection. The Assistant Director of Nursing confirmed that the physician should have been notified promptly, as chills were a symptom that should have been monitored according to the resident's care plan.
Violation of Resident's Right to Choose Caregiver
Penalty
Summary
The facility failed to respect a resident's right to make informed decisions regarding their care, specifically in choosing who provides that care. The resident, who had intact cognitive skills and the capacity to make medical decisions, explicitly refused assistance from a particular CNA due to previous negative interactions. Despite this, CNA 1 brought CNA 2 into the resident's room to assist with hygiene care, against the resident's wishes. The resident expressed dissatisfaction with CNA 2's presence and behavior, stating that CNA 2 was rude and irritating. The resident's care plan emphasized the importance of providing consistent and trusted caregivers, as well as seeking the resident's input to make their stay meaningful. The facility's policies also supported the resident's right to participate in care planning and treatment decisions. However, these policies were not adhered to in this instance, as CNA 1 involved CNA 2 in the resident's care despite the resident's clear refusal. This action violated the resident's rights and the facility's own policies, as confirmed by interviews with the resident, CNA 2, and the Director of Nursing.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, resulting in an incident where one resident punched another in the face, causing a cut to the lip. Resident 1, who has unspecified dementia and lacks the capacity to understand and make decisions, was found with redness on the right side of the face and a minor skin tear on the upper lip after being punched by Resident 2. Resident 2, who has major depressive disorder and anxiety disorder, claimed that Resident 1 was going through his personal belongings and scratched him, prompting Resident 2 to defend himself by punching Resident 1. The investigation revealed that Resident 1's care plan did not include specific timeframes, initiation dates, or revision dates, and there were no orders to monitor Resident 1's behavior despite his dementia diagnosis. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that there were no behavioral monitoring orders for Resident 1, and his behavior was not documented in his medical chart or electronic medical record (eMAR). The DON acknowledged the importance of monitoring residents with dementia to prevent such incidents and stated that the charge nurse could initiate a care plan without a doctor's order. The facility's policies and procedures for behavior management and abuse prevention were reviewed, indicating that the interdisciplinary team should identify underlying causes of residents' behavior and ensure appropriate treatment. However, the lack of monitoring and documentation for Resident 1's behavior contributed to the incident, highlighting a deficiency in the facility's ability to protect residents from abuse and ensure their safety.
Failure to Monitor Resident with Dementia Leads to Altercation
Penalty
Summary
The facility failed to obtain a physician's order for behavior monitoring and implement behavior monitoring for signs and symptoms of dementia for Resident 1. Resident 1, who was diagnosed with unspecified dementia and exhibited agitated and disruptive behavior, did not have a physician's order for behavior monitoring documented in their medical records. This lack of monitoring led to an incident where Resident 2, who had major depressive disorder and anxiety disorder, punched Resident 1 in the face, resulting in a cut to Resident 1's lip. Resident 1 was found on Resident 2's bed, which triggered the altercation. Resident 1's care plan indicated a goal to reduce behavioral problems but lacked specific timeframes, initiation dates, or revision dates. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that there were no orders to monitor Resident 1's behavior, and no documentation of Resident 1's behavior was found in the medical chart or electronic medical record (eMAR). The DON and LVN both acknowledged the importance of behavior monitoring for residents with dementia to ensure safety and prevent incidents like the one that occurred. Resident 2's records showed that they had a physician's order to monitor for episodes of agitation, screaming, and aggressive behaviors. However, the lack of similar monitoring for Resident 1, who had dementia and was prone to wandering and confusion, contributed to the altercation. The facility's policy on behavior management emphasized the need for appropriate treatment and services for residents diagnosed with mental disorders, but this was not adequately implemented for Resident 1, leading to the deficiency identified in the report.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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