Costa Del Sol Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 1016 S. Record St., Los Angeles, California 90023
- CMS Provider Number
- 055697
- Inspections on file
- 50
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Costa Del Sol Healthcare during CMS and state inspections, most recent first.
A resident with ESRD on dialysis and heart failure, who was cognitively able to express needs, had a care plan and diet orders specifying a renal, controlled carbohydrate diet and documented food dislikes, including pasta. The care plan required staff to review the food preference sheet and provide alternative choices when the main entrée conflicted with preferences. During a meal observation, the resident was served penne pasta despite this documented dislike, and the Dietary Manager acknowledged the mismatch and noted that LVNs were responsible for verifying trays against lunch tickets, indicating the resident’s food preferences were not followed.
Facility staff did not perform or document required daily quality-control testing for glucometers on two medication carts, as shown by blank quality control logs on multiple days. LVNs confirmed the devices were used to test several residents' blood glucose levels during these periods, despite the absence of documented quality control checks, in violation of facility policy.
A multi-dose insulin pen used for a resident with diabetes was not labeled with the date it was opened or its expiration date. Staff interviews and record reviews confirmed that the pen should have been labeled according to facility policy and manufacturer instructions, which require disposal after 28 days. The DON acknowledged that the policy was not followed, and staff could not determine when the pen was first used or when it should be discarded.
A resident was transferred or discharged without adequate assessment of their needs and preferences, and without proper preparation for a safe transition to the next care setting.
A resident dependent on dialysis missed a scheduled session due to transportation delays, and the dialysis center was unable to accommodate the late arrival. Although the session was rescheduled for the next day and the resident was monitored for complications, the physician was not notified of the missed treatment, contrary to facility policy. Staff interviews confirmed the oversight.
Three residents did not have complete, individualized care plans addressing their specific needs, including one resident's preference for a Cambodian-speaking interpreter and two residents' requirements for oxygen therapy. Staff were unaware of these needs due to missing or incomplete care plans, and facility leadership confirmed that care plans were necessary to guide safe and effective care.
Three residents with orders for oxygen therapy did not receive care consistent with their physician's orders, including incorrect oxygen flow rates, lack of monitoring and documentation of oxygen saturation, missing care plans, and absence of required 'Oxygen in Use' signage, as observed and confirmed by facility staff.
Licensed nursing staff failed to follow physician orders for holding medications on dialysis days, did not administer a newly prescribed antifungal medication in a timely manner, and did not accurately document controlled medication counts for several residents. These actions resulted in medication administration errors, delays in treatment, and discrepancies in medication records.
Two residents with ESRD and other chronic conditions received medications, including blood pressure drugs, on their scheduled dialysis days despite physician orders to hold these medications. Nursing staff did not clarify or follow the orders, and medication administration records confirmed the errors, which were acknowledged by the ADON, DON, and involved nurses.
A resident with severe cognitive impairment and no decision-making capacity received an increased dose of Seroquel after informed consent was obtained directly from the resident, rather than from a responsible party, contrary to facility policy and documented incapacity.
Two residents' needs and preferences were not accommodated when one was repeatedly left without access to a call light despite severe cognitive impairment and dependence on staff, and another, who preferred Cambodian and required an interpreter, was not provided with language assistance or communication aids. Staff communicated in English and did not use available tools or interpreters, contrary to facility policy.
A nurse failed to notify the physician or complete required assessments after a resident with severe cognitive impairment experienced multiple seizures and received Ativan on several occasions. The nurse only documented the medication administration and did not follow facility policy for change of condition notifications, preventing timely physician intervention.
Two residents received psychotropic medications without documented attempts at non-pharmacological interventions or clear behavioral indications. One resident with dementia and anxiety was given Ativan and Seroquel repeatedly, even when few or no behavioral episodes were recorded, and medication dosages were increased based on verbal reports rather than documented evidence. Another resident with anxiety and other conditions received clonazepam without specific behavioral monitoring, as orders and records lacked clear documentation of the behaviors being treated. Staff interviews confirmed these deficiencies in documentation and practice.
The facility did not ensure that MDS assessments accurately reflected the care and services provided to two residents. One resident receiving oxygen therapy and another receiving anticonvulsant and anti-anxiety medications were not properly documented in their respective MDS assessments, despite physician orders and medication records indicating these treatments.
A resident with severe cognitive impairment and a seizure history experienced a seizure, but staff did not obtain timely physician orders to monitor for further seizure activity as required by facility policy. This resulted in a lack of appropriate monitoring and documentation until orders were eventually put in place.
A resident with end stage renal disease and diabetes had IV lines in both arms that were not assessed or maintained according to physician orders and facility policy. The left arm IV and dressing were not changed for over a week, while the right arm IV dressing was dislodged, undated, and the tubing was bloodied. Staff failed to communicate and document the presence and condition of the right arm IV, resulting in the resident experiencing pain, discomfort, and increased risk of infection.
The facility failed to submit a written report of an abuse investigation within the required five working days. Two residents, both with cognitive impairments, were involved in a physical altercation. The incident was reported to local authorities on the same day, but the Director of Nursing admitted the investigation report was not sent to the state agency within the required timeframe, as per facility policy.
A resident with chronic pain conditions did not receive prescribed medications due to the facility's failure to ensure timely delivery from the pharmacy. The resident's muscle relaxant and pain injection medications were unavailable when needed, as the facility did not follow its policy to reorder medications in advance. Interviews with staff confirmed the oversight in medication management.
Two residents were discharged from an LTC facility without proper arrangements for home health services and necessary medical equipment. One resident, requiring extensive assistance with ADLs, was left confined to a wheelchair at home, leading to skin issues and hospitalization. Another resident, needing continuous oxygen therapy, was discharged without verified oxygen equipment or instructions, risking respiratory distress. The facility failed to follow its discharge planning policy, resulting in significant health risks.
A resident with severe cognitive impairment and multiple health issues was found with a large bruise on the left breast and rib cage. The facility failed to report this injury of unknown origin to the CDPH within the required 24-hour period, as per their policy. This delay was confirmed through staff interviews and a review of the facility's procedures.
The facility failed to ensure call lights were within reach for three residents, impacting their ability to call for assistance. Observations revealed call lights were out of reach for residents with muscle weakness and Parkinson's Disease, who required assistance with ADLs. Staff interviews confirmed the importance of accessible call lights, aligning with facility policy.
The facility failed to administer timely gastrostomy tube (GT) feedings for two residents as per physician's orders. Observations showed that one resident's GT feeding was turned off and another's was disconnected, despite orders for continuous feeding. Both residents had diagnoses including adult failure to thrive and diabetes, and were dependent on assistance for daily activities. The facility's policy required adherence to physician's orders for enteral nutrition, which was not followed in these instances.
The facility failed to maintain effective infection control by storing cleaned and uncleaned oxygen concentrators together without proper labeling. Staff interviews revealed confusion and miscommunication about the cleaning and storage process, with some staff unaware of the designated storage areas for clean equipment. The Infection Preventionist confirmed that uncleaned concentrators were mistakenly stored with clean ones, contrary to facility policy, leading to potential cross-contamination risks.
A resident in respiratory distress did not receive proper ventilation due to incorrect use of an Ambu-bag, as staff failed to achieve a full seal. Additionally, the emergency cart was not checked daily and lacked a non-rebreather mask, contrary to facility policies. The DON admitted that the absence of necessary supplies could delay emergency treatment.
The facility failed to provide adequate nursing staff, resulting in insufficient Restorative Nursing Assistant (RNA) services for residents requiring range of motion exercises and splint application. A resident with limited mobility did not receive prescribed RNA services, while another resident was unable to get out of bed daily due to staff being too busy. The staffing shortage led to deficiencies in care and psychosocial distress for residents.
The facility failed to accurately assess ROM limitations for five residents, leading to discrepancies between evaluations and MDS assessments. Residents with conditions like hemiplegia, Parkinson's disease, and contractures had their mobility limitations inaccurately documented, potentially affecting their care. Observations confirmed limited mobility, and the MDS Coordinator acknowledged the inaccuracies.
The facility failed to provide prescribed ROM and mobility services to five residents, leading to potential decline in their physical condition. Observations and interviews revealed that residents did not receive necessary exercises and splint applications as ordered, due to staffing shortages.
A resident at high risk for falls was observed ambulating without staff assistance in a room where a pool of enteral nutrition had spilled on the floor, creating a slipping hazard. The facility's policy requires floors to be clean and free of spills to prevent accidents, but this was not adhered to, as confirmed by a nurse and the DON.
A facility failed to provide necessary respiratory care for three residents, leading to potential health risks. One resident with COPD did not receive required respiratory equipment and treatments, another received high-flow oxygen without a humidifier, and a third was given oxygen therapy without a physician's order. These deficiencies highlight lapses in following medical protocols and facility policies.
The facility failed to ensure safe food storage and preparation practices, with unlabeled nutritional supplements and expired food items found in storage. Staff did not follow proper hygiene practices, such as handwashing and glove changing, increasing the risk of cross-contamination and foodborne illness. These deficiencies were observed during a survey, highlighting lapses in food safety and sanitation protocols.
The facility failed to accurately document RNA services for two residents with limited mobility. One resident's records did not indicate the application of knee splints, while another's lacked documentation of PROM exercises. Despite physician orders and therapy recommendations, these tasks were not properly recorded in the electronic system, leading to incomplete records.
The facility failed to maintain infection control measures, including the use of PPE for a resident on enhanced barrier precautions and proper cleaning of assistive devices. A nurse did not wear required PPE while handling a gastrostomy tube, and a nursing aide neglected to clean a gait belt and walker after use. Additionally, cloth gait belts were improperly cleaned with bleach wipes, which are ineffective on porous surfaces.
A resident with mobility impairments due to a stroke was not assisted by staff to get out of bed and sit in his wheelchair daily, as per his preference. Despite the facility's policy to accommodate residents' needs, staff cited high patient assignments as a reason for not providing the necessary assistance, resulting in the resident getting out of bed only twice a week.
A resident with anxiety disorder, schizophrenia, and depression was admitted to the facility with an inaccurate PASRR Level I screening, which failed to identify her serious mental disorders. The facility's Admission Coordinator and DON did not catch this discrepancy, resulting in the resident not being referred for a necessary Level II evaluation, as required by the facility's policy.
A resident with multiple health conditions did not receive her morning medications on time due to the nursing staff's failure to follow the physician's orders. The resident, who was supposed to receive medications for hypertension, depression, and COPD, reported feeling dizzy when she woke up. The LVN responsible admitted to not administering the medications as scheduled, citing the resident's sleep as the reason. This oversight was recognized by the DON as a risk for serious health complications.
Two residents in the facility were found with long and dirty fingernails, indicating a failure in providing adequate fingernail care and maintaining personal hygiene. One resident required maximum assistance for personal hygiene, while the other required moderate assistance. Staff, including a CNA, LVN, RN, and the DON, acknowledged the responsibility of CNAs to clean and trim residents' fingernails daily, as per facility policy.
A resident with a gastrostomy tube was not receiving enteral nutrition as ordered, as the tube was closed and nutrition was spilling onto the floor. The resident had conditions requiring tube feeding, and the failure to administer nutrition correctly was confirmed by an LVN. The DON highlighted the importance of proper nutrition administration to prevent decline in the resident's condition.
Licensed nurses failed to follow IV therapy protocols for a resident, including not labeling and dating the PIV site, not changing the dressing when compromised, and not removing the PIV after treatment completion. The resident, with multiple diagnoses and lacking decision-making capacity, was found with a soiled and dislocated PIV dressing, leading to potential harm.
Two residents experienced delays in pain management at a facility. One resident, with chronic pain, waited 36 minutes for pain medication after requesting it. Another resident, with neuropathy, missed a scheduled dose of Gabapentin and had no medication for breakthrough pain. Staff interviews confirmed that pain management protocols were not followed, leading to potential discomfort.
The facility failed to maintain sanitary conditions in the dumpster area, with one dumpster overfilled and uncovered, and trash littering the ground. This was observed during an interview with maintenance staff, who acknowledged the need for proper disposal to prevent pest attraction. Facility policies and FDA guidelines require dumpsters to be covered and free of litter.
The facility did not follow its policy on explaining binding arbitration agreements to residents and their responsible parties, leading to three residents signing agreements without understanding their implications. The Admissions Coordinator failed to document verbal acknowledgments of understanding, despite being trained on the policy.
Two residents in a LTC facility, both with conditions requiring assistance for ADLs, were found with long and dirty fingernails, indicating a failure in providing adequate fingernail care and maintaining personal hygiene. Staff acknowledged the issue and the associated risks, confirming that CNAs were responsible for daily cleaning and trimming of residents' fingernails.
Failure to Honor Documented Food Preferences for a Dialysis Resident
Penalty
Summary
The facility failed to provide meals that accommodated a resident’s documented food preferences. The resident, who had end stage renal disease, dependence on renal dialysis, and heart failure, was cognitively able to express needs and understand others, and required only supervision or partial assistance with activities of daily living. The resident’s care plan, dated 3/15/2026, documented a goal that the resident would receive meals aligned with food preferences daily and would verbalize satisfaction most weeks. Interventions directed staff to review the resident’s food preference sheet upon admission, update it as needed, and ensure alternative meal choices were provided if the main entrée conflicted with the resident’s preferences. On review of the resident’s diet orders, the resident was to receive a renal 80 g protein, constant carbohydrate diet with regular texture. The resident’s lunch ticket for 03/16/2026 listed specific dislikes, including pasta. During a concurrent dining observation, record review, and interview on 03/16/2026, the resident’s lunch plate was observed to contain penne pasta despite the documented dislike. The Dietary Manager confirmed that the resident disliked pasta and might not eat the food served, and stated that LVNs were responsible for comparing lunch tickets with lunch trays to ensure residents received the correct diet and preferences. The facility’s policy on Resident Food Preferences required that preferences be assessed upon admission, communicated to the IDT, and documented in the care plan, but the observed meal did not reflect the resident’s documented preference to avoid pasta.
Failure to Perform and Document Daily Glucometer Quality Control Testing
Penalty
Summary
The facility failed to ensure that daily quality-control testing was performed and documented for glucometers located in Medication Carts 1 and 3, as required by the facility's policy and procedure on Blood Glucose Monitoring and Quality Control. Record reviews revealed that the quality control logs for these glucometers were left blank on multiple days throughout the month, indicating that the required daily testing was not completed. Interviews with LVNs confirmed that the glucometers were used to test the blood glucose levels of several residents during the periods when quality control testing was not documented. The LVNs acknowledged their responsibility for performing and documenting daily quality control tests and stated that these tests are necessary to ensure the accuracy of blood glucose readings. Further review of the facility's policy and job descriptions confirmed that LVNs are responsible for maintaining equipment and documenting quality control testing daily. The Director of Nursing also confirmed that the facility's policy was not followed when daily quality control records were missing. The deficiency was identified through interviews and record reviews, which established that the lack of daily quality control testing and documentation could have affected the accuracy of blood glucose measurements for residents tested with these glucometers.
Failure to Label Multi-Dose Insulin Pen with Open and Expiration Dates
Penalty
Summary
A multi-dose insulin pen used for a resident with diabetes was found to be unlabeled with the date it was opened and its expiration date. The resident, who had a history of diabetes mellitus and fluctuating capacity to make medical decisions, was admitted to the facility and had an order for Insulin Glargine. During an observation, a nurse confirmed that the insulin pen in use for this resident was not labeled as required. Multiple staff interviews confirmed that the pen should have been labeled with both the open and expiration dates, in accordance with facility policy and the manufacturer's instructions, which specify that the pen should not be used more than 28 days after opening. Further review of the facility's policy and the insulin manufacturer's guidelines confirmed the requirement for labeling multi-dose vials and pens with the date opened and expiration date. The Director of Nursing acknowledged that the facility's policy was not followed in this instance. The lack of labeling meant that staff could not determine when the insulin pen was first used or when it should be discarded, as confirmed by interviews with nursing staff and the pharmacist.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Notify Physician After Missed Dialysis Session
Penalty
Summary
The facility failed to notify a resident's physician when the resident missed a scheduled dialysis session. The resident, who had diagnoses including end stage renal disease, dependence on dialysis, and other significant medical conditions, was scheduled to receive dialysis three times a week. On the day of the missed session, transportation for the resident was delayed, resulting in the dialysis center being unable to accommodate the resident due to the late arrival. Although the dialysis session was rescheduled for the following day, the physician was not informed of the missed treatment. Documentation showed that the resident was being monitored for signs and symptoms of fluid overload after missing the dialysis session. Interviews with staff, including an LVN and the DON, confirmed that the physician was not notified of the missed session, despite facility policy requiring prompt notification of changes in a resident's condition or status. The staff acknowledged that the physician should have been informed to allow for potential additional orders or interventions.
Failure to Develop and Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement complete, resident-centered care plans for three residents, resulting in staff being unaware of critical care needs and preferences. For one resident with severe cognitive impairment and a preference for communicating in Cambodian, the care plan did not include the need for an interpreter, despite documentation in the Minimum Data Set (MDS) and confirmation from the resident’s emergency contact that he preferred communication in Cambodian. Staff routinely communicated with the resident in English, and there was no evidence that an interpreter was used, leading to potential misunderstandings and frustration for the resident. Two other residents, both with physician orders for oxygen administration, did not have care plans addressing their oxygen therapy. One resident with chronic obstructive pulmonary disease (COPD) and diabetes mellitus was receiving oxygen at two liters per minute via nasal cannula, but no care plan was found outlining the administration, monitoring, or goals for oxygen therapy. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that a care plan was necessary to guide staff in providing safe and effective oxygen therapy, including details such as flow rate, oxygen saturation goals, and potential side effects. Similarly, another resident with heart failure and peripheral vascular disease had an order for oxygen therapy but lacked a corresponding care plan. The DON acknowledged that the absence of a care plan meant staff did not have guidance on the rationale for oxygen use, monitoring requirements, or interventions to ensure safe administration. Facility policy required that care plans be developed from comprehensive assessments, but these were not completed for the residents in question, resulting in staff being uninformed about essential aspects of their care.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with the residents' plans of care for three residents with orders for oxygen therapy. For one resident with COPD and diabetes, there was no assessment or documentation of oxygen saturation for a period of several days, despite physician orders to titrate oxygen based on saturation levels. Observations revealed that this resident was receiving four liters of oxygen per minute, contrary to the physician's order of two liters, and there was no 'Oxygen in Use' sign outside the room. The resident also did not have a care plan addressing oxygen administration, and the ADON confirmed that monitoring and documentation of oxygen saturation were not performed as required. Another resident with heart failure and peripheral vascular disease was observed receiving varying amounts of oxygen (one liter and 2.5 liters per minute) instead of the prescribed two liters per minute. There was also no 'Oxygen in Use' sign outside this resident's room, and the resident did not have a care plan for oxygen administration. The DON acknowledged the absence of a care plan and stated that such a plan was necessary to guide staff in providing safe and effective oxygen therapy. A third resident with COPD and sequelae of cerebral infarction was observed receiving more than the prescribed amount of oxygen (three liters and 2.5 liters per minute instead of two liters per minute) and also lacked an 'Oxygen in Use' sign outside the room. Although this resident had a care plan for oxygen therapy, the prescribed oxygen flow was not followed. Staff interviews confirmed the importance of adhering to physician orders for oxygen therapy and the need for appropriate signage to prevent fire hazards, as outlined in the facility's policy and procedure for oxygen administration.
Failure to Follow Physician Orders and Accurately Document Medication Administration
Penalty
Summary
Licensed nursing staff failed to follow physician orders regarding medication administration for multiple residents. For one resident with end stage renal disease on dialysis, blood pressure medications were administered on scheduled dialysis days despite an order to hold medications on those days. The nurse misinterpreted the order, believing it only applied when the resident was out of the facility, and did not clarify the order with the nurse practitioner. Both the nurse practitioner and the Director of Nursing confirmed that the order should have been clarified and that blood pressure medications should have been held prior to dialysis. Another resident with a fungal infection did not receive a newly prescribed dose of fluconazole in a timely manner. The assigned nurse failed to obtain the medication from the emergency kit when it was not delivered by the pharmacy, resulting in a two-day delay in treatment. Additionally, the antibiotic medication count sheet for this resident was inaccurate, as the nurse documented preparation of the medication but did not actually administer it, leaving all doses intact in the medication supply. For two other residents receiving pregabalin, the medication count sheets were not accurately maintained. In both cases, the number of doses documented on the count sheets did not match the actual number of doses remaining in the medication bubble packs. The nurses involved admitted to forgetting to document the preparation or administration of the medication, which resulted in discrepancies in the controlled medication records. The Director of Nursing acknowledged that such inaccuracies could lead to medication errors or undetected controlled medication discrepancies.
Failure to Hold Medications on Dialysis Days Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that two residents undergoing hemodialysis were free from significant medication errors by not holding medications as ordered by their physicians on scheduled dialysis days. For one resident with end stage renal disease (ESRD) and diabetes mellitus, the physician's order specified to hold medications on dialysis days. However, the Medication Administration Record (MAR) showed that the resident received multiple medications, including furosemide, on dialysis days. The Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN) confirmed that the order was not followed, and the nurses did not clarify which medications should be held, resulting in all medications being administered contrary to the order. Another resident with ESRD, chronic obstructive pulmonary disease (COPD), and diabetes mellitus also experienced a similar deficiency. The care plan indicated that blood pressure medications should be held on dialysis days as ordered by the physician. Despite this, the resident reported receiving blood pressure medications prior to dialysis appointments, and review of the electronic Medication Administration Record (eMAR) confirmed administration of these medications on multiple dialysis days. The LVN responsible for medication administration admitted to not checking the physician's orders before giving the medications. Interviews with nursing staff and the Director of Nursing (DON) further confirmed that the physician's orders were not followed for both residents. The facility's policy required medications to be administered as prescribed, but this was not adhered to, resulting in significant medication errors for residents with complex medical needs during their dialysis treatment.
Failure to Obtain Valid Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain proper informed consent for a psychotropic medication for one resident. The resident, who had diagnoses of dementia and anxiety disorder, was assessed as having severe cognitive impairment and was documented as lacking the capacity to understand and make decisions. Despite this, when the resident's Seroquel dosage was increased from 50 mg to 100 mg twice daily, the informed consent for the new dosage was obtained directly from the resident, rather than from a resident representative or responsible party as required by facility policy and the resident's documented incapacity. Interviews with facility staff, including the nurse practitioner and assistant director of nursing, confirmed that informed consent should be obtained from the resident or their representative prior to administering psychotropic medications, especially when there is a dosage change. The facility's policy also required that the prescribing clinician obtain informed consent from the appropriate party before administration. The failure to follow these procedures resulted in the administration of a higher dose of Seroquel without valid informed consent, as the resident was not capable of providing it.
Failure to Accommodate Resident Needs and Preferences for Call Light Access and Language Interpretation
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents by not ensuring a call light was within reach for one resident and by not providing appropriate language interpretation for another. In the first instance, a resident with severe cognitive impairment, dementia, anxiety disorder, and a history of falls was observed on multiple occasions with his call light placed out of reach, despite being dependent on staff for activities of daily living and repositioning. The resident stated he could not reach the call light, and staff confirmed that the call light should be accessible to allow the resident to request assistance. Facility policy required staff to ensure the call light was within easy reach, but this was not followed. In the second instance, a resident with Parkinson's disease, hemiplegia, generalized muscle weakness, and depression, who preferred to communicate in Cambodian and required an interpreter, was not provided with language assistance. Staff communicated with the resident in English, assuming he understood because he could say a few words, and did not use a communication board or interpreter. Observations showed the resident did not respond to staff communication in English, and staff relied on facial expressions to interpret his needs. The resident's emergency contact confirmed his preference for Cambodian, and facility policy required the use of interpreters or visual aids for residents with communication barriers, which was not implemented. Interviews with staff and review of facility policies confirmed that the call light should be within reach and that residents have the right to be informed and participate in their care planning in their preferred language. The failure to follow these policies resulted in the residents being unable to request assistance or understand the care being provided to them.
Failure to Notify Physician of Recurrent Seizure Activity
Penalty
Summary
Licensed Vocational Nurse (LVN) 3 failed to notify the physician when a resident with a history of seizures experienced multiple seizure episodes on six separate occasions. The resident, who had severe cognitive impairment and required substantial assistance for mobility, was prescribed Ativan as needed for seizures. The Medication Administration Records (MAR) indicated that Ativan was administered on each of these occasions for seizure activity. However, aside from documenting the administration of Ativan on the MAR, LVN 3 did not document the seizure activity elsewhere in the resident's medical record, did not notify the physician, and did not complete Change of Condition (COC) assessments as required by facility policy. During interviews, LVN 3 confirmed that she followed the medication administration orders but did not inform the physician or complete the necessary assessments after each seizure event. The Assistant Director of Nursing (ADON) stated that a COC assessment should be completed for each seizure and that physician notification is necessary, especially if seizures occur despite medication. The facility's policy requires physician notification for changes in a resident's medical or mental condition. This failure to notify the physician prevented timely adjustments to the resident's plan of care.
Failure to Document and Attempt Non-Pharmacological Interventions Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and that behavioral indications were present and documented prior to administering psychotropic medications for two residents. For one resident with dementia and anxiety disorder, records showed that medications such as Ativan and Seroquel were administered without prior documentation of non-pharmacological interventions or consistent behavioral indications. The resident's Medication Administration Records (MARs) indicated frequent administration of these medications even when there were few or no documented episodes of the behaviors they were intended to treat. Interviews with nursing staff and the Assistant Director of Nursing (ADON) confirmed that non-pharmacological interventions were not documented or attempted prior to medication administration, and that increases in medication dosage were based on verbal reports rather than verified behavioral documentation. For another resident with anxiety, depression, insomnia, and paraplegia, clonazepam was administered three times daily for anxiety manifested by "multiple concerns." However, the MARs and order summaries lacked specific documentation of the behavioral manifestations being monitored. Staff interviews revealed that the orders did not specify exact behaviors, and the lack of specificity in documentation and monitoring placed the resident at risk for prolonged and potentially unnecessary use of psychotropic medication. The Director of Nursing (DON) acknowledged that the absence of clear behavioral indications and monitoring could lead to inappropriate care planning and medication use. The facility's own policy required that psychotropic medications only be used when necessary to treat specifically diagnosed conditions, with clear documentation of symptoms and attempted non-pharmacological interventions. Despite this, the records and staff interviews demonstrated that these steps were not consistently followed for the two residents, resulting in the administration and escalation of psychotropic medications without adequate justification or documentation.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents accurately reflected the care and services they received. For one resident with a diagnosis of congestive heart failure, physician orders indicated the use of oxygen therapy as needed for shortness of breath, and the resident was observed receiving oxygen therapy at the bedside. However, the MDS assessment did not document the use of oxygen therapy. The MDS nurse confirmed that the physician order and observation supported the use of oxygen, but this was not reflected in the MDS. For another resident with a history of seizures and severe cognitive impairment, physician orders and the Medication Administration Record (MAR) showed the resident was receiving anticonvulsant and anti-anxiety medications. Despite this, the MDS assessment did not indicate the use of these medications. The MDS nurse acknowledged that the MDS failed to document the resident's use of anti-anxiety and anticonvulsant medications, which was inconsistent with the resident's medical records and medication administration history. The facility's policy required that MDS assessments consistently reflect information from progress notes, care plans, and resident observations.
Failure to Initiate Timely Seizure Monitoring Orders After First Seizure
Penalty
Summary
The facility failed to ensure that a resident with a history of seizures had appropriate physician orders to monitor for seizure activity following the resident's first documented seizure. The resident, who had severe cognitive impairment and required substantial assistance for mobility, experienced a seizure lasting three minutes. Despite this event, there were no orders in place to monitor for further seizure activity until a later date, leaving a gap in monitoring and documentation. Record review and staff interviews confirmed that nursing staff did not contact the physician for seizure monitoring orders immediately after the initial seizure episode. The facility's own policy required staff to monitor and document seizure activity for individuals with new seizures or seizure disorders, but this protocol was not followed in a timely manner for the resident in question.
Failure to Follow IV Line Care Policy and Physician Orders
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's policy and physician's orders regarding intravenous (IV) line care for a resident with end stage renal disease and diabetes mellitus. The resident had IV lines in both arms, with orders to check the IV line every shift and to change the IV line, dressing, and cap every three days. Observations over several days revealed that the left arm IV and its dressing had not been changed for at least nine days, and the right arm IV dressing was dislodged, undated, and the tubing was bloodied. The resident reported pain and discomfort from the IV, stated that the IV and dressing had never been changed, and was unaware of the reason for the continued presence of the right arm IV, which was not being used for medication administration. Record reviews and staff interviews confirmed that the required assessments and dressing changes were not performed as ordered. The Assistant Director of Nursing (ADON) acknowledged that she did not know the date the IV dressing was labeled, did not change the IV line or dressing as required, and did not inform the physician about the failure to change them. The ADON was also unaware of the right arm IV's continued presence and condition, which had not been assessed or maintained. The Treatment Nurse (TN) documented the presence of both IVs but did not communicate the right arm IV to the ADON, and the Director of Nursing (DON) confirmed that the right arm IV was not monitored, increasing the risk of infection. The facility's policy required IV site care and dressing changes at established intervals or immediately if the dressing was compromised, with assessments at least every eight hours. Despite these requirements, the resident's IV sites were not properly assessed or maintained, and communication failures among staff led to the right arm IV being overlooked for an extended period. The lack of adherence to policy and physician orders resulted in the resident experiencing pain, discomfort, and increased risk of infection.
Failure to Timely Report Abuse Investigation Findings
Penalty
Summary
The facility failed to provide a written report of the findings of an investigation into an allegation of abuse within five working days, as required by their policy. This deficiency involved two residents who were involved in a physical altercation. Resident 1, who has dementia, anxiety, dysphagia, and muscle weakness, was dependent on staff for activities of daily living and had moderately impaired cognitive skills. Resident 2, with altered mental status, diabetes mellitus, and a history of seizures, required supervision for daily activities and had severely impaired cognitive skills. On the day of the incident, Resident 1 was lying in bed and talking loudly, which irritated Resident 2. Despite being asked to lower his voice, Resident 1 continued talking loudly, leading Resident 2 to become agitated and hit Resident 1 on the face. This incident was reported to the Los Angeles County Department of Public Health on the same day via fax using the SOC 341 form, as required under the Welfare and Institutions Code. However, the Director of Nursing admitted that the five-day investigation report was completed but not faxed to the California Department of Public Health within the required timeframe. The facility's policy, revised in September 2022, mandates that reports of resident abuse be submitted to local and federal agencies within five working days of the reported allegations. This failure to comply with the reporting timeline had the potential to delay the State Survey Agency's investigation and placed the residents at risk for elder abuse.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that a resident's prescribed medications were readily available, leading to a deficiency in pharmaceutical services. The resident, who was admitted with conditions including osteoarthritis, neuropathy, and chronic pain syndrome, had a physician's order for Metaxalone, a muscle relaxant, to be administered as needed. However, the medication was not available when the resident requested it, as the pharmacy had not delivered the refill. Additionally, the resident had a physician's order for Kenalog injections to manage shoulder pain, but these medications were also not available when the physician attempted to administer them. Interviews with the resident and staff revealed that the refill for Metaxalone was sent to the pharmacy but had not been delivered, and the Kenalog order was not reflected in the facility's system. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledged the importance of timely medication delivery and the need for follow-up with the pharmacy. The facility's policy required medications to be reordered at least three days before the last dose to ensure availability, but this procedure was not followed, resulting in the resident experiencing discomfort and potential pain due to the unavailability of prescribed medications.
Failure in Safe Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure a safe discharge for two residents, leading to significant health risks and complications. Resident 1, who required extensive assistance with activities of daily living (ADLs) and mobility, was discharged without confirmed arrangements for home health services. Despite physician orders for home health services, the referral was delayed, resulting in Resident 1 being confined to her wheelchair at home, unable to perform basic hygiene tasks, and developing skin issues due to prolonged exposure to moisture. Interviews with the resident and a family friend revealed that Resident 1 was left without the necessary support, leading to emergency hospitalization for severe leg pain and a venous stasis rash. Resident 2, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and required continuous oxygen therapy, was discharged without ensuring the availability of necessary oxygen equipment and instructions. The facility did not verify the functionality of Resident 2's portable oxygen delivery device or provide education on the required oxygen therapy. This oversight placed Resident 2 at risk for respiratory distress and other complications associated with inadequate oxygen therapy. Interviews with a family friend and facility staff confirmed that the necessary checks and education were not conducted prior to discharge. The facility's policy and procedure for discharge planning were not followed, as evidenced by the lack of confirmed arrangements for follow-up care and services for both residents. The Social Services Director and other staff members acknowledged the deficiencies in the discharge process, highlighting the importance of ensuring that residents have the necessary support and equipment before leaving the facility. The failure to adhere to these protocols resulted in significant health risks for both residents, underscoring the need for thorough discharge planning and coordination with home health agencies.
Failure to Report Resident Injury in a Timely Manner
Penalty
Summary
The facility failed to report an unusual occurrence involving a resident to the California Department of Public Health (CDPH). The resident, who was admitted with diagnoses including adult failure to thrive, unspecified protein-calorie malnutrition, and type 2 diabetes, was found with a large bruise on the left side of the breast and rib cage. The resident's cognitive skills were severely impaired, requiring substantial assistance with activities of daily living. Despite the bruise being noticed on 9/5/2024, it was not reported to the CDPH within the required 24-hour timeframe, as per the facility's policy. The incident was discussed in an interdisciplinary team meeting on 9/6/2024, where it was noted that the resident complained of pain when care was provided to the affected area. The facility's policy on reporting injuries of unknown origin mandates immediate reporting to the administrator and state officials within 24 hours. However, this protocol was not followed, resulting in a delay in the investigation by CDPH. Interviews with staff, including the Restorative Nursing Assistant and the Director of Nursing, confirmed that the injury was not reported as required, highlighting a lapse in adherence to the facility's policies and procedures.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for three of eight sampled residents, potentially impacting their ability to have their needs met promptly. During observations, Resident 2's call light was found hanging on the wall, out of reach, until a CNA provided it to the resident. Resident 2 had a history of muscle weakness and required supervision for activities of daily living (ADLs). Similarly, Resident 5's call light was stuck on the bed rail, out of reach, and the resident was unaware of its location. Resident 5 was dependent on assistance for ADLs and had no mental capacity to make medical decisions. Resident 6's call light was also out of reach, hanging on the bed rail, and the resident was dependent on assistance for ADLs due to Parkinson's Disease. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that call lights should always be within easy reach of residents to ensure their needs are met promptly. The facility's policy, dated 2010, also indicated that call lights should be within easy reach when residents are in bed or confined to a chair. The failure to adhere to this policy could result in residents being unable to call for assistance, potentially impacting their physical, mental, and psychosocial well-being.
Failure to Administer Timely GT Feedings
Penalty
Summary
The facility failed to ensure timely administration of gastrostomy tube (GT) feedings for two residents, Resident 3 and Resident 4, as per physician's orders. Observations revealed that Resident 3's GT feeding was turned off when it should have been on, according to the physician's order, which specified that the feeding should start at 2:00 p.m. and continue for 20 hours. Similarly, Resident 4's GT was found disconnected, despite the physician's order indicating that the feeding should also start at 2:00 p.m. and continue for 20 hours. Licensed Vocational Nurse 1 confirmed these discrepancies during interviews, acknowledging that the feedings were not administered as ordered. Resident 3 was admitted with diagnoses including adult failure to thrive, diabetes, and gastrostomy status, and was noted to have intact cognitive skills but was dependent on assistance for activities of daily living. Resident 4, also diagnosed with adult failure to thrive and diabetes, had the mental capacity to make medical decisions and was similarly dependent on assistance for daily activities. The facility's policy on enteral nutrition emphasized the importance of providing adequate nutritional support as ordered, which was not adhered to in these cases, potentially compromising the residents' nutritional needs.
Improper Storage of Oxygen Concentrators
Penalty
Summary
The facility failed to ensure effective infection control measures by improperly storing oxygen concentrators. Cleaned and uncleaned oxygen concentrators were stored together in the same room, Storage 1, without any labeling to distinguish between them. This practice was observed during an inspection, where it was noted that the concentrators were placed in various directions, some touching each other, and only one was covered in plastic. Licensed Vocational Nurse (LVN) 1 admitted that the room was too small to separate the clean from the unclean concentrators and that there was no labeling system in place. Interviews with staff revealed a lack of clarity and communication regarding the cleaning and storage process of the concentrators. The Director of Maintenance (DOM) stated that housekeeping was responsible for cleaning the concentrators every Monday, but there was no written policy to support this. Housekeeper 1 initially claimed all concentrators in Storage 1 were clean but later admitted that only the one covered in plastic was clean. LVN 2, who also served as a respiratory therapist, was unaware of the existence of Storage 2, where clean concentrators were supposed to be kept, and mistakenly believed that Storage 1 was for clean concentrators. The Infection Preventionist (IP) Nurse confirmed that clean concentrators should be stored in Storage 1 after being disinfected at the bedside, but uncleaned concentrators were mistakenly placed there. The facility's policy and procedure documents outlined the proper cleaning and storage protocols, but these were not being followed, leading to potential cross-contamination and infection risks. The DOM acknowledged the need for a separate room to store clean and dirty equipment and admitted that the current process could result in contamination of all equipment in Storage 1.
Deficient Emergency Response and Equipment Management
Penalty
Summary
The facility failed to correctly use a valve-bag-mask (Ambu-bag) for a resident in respiratory distress and did not ensure the emergency cart was adequately stocked and checked daily. A resident, who was admitted with respiratory failure and shortness of breath, was observed in respiratory distress with an oxygen saturation of 60% while on 3 liters per minute of oxygen. The respiratory therapist attempted to use an Ambu-bag but failed to achieve a full seal, which is necessary for effective ventilation, as the resident was moving and sitting up. The registered nurse confirmed that a proper seal is crucial to prevent oxygen from escaping and to provide effective ventilation. Additionally, the emergency cart lacked a non-rebreather mask, and there was no checklist to ensure the cart was checked daily, as per the facility's policies and procedures. The director of nursing acknowledged that staff should have checked the emergency cart daily and that the absence of necessary supplies could lead to delays in treatment during emergencies. The facility's policy required licensed nurses or designated staff to ensure the emergency cart was complete and stocked with essential items, including non-rebreather masks.
Inadequate Staffing Leads to Deficient Care and Resident Distress
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents requiring Restorative Nursing Assistant (RNA) services. Observations and interviews revealed that the facility had only one RNA staff available due to another RNA being on leave, which resulted in inadequate provision of range of motion (ROM) exercises, splint application, and ambulation for 43 residents. This included specific deficiencies in care for residents with limited mobility, such as Resident 8, who did not receive the prescribed RNA services for applying a left elbow extension splint five times per week. Further investigation showed that Resident 27, who had diagnoses including Parkinson's disease and contractures, did not receive passive range of motion (PROM) exercises to both arms and legs as ordered by the physician. Similarly, Resident 49, who was on palliative care, did not receive the required PROM exercises due to the staffing shortage. Interviews with the Director of Rehabilitation and the Director of Staff Development confirmed that the lack of adequate staffing was the reason for these deficiencies. Additionally, the facility failed to accommodate the preferences of Resident 61, who wished to get out of bed daily to sit in a wheelchair. Despite having the capacity to understand and make decisions, Resident 61 was unable to participate in his preferred activities due to staff being too busy to assist him. This led to psychosocial distress for the resident, as he was only able to get out of bed twice a week on average. The Director of Nursing acknowledged that staff should assist residents with such requests and that it was inappropriate for staff to claim they were too busy to help.
Inaccurate ROM Assessments in Residents
Penalty
Summary
The facility failed to accurately assess the range of motion (ROM) limitations for five residents, which could potentially affect the provision of care. Resident 8 was admitted with diagnoses including hemiplegia, dementia, and contractures. Despite assessments indicating severe and moderate ROM impairments in various joints, the Minimum Data Set (MDS) inaccurately reflected these limitations. Observations confirmed the resident's limited mobility, and the MDS Coordinator acknowledged the inaccuracies in the assessments. Resident 27, diagnosed with Parkinson's disease and contractures, also had discrepancies between the Rehab - Joint Mobility Screen (JMS), Occupational Therapy (OT), and Physical Therapy (PT) evaluations, and the MDS assessments. The MDS failed to document the ROM impairments noted in the evaluations, and observations showed the resident's limited mobility. The MDS Coordinator confirmed the inaccuracies, emphasizing the importance of accurate assessments for ensuring appropriate care. Similar issues were found with Residents 49, 61, and 63, where the MDS assessments did not accurately reflect the ROM limitations documented in other evaluations. These inaccuracies were confirmed through interviews and record reviews with the MDS Coordinator, who reiterated the necessity of accurate MDS assessments to monitor residents' conditions and ensure they receive the necessary care.
Failure to Provide Prescribed ROM and Mobility Services
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) and mobility for five residents with limited mobility. Resident 8 did not receive the prescribed application of a left elbow extension splint five times per week as ordered by the physician. Observations revealed that the splint was not applied on several occasions, and the resident reported pain when the splint was used. The Director of Staff Development (DSD) confirmed that the splint was not applied as required due to staffing issues. Resident 61 did not receive the prescribed passive range of motion (PROM) and active assistive range of motion (AAROM) exercises to the right leg and both arms, respectively. The resident reported that exercises were not performed regularly, and observations confirmed the lack of consistent exercise provision. The DSD acknowledged the failure to provide the required exercises, attributing it to insufficient staffing. Residents 27, 49, and 65 also did not receive the prescribed PROM exercises for their arms and legs. Observations and interviews indicated that these residents rarely received the necessary exercises, and the RNA Task Schedules were often left blank. The DSD and Director of Rehabilitation (DOR) confirmed the lack of services, again citing staffing shortages as the reason for the deficiency.
Hazardous Environment Due to Spilled Enteral Nutrition
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment for a resident, identified as Resident 75, who was at high risk for falls due to generalized weakness, gait/balance problems, and impaired mobility. The resident was admitted on January 15, 2024, and had intact cognitive skills for daily decision-making, requiring only set-up or clean-up assistance with ambulation. Despite these needs, the resident was observed ambulating in his room without staff assistance, where a pool of enteral nutrition was present on the floor, creating a slipping hazard. The pool of enteral nutrition originated from the bedside of Resident 75's roommate and extended into Resident 75's side of the room, accumulating under his bed. During an observation and interview, a Licensed Vocational Nurse acknowledged the slipping hazard posed by the liquid on the floor, which could lead to a fall for Resident 75. The Director of Nursing confirmed that floors and walkways should be clean and free of spills to prevent slips and falls, as per the facility's policy on safety and supervision of residents.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for three residents, leading to potential health risks. Resident 13, diagnosed with COPD, hypertension, dementia, and depression, was not provided with essential respiratory equipment such as a nebulizer, incentive spirometer, and oxygen supplies as per physician orders. Observations over two days confirmed the absence of these supplies in the resident's room, and interviews with nursing staff revealed a lack of clarity on who was responsible for administering the treatments. The Medication Administration Record showed no documentation of the required treatments being administered, placing the resident at risk for respiratory distress and exacerbation of COPD. Resident 57, admitted with acute respiratory failure and pneumonia, was receiving oxygen at 4.5 liters per minute without a humidifier, contrary to the facility's policy. The absence of a humidifier when administering oxygen at this level could lead to discomfort and nosebleeds due to dry nasal mucous membranes. Interviews with the Respiratory Therapist and the Director of Nursing confirmed the necessity of a humidifier in such cases, highlighting a failure in adhering to the facility's oxygen administration policy. Resident 69, with diagnoses including shortness of breath and heart failure, was receiving oxygen therapy without a physician's order. Observations confirmed the administration of oxygen via nasal cannula, and interviews with nursing staff and the Director of Nursing emphasized the requirement for a physician's order for oxygen therapy. This oversight in obtaining the necessary order for oxygen administration represents a significant lapse in following medical protocols, potentially compromising the resident's care.
Deficiencies in Food Storage, Labeling, and Staff Hygiene
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, which were observed during a survey. Nutritional supplements labeled to be stored frozen and used within 14 days of thawing were not monitored for their thaw date, leading to the potential risk of expired supplements being consumed by 24 residents on nutritional supplements. Four boxes containing 50 individual cartons of strawberry-flavored nutrition supplements were found in the walk-in refrigerator without a thaw date. The Dietary Aide confirmed that the supplements were delivered frozen and should have a thaw date to monitor their expiration. Additionally, the facility did not properly label and date food items in storage, leading to the potential consumption of expired food. A plastic bag of breaded food items was found in the walk-in freezer without a label or date, and previously opened ham and diced stew meat were stored beyond their recommended storage periods, covered in ice crystals and freezer burn. The Dietary Supervisor acknowledged that the freezer was overcrowded, and old items were not rotated, which contributed to the issue. Furthermore, a container holding dry food products was found dirty with food debris, indicating a lack of proper sanitation in the kitchen. The facility also failed to maintain proper hygiene practices among staff, which could lead to cross-contamination and foodborne illness. One staff member in the dishwashing area did not wash their hands before handling clean dishes, and another cook did not change gloves or wash hands before handling ready-to-eat food. These practices were observed during lunch service, where a staff member was seen performing multiple tasks without changing gloves or washing hands, increasing the risk of contamination. The facility's policies and procedures emphasized the importance of handwashing and proper glove use, but these were not followed, as observed during the survey.
Documentation Errors in RNA Services for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide accurate documentation for two residents with limited mobility and range of motion. Resident 8's clinical records did not indicate the application of both knee splints from November 2023 to February 2024, despite physician orders and physical therapy recommendations for such interventions. The RNA Task Schedule failed to include the application of knee splints as a separate task, leading to documentation errors. The Director of Rehabilitation and Director of Staff Development acknowledged these errors during a review of the records. Resident 63's clinical records also lacked documentation of passive range of motion (PROM) exercises to both legs from December 2023 to February 2024. Although physician orders and physical therapy discharge summaries recommended PROM exercises five times per week, the RNA Task Schedule did not reflect this task. The RNA Weekly Summary indicated that PROM was provided, but the task was not created in the electronic documentation system, resulting in incomplete records. The facility's policy and procedure on documentation require nursing personnel to maintain complete and accurate records. However, the documentation for both residents was found to be deficient, as it did not accurately reflect the RNA services provided. The discrepancies were identified during interviews and record reviews with the Director of Rehabilitation and Director of Staff Development, who confirmed the documentation errors.
Infection Control Deficiencies in PPE and Equipment Cleaning
Penalty
Summary
The facility failed to maintain proper infection control measures for Resident 27, who was on enhanced barrier precautions (EBP) due to the presence of a gastrostomy tube. Despite signage indicating the need for EBP and the availability of personal protective equipment (PPE) outside the resident's room, a Licensed Vocational Nurse (LVN) entered the room without donning the required gown and gloves. The LVN proceeded to handle the resident's gastrostomy tube without the necessary protective gear, acknowledging the oversight during an interview. The Infection Preventionist Nurse (IPN) confirmed that EBP was crucial for preventing the spread of multidrug-resistant organisms (MDROs) and that the failure to implement these precautions increased the risk of infection spread within the facility. In another instance, the facility did not adhere to infection control protocols concerning the cleaning of assistive devices used by Resident 69. After assisting the resident with ambulation using a vinyl gait belt and a front-wheeled walker (FWW), the Restorative Nursing Aide (RNA) failed to clean these items with bleach sanitizing wipes as required. The RNA admitted to neglecting this step due to the resident's eagerness to return to their room. The IPN reiterated the importance of disinfecting reusable equipment between uses to prevent cross-contamination among residents. Additionally, the facility did not follow proper cleaning procedures for cloth gait belts used by multiple Certified Nursing Assistants (CNAs). Observations revealed that CNAs wore cloth gait belts throughout the day, and some attempted to clean them with bleach sanitizing wipes, which are ineffective on porous surfaces like cloth. The IPN confirmed that the manufacturer's recommendations for the wipes specified use on non-porous surfaces only, and that cloth gait belts should be washed instead. The improper cleaning of these gait belts posed a risk of contamination, as they were used on multiple residents without adequate disinfection.
Failure to Accommodate Resident's Preference for Daily Wheelchair Use
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident, identified as Resident 61, who expressed a desire to get out of bed and sit in his wheelchair at least once a day. Despite having the capacity to understand and make decisions, Resident 61, who had impairments due to a stroke, required substantial assistance from staff to transfer from bed to wheelchair. Observations and interviews revealed that Resident 61 was often left in bed watching TV and was not assisted to get out of bed as per his preference. The resident reported that when he requested assistance, the CNAs informed him they were too busy due to high patient assignments, resulting in him getting out of bed only twice a week on average. Interviews with the Activity Director and the Director of Nursing confirmed that there were no restrictions on residents using the patio and that staff should assist residents in transferring to wheelchairs and supervise them as needed. The facility's policy indicated that residents' individual needs and preferences should be accommodated unless it endangered health and safety. However, the staff's failure to assist Resident 61, citing workload as a reason, was not in line with the facility's policy, leading to the deficiency.
Inaccurate PASRR Screening Leads to Deficiency
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for a resident, leading to a deficiency. The resident, who was admitted with diagnoses of anxiety disorder, schizophrenia, and depression, had a PASRR Level I screening that incorrectly indicated the absence of a serious mental disorder. This discrepancy was not identified during the facility's review process, which involved the Admission Coordinator and the Director of Nursing. As a result, the resident was not referred for a Level II evaluation by the state-designated mental health authorities, which is necessary to determine the need for specialized services. The facility's policy requires that all new admissions be screened for mental disorders through the PASRR process, and if a potential mental disorder is identified, a Level II evaluation should be conducted. However, in this case, the facility did not adhere to its policy, as the PASRR Level I screening was not accurately completed, and the necessary follow-up actions were not taken. This oversight had the potential to impact the resident's receipt of required services and care for her mental health conditions.
Failure to Administer Medications Timely
Penalty
Summary
The licensed nursing staff at the facility failed to adhere to professional standards of practice by not implementing the physician's written order for the administration of routine medications to Resident 13. Resident 13, who was admitted with diagnoses including COPD, hypertension, dementia, and depression, was supposed to receive several medications at 9:00 a.m. as per the Medication Administration Records. However, during an observation and interview, it was found that Resident 13 had not received her morning medications by 11:10 a.m., and she reported feeling dizzy. The medications included Amlodipine Besylate, Metoprolol Succinate, Aspirin, Sertraline, Folic Acid, and Albuterol Sulfate, which were crucial for managing her conditions. Licensed Vocational Nurse 3 admitted to not administering the medications on time, stating that she did not want to wake Resident 13, who was sleeping. This delay in medication administration was acknowledged by both LVN 3 and the Director of Nursing as a risk for health complications, including high blood pressure and heart attack. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed and according to the physician's orders, which was not followed in this instance.
Deficient Fingernail Care and Hygiene Maintenance
Penalty
Summary
The facility failed to provide adequate fingernail care and maintain grooming and personal hygiene for two residents who were unable to perform activities of daily living independently. Resident 52, who had diagnoses including diabetes, hypertension, dementia, and dysphagia, required maximum assistance for personal hygiene. During an observation, Resident 52 was found with long and dirty fingernails, and the resident expressed a desire for staff to clean and cut them. A Certified Nursing Assistant (CNA) acknowledged the condition of the resident's fingernails and stated that it was the responsibility of CNAs to clean and trim residents' fingernails daily. Similarly, Resident 77, who also had diagnoses of diabetes, hypertension, dementia, and dysphagia, required moderate assistance for activities of daily living. During an observation, Resident 77 was found with long and dirty fingernails. A Licensed Vocational Nurse (LVN) and a Registered Nurse (RN) both acknowledged the potential risks associated with long and dirty fingernails, such as infection and injury. The Director of Nursing (DON) confirmed that it was the CNAs' responsibility to ensure residents' fingernails were cleaned and trimmed as needed, in accordance with the facility's policy on activities of daily living.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
Facility staff failed to administer enteral nutrition as ordered for a resident, identified as Resident 27, who was receiving nutrition through a gastrostomy tube. The resident had been admitted with conditions including gastrostomy status, protein-calorie malnutrition, muscle wasting, atrophy, and dysphagia. The care plan for Resident 27 required tube feeding to maintain adequate nutritional and hydration status, with specific instructions for staff to administer enteral nutrition as ordered. However, during an observation, it was noted that the enteral nutrition was not being administered correctly, as the gastrostomy tube was closed, and the nutrition was spilling onto the floor and bed instead of being delivered to the resident. An interview with an LVN confirmed that the resident was not receiving the enteral nutrition as ordered, and there was uncertainty about how long the tube had been closed. The Director of Nursing acknowledged the importance of administering enteral nutrition as ordered to prevent potential decline in the resident's condition and unwanted weight loss. The facility's policy and procedure on enteral nutrition emphasized the need for regular inspection of tubing for proper and secure connections, which was not adhered to in this instance.
Failure to Follow IV Therapy Protocols
Penalty
Summary
The licensed nurses at the facility failed to adhere to the established policy and procedure for the initiation and maintenance of intravenous therapy for Resident 243. Specifically, they did not label and date the peripheral intravenous catheter (PIV) site, did not change the PIV site and dressing when it appeared compromised, and did not remove the PIV after the completion of IV treatment. These actions were observed during a survey, where the PIV dressing was found to be soiled, dislocated, and undated, and the resident expressed discomfort at the site. Resident 243 was admitted with multiple diagnoses, including diabetes, urinary tract infection, hypertension, and muscle weakness, and lacked the capacity to make decisions. The IV treatment with Ceftriaxone Sodium was completed, but the PIV was not removed as required. The facility's policy mandates that PIV dressings be changed if compromised and labeled with the date and time of the change, which was not followed in this case. This oversight had the potential to result in harm, including infection and phlebitis, for Resident 243.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for two residents, leading to potential discomfort and distress. Resident 47, who was admitted with a history of lumbar spinal fusion and chronic pain, requested pain medication for back pain at 10:32 a.m. on May 13, 2024. Despite the request being reported to a nurse, Resident 47 did not receive the prescribed Hydrocodone-Acetaminophen until 11:08 a.m., 36 minutes after the initial request. The care plan for Resident 47 indicated that staff should respond immediately to complaints of pain, but this was not adhered to, resulting in a delay in pain relief. Resident 61, admitted with reduced mobility and neuropathy following a stroke, did not have any medication ordered for breakthrough pain. On May 13, 2024, Resident 61 missed a scheduled 6:00 p.m. dose of Gabapentin, a medication for nerve pain. There was no documentation explaining why the medication was not administered, and the lack of breakthrough pain medication could lead to unnecessary pain. The care plan for Resident 61 required staff to anticipate pain relief needs and respond immediately to complaints of pain, but these interventions were not effectively implemented. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that pain management protocols were not followed. The DON emphasized that staff should promptly address pain complaints and that delayed administration of pain medication could cause resident discomfort. The failure to administer pain medication as ordered and the absence of breakthrough pain management for Resident 61 were identified as deficiencies in the facility's pain management practices.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster area in a sanitary manner. During an observation and interview with a maintenance staff member, it was noted that one of the three garbage dumpsters located outside the kitchen back exit was overfilled with cardboard boxes and left uncovered. Additionally, the ground around the dumpsters was littered with plastic utensils, gloves, and paper. The maintenance staff acknowledged that the cardboard boxes should be flattened to fit properly in the dumpster, allowing the lid to close, and that the area should be kept clean to prevent attracting pests. The facility's policies and procedures, as well as the FDA Food Code, require that outside dumpsters be kept closed and free of surrounding litter. The facility's policy on Food-Related Garbage and Refuse Disposal, revised in 2017, and the Sanitation policy, revised in 2022, both indicate that garbage and refuse containers should be in good condition, without leaks, and properly contained with lids or otherwise covered. The FDA Food Code further specifies that receptacles for refuse should be kept covered with tight-fitting lids or doors if kept outside, and stored in a manner that makes them inaccessible to insects and rodents.
Failure to Properly Explain Binding Arbitration Agreements
Penalty
Summary
The facility failed to adhere to its policy regarding the discussion of binding arbitration agreements with residents and their responsible parties. This deficiency was identified through interviews and record reviews involving three residents. For Resident 73, the responsible party signed the arbitration agreement without recalling any discussion or understanding of its implications. Similarly, Resident 80's responsible party signed the agreement, but there is no indication that the terms were explained or understood. Resident 241, who was self-responsible, also signed the agreement without recalling any explanation or understanding of what the agreement entailed. The facility's policy requires that the nature and implications of binding arbitration agreements be explained to residents or their representatives, ensuring their understanding before signing. The policy also mandates that verbal acknowledgment of understanding be documented by the staff member explaining the agreement. However, the Admissions Coordinator admitted to not documenting such verbal acknowledgments, despite being trained on the facility's policy. This oversight led to the residents and their responsible parties potentially forfeiting their right to resolve disputes in court without being fully informed.
Deficient Fingernail Care and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide adequate fingernail care and maintain grooming and personal hygiene for two residents who were unable to perform activities of daily living independently. Resident 52, who had diagnoses including diabetes, hypertension, dementia, and dysphagia, required maximum assistance for personal hygiene. During an observation, Resident 52 was found with long and dirty fingernails, and he expressed a desire for staff to clean and cut them. A Certified Nursing Assistant acknowledged the condition of Resident 52's fingernails and stated that it was the responsibility of CNAs to clean and trim residents' fingernails daily. Similarly, Resident 77, who also had diagnoses of diabetes, hypertension, dementia, and dysphagia, required moderate assistance for ADLs. During an observation, Resident 77 was found with long and dirty fingernails and could not recall when they were last cleaned or trimmed. A Licensed Vocational Nurse and a Registered Nurse both highlighted the risks associated with long and dirty fingernails, including potential infections and injuries. The Director of Nursing confirmed that it was the CNAs' responsibility to ensure residents' fingernails were cleaned and trimmed as needed, as per the facility's policy on maintaining good grooming and personal hygiene.
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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