Cottage Crest Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, California.
- Location
- 12350 Rosecrans, Norwalk, California 90650
- CMS Provider Number
- 055758
- Inspections on file
- 43
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Cottage Crest Post Acute during CMS and state inspections, most recent first.
A resident with dementia and documented lack of decision-making capacity underwent a tooth extraction after a dentist, assisted by an LVN acting as translator, obtained the resident’s signature on a dental consent form without verifying capacity or contacting the Responsible Party (RP). The attending physician had cleared the resident for possible extractions and directed the dentist to call the RP, but no call or consent from the RP was obtained. The RN supervisor declined to witness the consent post‑procedure because he knew the resident lacked capacity and that the family made healthcare decisions. The RP later reported not being informed of the dental problem or the extraction, despite facility policies and a dental services agreement requiring that resident representatives be informed and valid informed consent be obtained before treatment.
A resident with dementia, metabolic encephalopathy, impaired decision-making, incontinence, and need for assistance with ADLs had an existing fall-risk care plan identifying risks related to incontinence, psychoactive medications, and poor safety awareness, with interventions focused on environmental safety and staff responsiveness. The resident sustained an unwitnessed fall, was found on the floor with a bleeding forehead laceration, and was transferred to a hospital by paramedics. After the fall, there was no documented IDT care conference with the resident’s representative, and the fall-risk care plan was not revised to include new or modified interventions, despite RN, DOR, and DON acknowledgments that licensed nurses and the IDT are responsible for updating care plans and facility policies requiring care plan review and revision following such events.
A resident with depression, intact decision-making capacity, and documented preferences for outdoor patio activities, outings, and shopping was not provided with these preferred activities despite care plan interventions directing staff to offer meaningful, individualized activities. Activity assessments repeatedly identified the resident’s interest in going outside and into the community, but review of several months of activity calendars showed no outings or shopping opportunities. The resident reported feeling sad and frustrated about being confined indoors and expressed a desire to leave the facility to shop and feel more normal. Staff interviews confirmed that the facility primarily offered indoor activities and had not arranged group outings, with the Activity Director citing transportation permit issues while acknowledging that residents’ choices, including outings and shopping, should have been honored.
A resident with dementia, metabolic encephalopathy, and mobility difficulties experienced an unwitnessed fall resulting in facial bleeding and a forehead laceration, was found on the floor near the nurses’ station, and was transferred to a GACH via 911. Although an RN reported assessing and monitoring the resident’s vital signs during this change of condition, there was no documentation of vital signs in the Change of Condition Evaluation or progress notes. The DON confirmed that nursing staff are responsible for complete records and that assessments, including vital signs, should be documented at the time of service, consistent with facility policy requiring accurate, relevant, and complete medical record documentation.
Surveyors found that the facility did not develop or implement comprehensive, person-centered care plans for four residents, including missing care plans for anticoagulant monitoring, bowel and bladder retraining, and hypoglycemia management, despite documented needs and significant clinical events.
Three residents who were incontinent of bowel and bladder did not receive required assessments or retraining programs to restore or maintain continence. Assessments were incomplete or not conducted as required, and care plans and physician orders lacked interventions for bowel and bladder retraining, despite facility policy and staff acknowledgment that such programs were necessary.
Surveyors found that food items were not consistently dated, labeled, or discarded according to policy, and that a cook failed to perform proper hand hygiene and glove changes between tasks during meal service. These deficiencies in food storage and handling practices affected nearly all residents and were not in compliance with facility policies.
A COVID-19 outbreak involving several residents with various medical conditions was not reported to the State Agency as required. The IPN reported the outbreak to the local public health agency and the CDC's NHSN, but did not notify the State Agency, believing local reporting was sufficient. The DON was unaware of the direct reporting requirement until reviewing state guidance. This failure was identified through interviews and record review.
The facility did not follow its antibiotic stewardship protocols for two residents who were prescribed antibiotics without meeting McGeer’s criteria for infection. Required documentation and physician notification were not completed, and the infection preventionist nurse was unaware of one resident’s antibiotic use. The facility’s policy mandates use of McGeer criteria and timely review of antibiotic use, but these steps were not followed.
A resident with depression and multiple cardiac conditions was prescribed Celexa, an antidepressant, without documented informed consent. The resident was cognitively intact, and facility policy required that residents be informed of the risks and benefits of psychotropic medications prior to initiation, but this was not done or documented.
A resident with diabetes and dementia did not receive proper care after insulin administration, as staff failed to ensure meal consumption, did not monitor blood glucose after a missed meal, and delayed checking blood sugar when the resident became unresponsive. There was no care plan or standing order for hypoglycemia treatment, and the resident required hospitalization due to these failures.
A resident with a history of atrial fibrillation, CAD, and CHF was prescribed Apixaban, but the facility did not develop a comprehensive, person-centered care plan for anticoagulant monitoring. The care plan lacked details on monitoring for side effects, and staff confirmed that the resident was not being monitored for adverse effects as required.
A tube of Triamcinolone Acetonide cream used for a resident with diabetes and cognitive impairment was found in a medication cart without a label or date. The DON confirmed the medication should have been labeled and dated according to facility policy, which requires resident and medication information on all drug containers.
The facility did not meet federal requirements for minimum bedroom size, with 33 multi-resident rooms and two single-resident rooms measuring below the required square footage per resident. Despite awareness of the deficiency by facility leadership and the presence of an approved room waiver, observations showed residents had enough space for movement and use of mobility aids, and no complaints were reported by residents or staff.
The facility did not provide documentation that its 50-year-old sprinkler system met required testing or replacement standards, with inspection reports showing failed tests and overdue maintenance. Additionally, an electrical outlet at a nurse station was found with a broken faceplate, exposing metal terminals, and the issue had not been previously identified by facility staff.
Surveyors observed that the fire alarm system's circuit disconnecting means was not identified with a red marking as required by NFPA codes. The Maintenance Supervisor acknowledged the deficiency, and a review of the facility's preventative maintenance policy confirmed the expectation for compliance.
An electrical outlet at Nurse Station #2 was found with a broken faceplate, exposing metal terminals. The CMO confirmed the damage had not been previously noticed. Facility policy assigns the Maintenance Director responsibility for maintaining safe equipment, but the exposed outlet was not addressed as required by NFPA 70.
A full H-sized oxygen cylinder was stored in the beauty salon without the required 'No Smoking' signage, as observed by surveyors. The CMO confirmed the absence of the sign and the use of the salon for temporary storage. Facility policy requires precautionary signs to be posted where oxygen is stored, but this was not followed, resulting in noncompliance with NFPA 99 standards.
A resident with cognitive and mobility impairments was unable to reach their call light and telephone, leading to frustration and potential delays in care. Staff interviews confirmed the importance of keeping these items accessible, as outlined in the facility's policies, but the failure to do so resulted in the resident's distress and risk of injury.
A resident with a history of osteoporosis and dementia sustained an acute right femoral neck fracture and right temporal hematoma of unknown cause. The facility failed to report this unusual occurrence to CDPH within the required 24-hour timeframe, delaying an onsite inspection. Despite severe pain and visible injuries, the facility's DON and Administrator waited for hospital confirmation before reporting, contrary to policy requirements.
A resident with cognitive impairment and multiple health conditions experienced verbal abuse by a CNA, who made a hurtful comment about the resident's smell, causing significant emotional distress. The incident was reported by an LVN, and staff interviews confirmed the comment was considered verbal abuse according to facility policy.
A facility failed to create a person-centered care plan for a resident with diabetes, risking episodes of hypoglycemia or hyperglycemia. The care plan was delayed by 16 days and lacked details on medication and blood sugar monitoring frequency. The DSD confirmed these omissions, which violated the facility's policy for comprehensive care plans.
A resident with type 2 diabetes and a history of hypoglycemia was admitted to an LTC facility without an order for routine blood sugar monitoring, despite being on insulin. This oversight led to a hypoglycemic episode, highlighting a deficiency in following up with the physician for necessary monitoring orders.
A long-term care facility experienced a medication error rate of 48.78%, affecting all observed residents. Errors included omitted doses, incorrect administration techniques, and failure to follow physician-ordered parameters. Residents missed critical medications for hypertension, heart function, and infection, placing them at risk for serious complications.
The facility failed to ensure proper use and monitoring of psychotropic medications for several residents, leading to unnecessary drug administration and potential adverse effects. One resident received increased doses of Seroquel without documented necessity, and another was given Ativan and Sertraline without proper documentation of anxiety and depression episodes. Additionally, a resident continued to receive Seroquel after it was ordered to be discontinued, resulting in hospitalization due to adverse effects. The facility did not adhere to policies regarding informed consent and monitoring for adverse effects.
The facility failed to provide adequate RNA staff, resulting in 28 residents not receiving necessary restorative services. CNA direct care hours fell below the required minimum, and the facility did not use contracted registry staff to address the shortage. Interviews revealed that RNAs were often pulled to work as CNAs, and the Administrator was unaware of the staffing issues.
The facility failed to ensure LVNs were properly trained to administer medications via g-tube according to physician's orders, affecting three residents. One LVN used a push method instead of gravity, another prepared to administer medications without specific orders, and a third did not verify updated orders before administration. These actions could lead to cross-contamination and increased infection risk.
The facility failed to ensure the availability of critical medications for five residents, including metoprolol tartrate and apixaban, and did not maintain accurate medication administration records for two residents. This led to potential health risks due to untreated conditions and inaccurate documentation.
The facility failed to maintain safe food storage and hygiene practices, with expired and improperly stored food items found in the kitchen. Raw meats were stored alongside other foods, risking cross-contamination. Staff did not follow hand hygiene protocols, increasing the risk of bacterial spread.
The facility failed to properly cover two large dumpsters and two smaller carts, leading to potential cross-contamination risks for 54 residents. During an observation, the Dietary Manager noted that the dumpsters were overflowing and could not be closed, and acknowledged that the bins should be sealed to prevent infestations. The facility's policy and the Food Code 2017 require that such receptacles be covered when not in use.
The facility failed to address unresolved deficiencies in staffing and medication management, leading to insufficient CNA hours and a high medication error rate. Two RNAs were unavailable, affecting 28 residents, and medications were not in stock for five residents. The Administrator was unaware of these issues until the Immediate Jeopardy process, and the QAPI committee meetings did not effectively resolve them.
The facility failed to offer and document advance directives for two residents. One resident had an incomplete directive lacking required signatures, while another was not offered an advance directive upon admission or quarterly. Interviews with the Social Services Director and DON confirmed these deficiencies, which were contrary to the facility's policy.
A facility failed to accurately document a resident's nutritional status on the MDS, incorrectly indicating parenteral and enteral nutrition. Additionally, another resident's fall risk assessments were inconsistent with therapy evaluations, failing to reflect the true fall risk. These documentation errors could impact the residents' care plans and service delivery.
Two residents in an LTC facility experienced significant medication errors due to unavailable medications and failure to follow protocols. One resident did not receive metoprolol tartrate due to it being out of stock, while another missed doses of potassium chloride and apixaban. The LVN involved did not notify the pharmacy or physician about the shortages, and the DON acknowledged the need for timely medication administration and reordering.
The facility failed to implement proper infection control measures, including hand hygiene and PPE use, during resident care and medication administration. A CNA did not perform hand hygiene, and another did not wear PPE for a resident on enhanced precautions, risking cross-contamination. An LVN failed to disinfect medication trays and perform hand hygiene, compromising infection control.
A resident with chronic health issues was transferred to the hospital without a documented significant change of condition (COC) by the facility. Despite the facility's policy requiring notification of the resident's physician and next-of-kin, staff interviews revealed that no COC was completed, potentially leaving the resident's condition unmonitored.
The facility failed to accurately complete PASARR evaluations for several residents with serious mental illnesses and developmental disabilities. This deficiency involved incorrect or incomplete assessments, leading to potential risks in providing necessary care. The DON acknowledged the oversight, emphasizing the importance of accurate PASARR assessments.
The facility failed to develop timely baseline care plans for two residents, one with a history of falls and psychotropic medication use, and another with a history of seizures. The care plans were not initiated within the required timeframe, leaving gaps in the management of their conditions. Interviews with staff highlighted that the facility's policies on care plans were not followed, resulting in deficiencies in care.
A resident with multiple medical conditions and high fall risk experienced six falls due to the facility's failure to implement person-centered interventions and revise the fall risk care plan. The facility did not conduct proper post-fall assessments or neurological checks, and interventions were inconsistently applied. Despite being on psychotropic medication, the potential risk factors were not addressed, leading to inadequate fall prevention measures.
A resident with multiple medical conditions and high risk for pneumonia did not receive the pneumonia vaccine despite physician orders. The resident was dependent on nursing staff and lacked decision-making capacity. The absence of vaccine administration documentation led to the resident developing pneumonia twice, requiring hospital transfers.
The facility failed to meet the required space of 80 square feet per resident in multi-bed rooms and 100 square feet for single rooms, with 33 rooms falling short of these standards. Despite this, observations indicated that residents had enough space to move freely, and the room size did not affect the nursing care or privacy provided. The Administrator was aware of the requirements and had previously approved a room waiver.
Tooth Extraction Performed Without Responsible Party Consent
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Responsible Party (RP) was informed of the resident’s dental needs and that valid consent was obtained prior to a tooth extraction, despite the resident lacking decision-making capacity. The resident had diagnoses of metabolic encephalopathy and dementia, and the Minimum Data Set and History and Physical documented that the resident was not able to make reasonable and consistent decisions and did not have capacity to understand and make decisions. The resident required assistance with activities of daily living. A Dental Medical Order form proposed extraction of teeth numbers 12 and 29, and the attending physician signed this form to provide medical clearance, with instructions for the dentist to call the RP to explain the procedure. On the day of the procedure, the dentist proceeded with the extraction of tooth number 12 after explaining the procedure to the resident through LVN 1, who acted as a translator. The dentist obtained the resident’s signature on a Dental Procedure Consent form, which stated that the resident had read the consent and had questions answered to her satisfaction, and LVN 1 signed as a witness to the resident’s consent. The dental progress note documented that tooth number 12 was unrestorable and was extracted using forceps with local anesthetic, while tooth number 29 was not extracted. A Change of Condition evaluation recorded that the resident underwent extraction of tooth number 12. No documentation showed that the RP was contacted or that consent was obtained from the RP before the procedure. After the extraction, the RP complained that the tooth had been removed without her knowledge or consent and stated she had not been informed of the resident’s dental concerns or need for extraction by the dentist or nursing staff. LVN 1 acknowledged that she did not call the RP or check the medical record to verify the resident’s capacity or the need for RP consent, assuming this had already been done. The Registered Nurse Supervisor reported that he declined to witness the consent after the procedure because he knew the resident lacked capacity and that the family was responsible for healthcare decisions. The dentist stated he did not call the RP, assumed the dental office had contacted the family, did not verify the resident’s cognition or capacity, and noted that the face sheet did not indicate a designated RP. Facility policies on notification of changes, informed consent, resident rights, and dental services required that resident representatives be informed and involved in decisions and that informed consent be verified prior to treatment, and the Dental Facilities Services Agreement required the dentist to maintain legal informed consent signed by residents and/or their responsible parties.
Failure to Revise Fall-Risk Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s fall-risk care plan after a documented fall. The resident was admitted with diagnoses including metabolic encephalopathy, dementia, and difficulty walking. An MDS assessment dated 7/8/2025 showed the resident was unable to make reasonable and consistent decisions, required partial to moderate assistance with ADLs such as transfers and repositioning, and was incontinent of bowel and bladder. A care plan dated 8/10/2025 identified the resident as at risk for falls due to incontinence, psychoactive drug use, and unawareness of safety needs, with goals for the resident to be free from falls and serious injury. Interventions included anticipating and meeting needs, prompt staff response to calls, and maintaining a safe environment with clear pathways, adequate lighting, and personal items and call light within reach. On 12/25/2025, a Change of Condition Evaluation documented that the resident had a fall and was found sitting on the lobby floor with blood on her face. A Change in Condition Progress Note dated 12/26/2025 recorded that the resident was found on the floor by the nursing station with a quarter-sized, actively bleeding cut on the forehead. Paramedics were called, and the resident was transferred to a general acute care hospital via 911 for further treatment. The resident’s emergency contact later stated that staff informed her of the fall incident but did not call her to attend a meeting to discuss care concerns and interventions after the fall. Record review showed no documentation that the IDT implemented a care conference with the resident’s emergency contact to discuss recommendations, changes, or updates to the fall-risk care plan after the fall. The resident’s fall-risk care plan contained no revisions or updates to include interventions following the 12/25/2025 fall. RN 1 stated that the resident had an unwitnessed fall at change of shift, that he instructed the CNA to perform frequent visual checks, and that he was unable to review and revise the fall-risk care plan or formulate a care plan for an actual fall, acknowledging that licensed nurses are responsible for updating and revising care plans. The Director of Rehab and the DON both confirmed that there was no documented IDT meeting and that the resident’s fall-risk care plan was not revised or updated after the fall, despite facility policies requiring development, implementation, and revision of comprehensive care plans and review and updating of care plans under the fall prevention program.
Failure to Provide Resident With Preferred Outings and Shopping Activities
Penalty
Summary
The facility failed to provide a resident with preferred activities, specifically outdoor patio activities, outings, and shopping, as identified in the resident’s activity assessments and care plan. The resident, who had a diagnosis of depression and the capacity to understand and make decisions, was assessed on multiple occasions as enjoying outdoor and community-based activities. The Minimum Data Set indicated the resident could make reasonable and consistent decisions, required partial to moderate assistance with ADLs, and used a manual wheelchair for mobility. The resident’s care plan for depression included interventions to assist him in developing and providing meaningful activities of interest, with a goal of being free from signs and symptoms of distress and not exhibiting indicators of depression such as a sad mood or anxiety. Despite these documented preferences and care plan interventions, review of the facility’s activity calendars over several months showed no outings or shopping activities offered. In interviews, the resident reported wanting to leave the facility on good-weather days to purchase items from a store and stated that remaining inside made him feel sad and frustrated, expressing a desire to do something outside or away from the facility to feel like a normal human being. A restorative nursing assistant confirmed that the resident had expressed a wish to go shopping and that the facility mostly provided indoor activities rather than outings. The Activity Director acknowledged that no group outings had been provided, citing the need to apply for a government ride permit for each resident, and stated that residents’ activities of choice should have been planned and implemented, including outings and shopping when families were not available to take residents out. The DON and Administrator both stated that the resident’s activity interests should have been provided to promote meaningful experiences and ensure comfort and quality of life.
Failure to Document Vital Signs After Resident Fall and Change of Condition
Penalty
Summary
The facility failed to ensure accurate documentation of vital signs during a resident’s change of condition following a fall. Resident 2, who had diagnoses including metabolic encephalopathy, dementia, and difficulty walking, and who required partial to moderate assistance with ADLs and was incontinent of bowel and bladder, experienced an unwitnessed fall. A Change of Condition Evaluation dated 12/25/2025 documented that the resident was found sitting on the lobby floor with blood on her face, but there was no documentation of vital signs at that time. A subsequent Change in Condition Progress Note dated 12/26/2025 recorded that the resident was found on the floor by the nursing station with a quarter-sized cut on the forehead that was actively bleeding and that paramedics were called and the resident was transferred to a general acute care hospital via 911, again with no vital signs documented in the clinical record during this change of condition. In a telephone interview, RN 1 stated that the resident had an unwitnessed fall at change of shift and that he was able to assess and monitor the resident’s vital signs during the change of condition but did not document those vital signs in the clinical record. RN 1 acknowledged that he should have documented the vital signs to depict the resident’s accurate well-being after the fall. In an interview, the DON stated that RN 1 should have documented the assessments and monitoring during the change of condition, including current vital signs, to reflect the resident’s accurate well-being after the fall and to determine her condition and/or deterioration, and affirmed that it was the responsibility of nursing staff to ensure residents’ records are complete. The facility’s policy on Documentation in Medical Record required that medical records contain enough information to provide a picture of the resident’s progress and that nursing staff document accurate, relevant, and complete assessments and observations at the time of service, which was not followed in this instance.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, as required by federal regulations. For one resident with a history of paroxysmal atrial fibrillation, coronary artery disease, and congestive heart failure, the care plan did not adequately address the use of Apixaban, an anticoagulant. The Quality Assurance Nurse confirmed that the care plan lacked information on monitoring for side effects, such as bleeding, which is essential for residents on blood thinners. Two other residents, both with histories of urinary retention and neurological or muscular conditions, were identified as candidates for bowel and bladder retraining based on their assessments. Despite documented frequent incontinence and assessment scores indicating suitability for retraining programs, there were no care plans initiated or updated to address bowel incontinence or retraining for these residents. The Registered Nurse Supervisor acknowledged that the absence of these care plans could delay necessary treatment and that all concerns should be reflected in the care plan. Another resident with diabetes mellitus and dementia experienced a significant hypoglycemic event, as documented in the nurse's progress notes. Despite this event, there was no care plan developed to address hypoglycemia. The Director of Nursing confirmed that care plans should be specific and interventions should be implemented and reevaluated, especially following significant events. The facility's own policy required comprehensive, person-centered care plans to be developed and implemented for each resident, but this was not followed in these cases.
Plan Of Correction
F656 - Develop/Implement Comprehensive Care Plan • How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 6/2/25, the Quality Assurance Nurse (QAN) added the monitoring of the side effect for Apixaban, which included monitoring bleeding for Resident 45. (Exhibit #5) - On 5/29/25, the Registered Nurse Supervisor 1 (RNS1) added bowel incontinence and bowel and bladder retraining in the care plan for Resident 10 and Resident 44. (Exhibit #6) - On 5/30/25, the Director of Nursing (DON) included hypoglycemia monitoring in the care plan for Resident 23. (Exhibit #7) • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - On 6/17/25, the Director of Staff Development (DSD) and QAN reviewed the list of residents with anticoagulants, possible candidates for bowel and bladder retraining, and residents at risk for hypoglycemia to ensure care plans were completed accurately. (Exhibit #8) - No other residents were affected by the same deficient practice. • What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Comprehensive Care Plans" dated 12/19/2022. (Exhibit #9) - Starting on 6/17/25, the DON and QAN will conduct a weekly review for three months to ensure care plans were developed and implemented, particularly for anticoagulant medications, hypoglycemia, and bowel and bladder assessment and training programs. (Exhibit #10) - Starting on 6/17/25, the DON will report to the administrator any non-compliance. • How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DON will discuss any trends or patterns during the monthly QA committee meetings for three months for review and recommendations and will re-evaluate if any further concerns are identified afterward. Date of completion: June 20, 2025
Failure to Provide Bowel and Bladder Retraining for Incontinent Residents
Penalty
Summary
The facility failed to ensure that three residents who were incontinent of bowel and bladder received appropriate assessments and retraining programs to restore or maintain continence, as required by federal regulations. For one resident, the bowel and bladder assessment was not completed quarterly, and although an initial assessment indicated the resident was a candidate for retraining, there was no evidence of a retraining program being implemented. The resident's care plan and physician orders did not include any interventions for bowel and bladder retraining, and the most recent assessment was incomplete. Another resident did not have a bowel and bladder assessment conducted upon admission, and there was no evidence that the resident participated in a retraining program. The resident's condition changed from frequent incontinence to always incontinent, but no new assessment or retraining program was initiated. The care plan and physician orders for this resident also lacked any mention of bowel and bladder retraining interventions. A third resident was identified as a candidate for prompt toileting based on a completed assessment, but subsequent assessments were incomplete, and the resident was not placed in a bowel and bladder training program. Staff interviews confirmed that the resident should have been included in such a program, and the facility's policy required individualized, resident-centered restorative toileting programs to be care planned and reevaluated at least quarterly. Despite this, there was no evidence that the required assessments and interventions were consistently implemented for these residents.
Plan Of Correction
F690 - Bowel/Bladder Incontinence, Catheter, UTI How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 6/16/25, the Director of Nursing (DON) conducted a bowel and bladder assessment for Resident 3, 10, and 44. The respective residents were offered bowel and bladder training. (Exhibit #16) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 6/17/25, the Director of Staff Development (DSD) and Quality Assurance Nurse (QAN) reviewed the bowel and bladder assessments of the residents. The bowel and bladder training were offered to those residents that qualified for the bowel and bladder program. (Exhibit #17) - No other residents affected by the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Bladder and Bowel Incontinence: A Care Solution," Copyright 2022. (Exhibit #18) - Beginning on 6/17/25, the Minimum Data Set Director (MDSD) will review the bowel and bladder assessment of the residents weekly for three months to identify those residents who are good candidates for bowel and bladder training program. The MDSD will include those residents who are newly admitted to the facility. (Exhibit #19) - Starting on 6/17/25, the MDSD will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The MDSD will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025
Deficient Food Storage, Labeling, and Hand Hygiene Practices
Penalty
Summary
Surveyors identified deficiencies in the facility's food storage and handling practices, which affected 47 out of 50 residents. During observations in the dry storage area, several food items were found not properly dated, labeled, sealed, or discarded. Examples included opened sundried tomatoes without an open date, fresh yams with damaged and exposed surfaces, and opened muffin mix lacking required dates. In the refrigerator, opened pasteurized eggs and snap peas were also missing appropriate use-by dates. The Dietary Supervisor confirmed that all dietary staff, including herself, were responsible for ensuring food items were labeled, dated, and stored according to facility policy, which was not consistently followed. Further review of facility policies revealed that opened food items should be marked with receiving, open, and use-by dates, and that staff should refer to storage charts for appropriate shelf life. The policies also required that expired or outdated food products be discarded and that all products be inspected for safety and quality. Despite these policies, the survey found multiple instances where food items were not managed according to these standards, increasing the risk of foodborne illness among residents. Additionally, during meal service, a cook was observed failing to perform proper hand hygiene and glove changes between tasks. After handling a lunch cart and touching a doorknob, the cook did not wash hands or change gloves before handling another resident's tray, which she acknowledged was not in line with infection control practices. The Director of Nursing confirmed that all staff should perform hand hygiene between tasks to prevent cross-contamination. Facility policies reviewed by surveyors also emphasized the importance of hand hygiene and safe food handling, but these were not adhered to during the observed meal service.
Plan Of Correction
F812 - Food Procurement, Store/Prepare/Serve- Sanitary • How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/27/25, the Dietary Supervisor (DS) removed and discarded the food items identified without label and exceeded the used by dates. - On 5/27/25, the DS called the attention of cook 2 (CK2) to perform hand hygiene and change gloves in between tasks. • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - Not applicable. • What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 5/28/25, the Infection Prevention Nurse (IPN)/DS provided one-on-one in-service to CK2 regarding the facility policy and procedure entitled, "Food Safety and Food Storage," revised 11/4/2024, and "Hand Hygiene," revised 12/19/2022. (Exhibit #35) - On 5/28/25, the DS provided in-service to the active kitchen staff regarding the policy and procedure entitled, "Dry Storage Chart," dated 2023; "Refrigerated Storage Chart," dated 2020; "Date Marking for Food Safety," revised 12/19/2022; and "Food Storage," revised 8/29/2023. (Exhibit #36) - Beginning on 6/17/25, the DS will conduct observations weekly for three months to ensure food items are stored and labeled accordingly. In addition, the DS will observe the kitchen staff perform hand hygiene and change gloves in between tasks. (Exhibit #37) - Starting on 6/17/25, the DS will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained: - On 5/28/25, the Infection Prevention Nurse (IPN)/DS provided one-on-one in-service to CK2 regarding the facility policy and procedure entitled, "Food Safety and Food Storage," revised 11/4/2024, and "Hand Hygiene," revised 12/19/2022. (Exhibit #35) - On 5/28/25, the DS provided in-service to the active kitchen staff regarding the policy and procedure entitled, "Dry Storage Chart," dated 2023; "Refrigerated Storage Chart," dated 2020; "Date Marking for Food Safety," revised 12/19/2022; and "Food Storage," revised 8/29/2023. (Exhibit #36) - Beginning on 6/17/25, the DS will conduct weekly observations for three months to ensure proper food storage and labeling, as well as hand hygiene and glove-changing practices. (Exhibit #37) - The DS will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified afterward. Date of completion: June 20, 2025.
Failure to Report COVID-19 Outbreak to State Agency
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the State Agency as required by federal and state regulations. Multiple residents tested positive for COVID-19 over a period of time, with laboratory results confirming positive cases for six residents. The infection prevention nurse (IPN) acknowledged that the outbreak began when three residents tested positive and reported the incident to the local public health agency and the CDC's National Healthcare Safety Network, but did not notify the State Agency. The IPN believed that reporting to the local agency would automatically result in notification to the State Agency. Further review revealed that the Director of Nursing (DON) was not aware that the State Agency required direct notification and only realized this after reviewing the relevant All Facilities Letter (AFL 23-08), which clarified the reporting requirements. The facility's own policy and procedure on infection outbreak response indicated that outbreaks should be reported to local and/or state health departments in accordance with state requirements, but this was not followed in practice. The residents involved had various medical conditions, including pneumonia, prostate cancer, atrial fibrillation, coronary artery disease, congestive heart failure, stage 4 kidney disease, lupus, hypertension, colon cancer, bronchitis, morbid obesity, and hyponatremia. Some residents had moderate cognitive impairment, while others were cognitively intact. The failure to report the outbreak to the State Agency was identified through observation, interviews, and record review, and was considered a deficiency in the facility's infection prevention and control program.
Plan Of Correction
F880 - Infection Control Program How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 6/2/25, the Infection Prevention Nurse (IPN) initiated the reporting of COVID-19 outbreak to California Department of Public Health (CDPH). Exhibit #27 How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - Not applicable What measures put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/2/25, the Director of Nursing (DON) provided one-on-one in-service to the IPN regarding the facility policy and procedure entitled, "Infection Outbreak Response and Investigation," dated 12/19/2022. (Exhibit #28) - Starting on 6/2/25, the IPN will review the number of cases daily until the outbreak is over and report to CDPH accordingly. - Beginning on 6/2/25, the IPN will report to the CDPH the COVID-19 outbreak. - On 6/13/25, the IPN received Respiratory Illness Outbreak clearance letter. (Exhibit #29) How the facility plans to monitor its performance to make sure that solutions are sustained: - The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The IPN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. - Date of completion: June 20, 2025
Failure to Follow Antibiotic Stewardship Protocols for Two Residents
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program policy and procedure for two residents who were prescribed antibiotics without meeting the established criteria. One resident, admitted with type 2 diabetes, a foot ulcer, osteomyelitis, and a right foot amputation, was prescribed intravenous Piperacillin Sod-Tazobactam. Review of the resident's Infection Screening Evaluation indicated that the symptoms did not meet McGeer’s criteria for infection, and the Antibiotic Time Out form did not show that the physician was notified of this. Another resident, admitted with acute kidney failure and a urinary tract infection, was prescribed oral Ciprofloxacin. The Infection Screening Evaluation for this resident also indicated that McGeer’s criteria were not met, and the Antibiotic Time Out was not completed within the required timeframe. Interviews with the infection preventionist nurse revealed a lack of awareness regarding the antibiotic use for one resident and a failure to complete the required Antibiotic Time Out documentation. The infection preventionist nurse confirmed that the physician should be notified when criteria are not met and that this communication should be documented, but this was not done in either case. The facility’s policy states that McGeer criteria are used to define infections and that education on the antibiotic stewardship program should be provided to staff, practitioners, residents, and families, but these procedures were not followed for the two residents involved.
Plan Of Correction
F881 - Antibiotic Stewardship Program How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/29/25, the Infection Prevention Nurse (IPN) reviewed the antibiotic stewardship for Resident 43 and 154 and notified the MD. (Exhibit #30) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - On 6/2/25, the IPN reviewed the list of residents on antibiotics, checked if the residents met McGeer's criteria, and if the physician was notified for the antibiotic time out. (Exhibit #31) - No other resident was affected by the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/2/25, the Director of Nursing (DON) provided one-on-one in-service to the IPN regarding the facility policy and procedure entitled, "Antibiotic Stewardship Program" dated 12/2022. (Exhibit #32) - Starting on 6/17/25, the IPN provided in-service to the active licensed nurses regarding the policy and procedure entitled, "Antibiotic Stewardship Program" dated 12/2022. (Exhibit #33) - Beginning on 6/17/25, the DON will review the Antibiotic Stewardship Program weekly for three months to ensure the physicians were notified if there is an antibiotic time out. (Exhibit #34) - Starting on 6/17/25, the IPN will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained: - The IPN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency was identified when the facility failed to obtain informed consent for the administration of Celexa, an antidepressant medication, to a resident diagnosed with depression. The resident, who was cognitively intact and had a history of paroxysmal atrial fibrillation, coronary artery disease, and congestive heart failure, was admitted to the facility and subsequently prescribed Celexa for depression manifested by low interest and motivation with activities of daily living. Review of the resident's records confirmed that informed consent was not documented prior to starting the medication. During an interview, the Quality Assurance Nurse acknowledged that informed consent had not been obtained before initiating the psychotropic medication, despite facility policy requiring that residents, families, or representatives be informed of the risks and benefits of such medications and that this information be documented in the resident's chart. The facility's policy specifically included antidepressants as psychotropic medications for which informed consent is required.
Plan Of Correction
F552 - Right to be informed/ Make Treatment Decisions How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/30/25, the Quality Assurance Nurse (QAN) offered and secured the consent from Resident 45 regarding the Celexa medication. (Exhibit #1) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - On 6/2/25, the Social Service Director (SSD) and QAN reviewed the list of residents with psychoactive medications orders to ensure that informed consents were signed and obtained. (Exhibit #2) - No other resident was affected of the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in services to the licensed nurses regarding the facility's policy and procedure (P&P) titled "Use of Psychotropic Medications" dated 3/17/2025. (Exhibit #3) - Starting on 6/16/25, the SSD will conduct a weekly review for three months of the informed consents for those residents who will be receiving psychoactive medications orders. In addition, the SSD will review the informed consents of the newly admitted residents. (Exhibit #4) - Starting on 6/16/25, the SSD will report to the administrator any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The SSD will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025
Failure to Provide Appropriate Hypoglycemia Management
Penalty
Summary
A deficiency occurred when a resident with diabetes and dementia, who required significant assistance with activities of daily living, did not receive appropriate care for a hypoglycemic episode. The resident was administered eight units of insulin after a high blood glucose reading, but subsequently consumed none of their dinner. Staff failed to ensure the resident ate after receiving insulin, which is necessary to prevent hypoglycemia, and did not monitor the resident's blood glucose levels following the meal refusal. Later that evening, the resident was found unresponsive. Staff checked vital signs but did not immediately check the resident's blood glucose level to rule out hypoglycemia. The blood glucose was not measured until paramedics arrived, at which point it was found to be critically low (40 mg/dl). There was no evidence that staff provided timely treatment for hypoglycemia, such as administering Glucagon or other interventions, nor did they consult the primary physician promptly for emergency orders. Record review revealed that the resident did not have a care plan addressing hypoglycemia, and there were no standing orders for Glucagon or other hypoglycemia treatments. Facility policies required glucose monitoring and treatment protocols for residents at risk, but these were not followed. The failure to monitor, treat, and provide appropriate interventions for hypoglycemia resulted in the resident's preventable hospitalization for further evaluation and treatment.
Plan Of Correction
F658 - Services Provided Meet Professional Standard • How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 23 was transferred to acute and returned to the facility on 11/2/24. Resident 23 has no hypoglycemic episode after returning from acute. The care plan was developed and implemented. (Exhibit #11) • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 6/17/25, the Director of Staff Development (DSD) and Quality Assurance Nurse (QAN) reviewed the list of residents receiving insulin injection to ensure blood sugar monitoring was done and meal was offered after the insulin injection to prevent hypoglycemia episode. (Exhibit #12) No other resident affected of the same deficient practice. • What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Hypoglycemia Management," revised 12/19/2022. (Exhibit #13) Starting on 6/17/25, the QAN and DSD will conduct a weekly observation for three months to ensure licensed nurses are offering food and snacks after the insulin injection. (Exhibit #14) Starting on 6/17/25, the DON will conduct weekly review for three months to ensure residents receiving insulin will not have any hypoglycemic episode. If identified with hypoglycemic episode, a change of condition will be created, care plan will be revised and responsible party and physician will be notified for possible adjustment of the insulin. (Exhibit #15) The DON will also report to the administrator for any non-compliance. • How the facility plans to monitor its performance to make sure that solutions are sustained: The DON will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. The plan includes the following actions: - Starting on 6/17/25, the DON will conduct weekly review for three months to ensure residents receiving insulin will not have any hypoglycemic episode. If identified with hypoglycemic episode, a change of condition will be created, care plan will be revised and responsible party and physician will be notified for possible adjustment of the insulin. (Exhibit #15) - Starting on 6/17/25, the DON will report to the administrator for any non-compliance. The completion date for these actions is June 20, 2025.
Failure to Monitor Anticoagulant Therapy and Maintain Comprehensive Care Plan
Penalty
Summary
The facility failed to monitor the use of anticoagulant medication for one resident who was admitted with diagnoses including paroxysmal atrial fibrillation, coronary artery disease, and congestive heart failure. The resident was prescribed Apixaban, an anticoagulant, but the care plan related to this medication was not comprehensive or person-centered. Specifically, the care plan lacked information on monitoring for side effects such as bleeding, and there was no evidence that the resident was being monitored for these side effects as required. Interviews with the Quality Assurance Nurse and the Director of Nursing confirmed that the care plan did not include necessary details for monitoring the resident for adverse effects of anticoagulant therapy. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the resident in question. The deficiency was identified through review of the resident's records, care plan, medication administration record, and physician's orders.
Plan Of Correction
F755 - Pharmacy Services/Pharmacist/Records How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 6/2/25, the Quality Assurance Nurse (QAN) included the monitoring for the anticoagulant medication for Resident 45. (Exhibit #20) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - On 6/17/25, the Director of Staff Development (DSD) and QAN reviewed the list of residents on anticoagulant medication to ensure monitoring for side effects, including bleeding, was included. (Exhibit #21) - No other resident affected of the same deficient practice. What measures put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Comprehensive Care Plans" dated 12/19/2022. (Exhibit #22) - Beginning on 6/17/25, the QAN will review the care plan and electronic medication record (eMAR) weekly for three months of those residents who received anticoagulant medication to ensure monitoring for side effects including bleeding was indicated. (Exhibit #23) - Starting on 6/17/25, the QAN will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The QAN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025
Unlabeled and Undated Topical Medication Found in Medication Cart
Penalty
Summary
A tube of Triamcinolone Acetonide External Cream 0.5% was found in a medication cart without a label indicating the resident's name or the date the medication was opened. This medication belonged to a resident who had been admitted with type 2 diabetes and a history of falls, and who had moderate cognitive impairment. The physician's order for this medication specified its use for a rash, to be applied topically every 12 hours as needed. During an observation of the medication cart with an LVN, the unlabeled and undated tube was discovered. The DON confirmed that the medication belonged to the resident and acknowledged that all medications in the cart should be labeled and dated, with pharmacy labels including resident information. The facility's policy required all medications to be labeled and dated in accordance with state and federal regulations, including specific information such as the resident's name, prescribing physician, medication details, and appropriate instructions.
Plan Of Correction
F761 - Label/Store Drugs and Biologicals How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/29/25, the Licensed Vocational Nurse (LVN1) removed the Triamcinolone Acetonide External Cream 0.5% in the medication cart. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - On 6/16/25 and 6/17/25, the Director of Staff Development (DSD) and Quality Assurance Nurse (QAN) conducted a medication cart check to ensure medications stored were labeled accordingly and not expired. (Exhibit #24) - No other residents affected by the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Labeling of Medications and Biologicals" dated 12/19/2022. (Exhibit #25) - Beginning on 6/16/25, the QAN and DSD will conduct medication cart checks weekly for three months to ensure medications stored were labeled accordingly and not expired. (Exhibit #26) - Starting on 6/17/25, the QAN will report to the administrator for any noncompliance. How the facility plans to monitor its performance to make sure that solutions are sustained: - The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The QAN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025 F 761
Resident Bedrooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required minimum square footage as specified by federal regulations. Specifically, 33 multi-resident rooms measured less than 80 square feet per resident, and two single-resident rooms measured less than 100 square feet. This was confirmed through a review of the facility's Client Accommodation Analysis form, which listed the square footage of each room, and through interviews with the Maintenance Director and Administrator, both of whom acknowledged awareness of the room size deficiencies. The Administrator also referenced an approved room waiver dated 2025. Observations conducted during the survey period indicated that residents had sufficient space to move freely within their rooms, and there were no complaints from residents or staff regarding room size. Each resident had a bed and side table, and there was adequate space for mobility aids such as walkers, canes, wheelchairs, and shower chairs. The facility's policy and procedures required compliance with the minimum square footage standards, but the actual room sizes did not meet these requirements.
Plan Of Correction
Bedrooms Measure at Least 80 Sq Ft/Resident How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 6/19/25, the facility submitted a formal request for recognition of variation of room space for recertification. (Exhibit #38) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - All residents have the potential to be affected by the deficient practice. - Social Services Director will monitor residents for comfort and offer recommendations or alternatives if needed, upon admission, room change, quarterly after admission, annually after admission, and as needed. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - Social Services Director will monitor residents for comfort and offer recommendations or alternatives if needed, upon admission, room change, quarterly after admission, annually after admission, and as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - Administrator will report findings and trends to QA committee meeting on a monthly basis for 3 months then quarterly thereafter. Date of completion: June 20, 2025 How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - All residents have the potential to be affected by the deficient practice. - Social Services Director will monitor residents for comfort and offer recommendations or alternatives if needed, upon admission, room change, quarterly after admission, annually after admission, and as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - Administrator will report findings and trends to QA committee meeting on a monthly basis for 3 months then quarterly thereafter. Date of completion: June 20, 2025
Deficiencies in Sprinkler System Maintenance and Electrical Outlet Safety
Penalty
Summary
The facility failed to provide documentation that its sprinkler system, which had been in service for 50 years, met the testing requirements set by a recognized testing laboratory or had been replaced as required by NFPA 25. During review of inspection reports, it was found that the annual sprinkler inspection failed because the sprinklers were out of date, and laboratory testing indicated the sprinklers failed the water seal release test. The facility's records also showed that a significant number of sprinklers were due for testing or replacement, and the facility's preventative maintenance policy assigned responsibility for maintenance scheduling to the Maintenance Director. Additionally, the facility did not ensure that an electrical outlet at Nurse Station #2 was properly maintained, as an observation revealed that half of the faceplate cover was broken, exposing metal terminals. This was confirmed during an interview with the CMO, who stated he had not previously noticed the broken faceplate. The facility's policy and procedure for preventative maintenance was also reviewed in relation to this finding.
Plan Of Correction
K353 Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the MS called to follow-up the fire sprinkler heads replacement schedule by vendor on 05/28/2025 and 06/13/2025 and by the ADM on 06/16/2025 and 06/17/2025. All sprinkler heads will be replaced pending approval of plans submitted by vendor to HCAI/OSHPD (Exhibit #2, Exhibit #s 5-8). How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: K353 Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the MS called to follow-up the fire sprinkler heads replacement schedule by vendor on 05/28/2025 and 06/13/2025 and by the ADM on 06/16/2025 and 06/17/2025. All sprinkler heads will be replaced pending approval of plans submitted by vendor to HCAI/OSHPD (Exhibit #2, Exhibit #s 5-8). How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Preventative Maintenance Program, ensuring the need for regular testing and maintenance of the sprinkler system for compliance and safety. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified: An observational audit on the maintenance log for the sprinkler system will be done once a month for 3 months with Administrator/Designee. A summary of the identified trend of the audit will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness and sustainability. Date of compliance: June 20, 2025 K511 Utilities - Gas and Electric CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the MS changed the faceplate of the electrical outlet at Nurse Station #2 on 05/28/2025. (Exhibit #3) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Preventative Maintenance Program, ensuring all electrical receptacles were maintained free of damage. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified.
Fire Alarm System Circuit Disconnect Not Properly Marked
Penalty
Summary
The facility failed to ensure that the circuit disconnecting means for the fire alarm system control unit was properly identified with a red marking, as required by NFPA 101, NFPA 70, and NFPA 72. During an observation and interview at the electrical panel, the disconnecting means labeled as "F.A." was found not to have the required red marking. The Maintenance Supervisor confirmed that the fire alarm breaker should have been marked with red, but it was not. A review of the facility's policy and procedure for the Preventative Maintenance Program indicated that a program should be in place to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. However, the lack of proper identification of the fire alarm system's circuit disconnecting means was observed, which did not comply with the stated requirements and facility policy.
Plan Of Correction
K345 Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the Maintenance Supervisor (MS) placed a red marking on the fire alarm breaker. (Exhibit #1) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: On 5/28/25, the Administrator (ADM) provided re-education to Maintenance Supervisor (MS) regarding policies and procedures entitled "Preventative Maintenance Program," to ensure that the fire alarm breaker needs to have red marking. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified: An observational audit of the Fire Alarm System will be done once a month by MS for 3 months. A summary of this deficient practice will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness. Date of compliance: June 20, 2025
Broken Electrical Outlet Faceplate at Nurse Station
Penalty
Summary
A deficiency was identified when an electrical outlet at Nurse Station #2 was observed to have half of its faceplate cover broken, exposing metal terminals. This observation was made during a walkthrough with the Chief Medical Officer (CMO), who stated he had not previously noticed the broken faceplate. The facility's policy and procedure for the Preventative Maintenance Program, dated 12/19/2022, assigns responsibility to the Maintenance Director for ensuring that buildings and equipment are maintained in a safe and operable manner. The exposed outlet was not protected as required by NFPA 70, 2011 Edition, Article 406.6, and this lapse was found to affect one of five smoke compartments in the facility.
Plan Of Correction
K511 Utilities - Gas and Electric CFR(s) NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice Upon notification of the deficient practice on 05/28/2025, the MS changed the faceplate of the electrical outlet at Nurse Station #2 on 05/28/2025. (Exhibit #3) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Preventative Maintenance Program, ensuring all electrical receptacles were maintained free of damage. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified. An observational audit of the electrical receptacles will be done once a month by MS for 3 months. A summary of this deficient practice will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness and sustainability.
Failure to Post Required 'No Smoking' Signage in Oxygen Cylinder Storage Area
Penalty
Summary
Surveyors observed that a full H-sized oxygen cylinder was stored in the beauty salon, which is used as a temporary storage area when the salon is not in use. During the observation, it was noted that there was no 'No Smoking' sign posted in the area where the oxygen cylinder was stored, nor at the exterior entrances of the facility. The Chief Medical Officer (CMO) confirmed during the interview that the sign was missing and acknowledged the temporary storage practice in the salon. A review of the facility's policy and procedure titled 'Oxygen Safety' indicated that precautionary signs readable from five feet should be maintained on the door or gate where oxygen is used or stored. The lack of required signage in the area where the oxygen cylinder was stored was found to be out of compliance with NFPA 99, Health Care Facilities Code, 2012 Edition, Section 11.3.4. This deficiency was identified in one of five smoke compartments during the survey.
Plan Of Correction
Date of compliance: June 20, 2025 K923 Gas Equipment - Cylinder and Container Storage CFR(s): NFPA101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice Upon notification of the deficient practice on 05/28/2025, the MS posted "No Smoking signs" on the exterior of areas of the Oxygen Room and the Beauty Shop on 05/28/2025. (Exhibit #4 & Exhibit #5) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Oxygen Safety, ensuring that there are "No Smoking" signs in areas where oxygen cylinders were stored. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified. An observational audit of rooms with oxygen use will be done once a month by MS for 3 months and kept in a log. A summary of this deficient practice will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness and sustainability. Date of compliance: June 20, 2025
Resident's Call Light and Telephone Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's touch pad call light and telephone were within reach, which led to the resident feeling frustrated and helpless. The resident, who was admitted with diagnoses including a transient ischemic attack and cognitive communication deficit, required partial assistance with toileting and used a manual wheelchair and walker for mobility. During an observation, the resident was found lying in bed, unable to reach the call light and telephone, which were positioned out of reach, causing distress as the resident could not answer a ringing phone or call for help. Interviews with the resident and staff revealed that the resident often experienced difficulty reaching the call light and telephone, leading to feelings of sadness and frustration. The resident expressed that the facility staff frequently left these items out of reach, making it challenging to communicate with family or request assistance. Staff members, including CNAs and the Director of Staff Development, acknowledged the importance of keeping call lights and telephones within reach to prevent residents from attempting to get out of bed and risking injury. The facility's policies and procedures emphasized the need to accommodate residents' needs and ensure call lights are accessible. However, the failure to adhere to these policies resulted in the resident's inability to communicate effectively and potentially delayed care. The resident's care plan also highlighted the risk for falls and the necessity of having personal items within reach, which was not consistently implemented by the facility staff.
Failure to Timely Report Unusual Occurrence
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting an unusual occurrence involving a resident who sustained an acute right femoral neck fracture and a right temporal hematoma of unknown cause. The incident was not reported to the California Department of Public Health (CDPH) within the required 24-hour timeframe. This delay in reporting had the potential to result in a delay of an onsite inspection by CDPH to ensure timely investigation of injuries from unknown origins. The resident, who had a history of age-related osteoporosis, dementia, and spondylosis, was found with reddish-purple skin discoloration on the right hip and right side of the forehead. The resident was unable to recall how the injuries occurred and was in bed throughout the night. The resident complained of severe pain, rated 10 out of 10, especially when touched, and had limited range of motion. Despite these indicators, the facility's Director of Nursing (DON) and Administrator delayed reporting the incident to CDPH until they received medical confirmation of the fracture from the hospital. Interviews with facility staff revealed that the resident had been refusing to eat and receive morning hygiene care, appearing upset and unwilling to get out of bed. The facility's policy required unusual occurrences to be reported within 24 hours, but the Administrator waited until receiving the hospital's medical records before reporting. The facility's policy also indicated that physical injuries of unknown origin should be reported immediately, but this was not adhered to in this case.
Verbal Abuse Incident Involving a Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a certified nursing assistant (CNA). The incident involved a resident who was admitted with primary lateral sclerosis, generalized anxiety disorder, and was receiving palliative care. The resident was moderately cognitively impaired and dependent on assistance for all activities of daily living. The resident communicated through low sounds, spelling, pointing, and gesturing, and required a calm approach and patience from staff. The deficiency occurred when the resident became emotionally distraught after encountering CNA 1, who had previously told the resident that she smelled. This interaction caused the resident to cry hysterically, indicating significant emotional distress. The resident communicated through spelling that CNA 1 was rough, controlling, and not patient, and confirmed that the comment about her smell was hurtful. The resident's reaction was uncharacteristic, prompting a licensed vocational nurse (LVN) to report the incident to the director of staff development. Interviews with staff confirmed that the comment made by CNA 1 was considered verbal abuse, as it was perceived as hurtful by the resident and caused emotional harm. The facility's policy on abuse, neglect, and exploitation defined verbal abuse as communication that includes disparaging and derogatory terms, which was applicable in this case. The incident highlighted the need for staff to approach the resident with more sensitivity and patience due to her communication difficulties.
Failure to Develop Person-Centered Diabetes Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with diabetes, which could lead to episodes of hypoglycemia or hyperglycemia. The resident was admitted with multiple diagnoses, including type 2 diabetes, breast cancer, and immunodeficiency. Despite being admitted due to hypoglycemia and acute kidney failure, the care plan for diabetes was not initiated until 16 days after admission. The care plan lacked specific details about the diabetic medication the resident was taking and the frequency of blood sugar monitoring. The Director of Staff Development acknowledged that the care plan did not specify the insulin or other diabetic medications the resident was on, nor did it include the frequency of blood sugar checks. The facility's policy required comprehensive care plans to describe services necessary to maintain the resident's well-being, but the care plan for this resident did not meet these requirements. The deficiency was identified during a review of the resident's records and an interview with the Director of Staff Development.
Failure to Monitor Blood Sugar Levels in Diabetic Resident
Penalty
Summary
The facility failed to monitor the blood sugar levels of a resident with type 2 diabetes, who was receiving insulin, upon their admission. The resident was admitted with a history of hypoglycemia and acute kidney failure, and the plan of care included daily blood sugar monitoring. However, there was no physician's order for routine blood sugar checks upon admission, which led to an episode of hypoglycemia with a blood sugar level of 58. The resident was subsequently treated with orange juice and sugar, and new orders were placed to adjust insulin dosage and ensure the resident ate before taking Glipizide. Interviews with the Director of Staff Development and a registered nurse revealed that the resident should have had an order for blood sugar checks upon admission due to their insulin regimen and risk of hypoglycemia. The facility's policy indicated that residents with poorly controlled blood sugar or those taking insulin might require more frequent monitoring. The deficiency was identified as a failure to follow up with the physician regarding blood sugar monitoring orders for the diabetic resident, which could have prevented the hypoglycemic episode.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a significant deficiency with an error rate of 48.78%. This affected all five residents observed during medication administration. The errors included omitted doses, incorrect administration techniques, and failure to adhere to physician-ordered parameters. For instance, Resident 26 did not receive Metoprolol Tartrate and Clonidine as prescribed, which are critical for managing hypertension. Similarly, Resident 209 was nearly administered Furosemide and Metoprolol Succinate ER despite their blood pressure being below the physician-ordered threshold. Resident 209 also missed doses of Potassium Chloride, Apixaban, and Lactobacillus, which are essential for maintaining heart function and preventing blood clots. Resident 211 did not receive Amoxicillin for an ear infection, and Resident 210 missed the application of Lidocaine cream for pain management. Additionally, Resident 19 experienced multiple errors in medication administration via a G-tube, including incorrect techniques and failure to flush the tube as ordered, which could lead to complications. These deficiencies were observed during medication pass observations and interviews with the Licensed Vocational Nurse (LVN) responsible for administering the medications. The LVN admitted to not following up with the pharmacy or physician regarding unavailable medications and acknowledged errors in administering medications outside of prescribed parameters. The facility's failure to ensure proper medication administration placed residents at risk for significant medical complications.
Removal Plan
- A medication reconciliation for active medication orders and medication availability was completed by licensed staff for the residents listed above. Identified medication that was not available was called to the pharmacy for immediate delivery. Medications available based on physician summary orders, there were no missing medications.
- The Regional Nurse Consultant provided re-education to the Director of Nursing, the Director of Staff Development and the Infection Preventionist regarding medication administration, documentation, and medication availability. RNC observed the DON, the DSD and the IP perform medication administration.
- The pharmacy consultant reviewed physician orders and availability of the medications in the medication carts. There were no missing medications identified.
- All active licensed nurses identified were provided re-education related to medication administration, documentation, and medication availability by the Director of Nurses/Designee to include medication administration competency. Those nurses who did not have medication administration competency skill check will not be allowed to work on the floor. Medication administration competency was initiated and will continue until the eligible active licensed nurses have completed the course. Staff members on Family Medical Leave Act will be prohibited from administering medications until they have completed the competency skills. The DON, DSD, and IP observed licensed nurses conduct medication administration.
- Seven residents with g-tube were re-evaluated by licensed staff for medical complications due to potential medication administration error.
- Thirty-seven residents with medications requiring parameters were re-evaluated by licensed staff for medical complications due to medication administration error. None were identified.
- A medication reconciliation for active medication orders and medication availability were completed by licensed staff. Any identified medications not available were called to the pharmacy for immediate delivery. There were no missing medications identified.
- The Director of Nurses/Designee initiated re-education related to medication administration, documentation, medication availability, and re-ordering of medications by the Director of Nurses to include medication administration competency. Medication administration competency was conducted until active eligible Licensed Nurses completed. Staff on FMLA will not be allowed to administer meds without completing competency skills.
- The Director of Nurses initiated retraining to the night shift staff on how to audit the medication carts, re-order, and track medication. The medication cart audits will be reviewed weekly by the Director of Nursing/Designee for any necessary follow-up until substantial compliance is met.
- Quality Assurance Performance Improvement Project was implemented. The Director of Nursing / Designee will monitor medication administration and medication availability and documentation. Any trends will be discussed on Cottage Crest Post Acute monthly QA meetings.
Improper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for two residents, leading to potential adverse effects. Resident 22 was administered psychotropic medications, including Seroquel and Ativan, without documented necessity for a specific diagnosed condition. The resident's care plan indicated the use of these medications for behavior management and anxiety, but there was no documentation of behavioral episodes that justified the increased dosage of Seroquel. Additionally, informed consent for the new order of Seroquel was not properly documented, and a gradual dose reduction was not attempted despite the lack of documented behavioral episodes. Resident 6 was also administered psychotropic medications, including Ativan and Sertraline, without proper documentation of anxiety and depression episodes. The care plan indicated the use of these medications for anxiety and depression, but there was no documentation of episodes that warranted their continued use. The informed consent forms for these medications were incomplete, lacking documentation of who consented and the date of consent. Despite the absence of documented behavioral episodes, a gradual dose reduction was not attempted, and the facility failed to ensure informed consent was complete before administering the medications. The facility also failed to prevent adverse effects from psychotropic medications for two other residents. Resident 25 continued to receive Seroquel for 20 days after it was ordered to be discontinued, resulting in increased confusion, lethargy, and low blood pressure, leading to hospitalization. The facility did not monitor for adverse effects of Seroquel, and the discontinuation order was not carried over to the medication administration record. Resident 34 received Risperdal and Ativan without proper indication for use and without obtaining consent for one month. These deficiencies highlight the facility's failure to adhere to policies regarding the use of psychotropic medications and monitoring for adverse effects.
Inadequate RNA Staffing Leads to Service Deficiency
Penalty
Summary
The facility failed to provide adequate Restorative Nursing Assistant (RNA) staff to deliver necessary restorative services, such as range of motion exercises, splint application, and ambulation, to 28 out of 54 residents enrolled in the RNA program. This deficiency was identified through interviews and record reviews, revealing that the facility's Certified Nursing Assistant (CNA) direct care hours per patient day fell below the required minimum of 2.4 hours on several occasions. The Director of Staff Development (DSD) acknowledged that the RNA staff were unavailable due to personal issues, and the facility did not utilize contracted registry staff to fill the gap, resulting in the residents not receiving the RNA services they needed. Interviews with the Director of Nursing (DON) and the Administrator (ADM) further highlighted the staffing issues, with both acknowledging the practice of pulling RNAs to work as CNAs due to short staffing. The DON admitted that residents might not receive RNA services as ordered, and the ADM was unaware of the staff shortage, despite the facility having a contract with a staffing agency. The facility's policy and procedure emphasized the importance of providing sufficient staff to ensure resident safety and well-being, yet the failure to adhere to these guidelines led to the deficiency.
Improper G-Tube Medication Administration by LVNs
Penalty
Summary
The facility failed to ensure that Licensed Vocational Nurses (LVNs) were properly trained to administer medications via gastrostomy tube (g-tube) according to physician's orders, affecting three residents. For Resident 19, LVN 1 did not follow the physician's orders for g-tube medication administration. The nurse used a push method instead of the gravity method to administer medications and failed to flush the g-tube with the required amount of water between medications, which could lead to cross-contamination and increased risk of infection. Resident 6's case involved LVN 2, who initially prepared to administer medications without specific physician orders for g-tube administration. Although LVN 2 followed standard g-tube instructions, she acknowledged the importance of having specific orders for each resident, especially those with fluid restrictions. The nurse was stopped before administering medications, highlighting the need for clarity and adherence to physician orders. For Resident 47, LVN 5 prepared medications without checking the updated physician orders, which specified the water volume for dissolving medications and flushing the g-tube. The nurse initially used a standard method rather than the specific orders, but upon review, acknowledged the mistake and corrected the approach. This incident underscores the necessity of verifying physician orders before medication administration to prevent errors.
Medication Availability and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to ensure the availability of several critical medications for five residents, including metoprolol tartrate, apixaban, furosemide, amoxicillin, lidocaine cream, and tussin DM. These medications were not available in stock as per physician orders or professional standards of practice. For instance, Resident 26 did not receive metoprolol tartrate due to it being out of stock, which could have led to uncontrolled hypertension. Similarly, Resident 209 did not receive apixaban, increasing the risk of stroke due to blood clots. The facility also failed to maintain accurate medication administration records for two residents. Resident 19's medication administration record was marked as if vitamin D3 was administered, although it was not given. Similarly, Resident 209's record inaccurately indicated that lactobacillus, potassium chloride, and apixaban were administered, although they were not. These inaccuracies in medication records could lead to untreated medical conditions. Interviews with the LVN and the Director of Nurses revealed that the facility did not follow its policy of reordering medications when three to five doses remained. The facility also failed to utilize the emergency kit for out-of-stock medications. The Director of Nurses acknowledged that the residents' conditions would not improve if medications were not administered on time, and the facility's actions increased the risk of serious health complications.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Expired food items, such as cilantro, Tabasco sauce, almond extract, and instant coffee grounds, were found in the refrigerator, freezer, and dry pantry. Additionally, some food items, including avocado, ginger, yellow pepper, lemon, and melons, were stored without proper labeling or expiration dates. The Dietary Manager acknowledged these issues, stating that expired items should be discarded to prevent foodborne illnesses. Improper food storage practices were also noted, with raw meats like bacon and sausages stored on the same shelves as other food items, risking cross-contamination. The Dietary Manager admitted that raw meats should be stored at the bottom to prevent contamination, especially if the packaging is open. Furthermore, the facility's policy on food storage was not followed, as vegetables were not stored in a manner that retards spoilage, and labeling was inconsistent, leading to expired items remaining in storage. The facility also failed to maintain proper hygiene practices in the kitchen. Dietary Aide 2 was observed not performing hand hygiene after removing gloves and leaving the kitchen, and again upon returning and handling clean items. Dietary Aide 1 was seen using the same gloves for multiple tasks, including handling a sanitation bucket and food preparation, which is against the facility's policy. These actions increase the risk of spreading bacteria and compromising infection control, as acknowledged by the staff involved.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not completely covering two large dumpsters and two smaller carts for an unspecified duration. This oversight was observed during a concurrent observation and interview with the Dietary Manager (DM), where it was noted that the dumpsters were full, overflowing, and their lids could not be closed. Additionally, two extra carts in front of the dumpsters were uncovered. The DM acknowledged that the trash was picked up the previous day and was scheduled for another pickup on the same day as the observation. The DM also confirmed that the garbage bins should be sealed to prevent attracting flies, rodents, and potential infestations. The facility's policy and procedure (P&P) on the disposal of garbage and refuse, revised in December 2022, mandates that containers and dumpsters must be covered when not being loaded. Furthermore, the Food Code 2017 specifies that receptacles and waste handling units containing food residue should be kept covered with tight-fitting lids or doors, especially when located outside the food establishment. This deficiency posed a potential risk of cross-contamination for 54 out of 59 residents receiving food from the kitchen.
Staffing and Medication Management Deficiencies
Penalty
Summary
The facility failed to address unresolved quality deficiencies, including issues with staffing and medication management, which were previously cited in earlier surveys. The facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) from April 15 to April 20, 2024, showed that the actual Certified Nursing Assistant (CNA) direct care hours were at or below the minimum required hours of 2.4. During this period, two Restorative Nursing Assistants (RNAs) were unavailable due to personal issues, resulting in 28 residents not receiving RNA services. The Director of Staff Development acknowledged that the facility had a contract with a staffing agency but did not utilize their services, contributing to the staffing shortage. Additionally, the facility experienced significant medication errors, with a medication error rate of 48.78% observed during the Immediate Jeopardy process. Medications such as Metoprolol, Apixaban, Amoxicillin, and Lidocaine were not in stock, affecting five residents. The Administrator admitted to being unaware of these medication and staffing issues until the Immediate Jeopardy process and acknowledged that the Quality Assurance Performance Improvement (QAPI) committee meetings had not effectively resolved these issues. The facility's policy on Quality Assurance and Performance Improvement was not effectively implemented, as evidenced by the lack of corrective actions and performance improvement activities.
Failure to Offer Advance Directives to Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 7 and Resident 44, were offered and provided information regarding advance directives. Resident 7, who was readmitted to the facility with multiple diagnoses including COPD, diabetes, chronic kidney disease, and cardiomyopathy, had an incomplete Advance Health Care Directive. The directive, dated 8/24/2014, lacked the required two witnessed signatures. During interviews with the Social Services Director and the Director of Nursing, it was confirmed that the directive was incomplete, and without the necessary signatures, the staff would not be able to adhere to Resident 7's healthcare wishes. Resident 44, admitted with conditions such as end-stage renal disease, heart failure, hypertension, and diabetes, did not have an advance directive on file. The Social Services Director admitted that Resident 44 was only offered an advance directive on 6/7/2024 and could not recall offering it upon admission or quarterly as required. The Director of Nursing confirmed the absence of documentation indicating that an advance directive was offered to Resident 44. The facility's policy, dated 12/19/2022, mandates that the facility determine if a resident has an advance directive upon admission and offer one if not, which was not adhered to in these cases.
Inaccurate Documentation of Nutritional and Fall Risk Assessments
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's nutritional status on the Minimum Data Set (MDS). The MDS for one resident inaccurately indicated that the resident was receiving parenteral and enteral nutrition, which was not the case. Interviews with the Certified Nursing Assistant, Registered Nurse Supervisor, MDS Coordinator, and Director of Nursing confirmed that the resident was not receiving such nutrition and that the error was due to incorrect coding. This discrepancy in documentation could potentially affect the resident's care plan and the delivery of necessary services. Additionally, the facility did not conduct an accurate fall assessment for another resident. The resident's fall risk assessments were inconsistent with the physical and occupational therapy evaluations, which indicated the resident was at risk for falls due to physical impairments and functional deficits. Despite these evaluations, the fall risk assessments documented the resident as having normal gait and balance, and the fall risk score did not reflect the resident's true risk level. The Director of Nursing acknowledged the inaccuracies in the fall risk assessments and the lack of a timely care plan addressing the resident's fall risk. The facility's policies and procedures require accurate documentation and assessment to ensure quality resident care. However, the failure to accurately document the nutritional status and fall risk assessments for the residents indicates a lapse in adhering to these policies. The discrepancies in documentation and assessment could lead to inadequate care and services for the residents involved.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the cases of two residents who did not receive their prescribed medications. Resident 26, who was admitted with diagnoses including end-stage renal disease and hypertension, did not receive metoprolol tartrate as prescribed due to the medication being out of stock. The Licensed Vocational Nurse (LVN) responsible for administering the medication did not notify the resident's doctor or pharmacy about the shortage, which could have led to uncontrolled blood pressure and increased risk of stroke. Resident 209, diagnosed with paroxysmal atrial fibrillation and chronic systolic heart failure, also experienced medication errors. The LVN prepared medications for administration but failed to give potassium chloride due to nervousness and did not have apixaban in stock. The absence of apixaban increased the resident's risk for stroke due to potential blood clot formation. The LVN did not realize that the resident's blood pressure and heart rate parameters did not permit the administration of certain medications at that time. The Director of Nurses (DON) acknowledged that licensed nurses should contact the pharmacy and physician when medications are unavailable and check for out-of-stock medications in the emergency kit. The facility's policy and procedure documents emphasize the importance of timely medication administration and reordering to meet residents' needs. However, these protocols were not followed, leading to significant medication errors for the residents involved.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by several observations and interviews. Certified Nurse Assistant (CNA) 1 did not perform hand hygiene during and after providing care to a resident with multiple diagnoses, including extended spectrum beta lactamase resistance and immunodeficiency. CNA 1 was observed touching the trash lid without washing or sanitizing her hands before and after wearing gloves, which she acknowledged should have been done to prevent the spread of infections. Another incident involved CNA 2, who did not wear the appropriate Personal Protective Equipment (PPE) while caring for a resident on enhanced precautions. This resident shared a room with another resident who was not on any precautions, leading to potential cross-contamination. CNA 2 admitted to forgetting about the enhanced barrier precautions and acknowledged the need to wash hands between attending to different residents to prevent cross-contamination. Additionally, during medication administration, a Licensed Vocational Nurse (LVN) failed to disinfect the medication tray or cart counter before and after administering medications to multiple residents. The LVN also did not consistently perform hand hygiene, even when handling residents with gastrostomy tubes, which are open devices that increase the risk of infection. These actions compromised infection control measures and had the potential to spread infections among residents, staff, and visitors.
Failure to Document Significant Change of Condition
Penalty
Summary
The facility failed to document a significant change of condition (COC) for a resident who was transferred to the hospital. The resident, who had a history of chronic obstructive pulmonary disease, diabetes, chronic kidney disease, and cardiomyopathy, was admitted to the facility and later readmitted with these diagnoses. Despite the resident's need for varying levels of assistance with daily activities, the facility did not document a COC when the resident was hospitalized for left lower extremity edema and abnormal vital signs. Interviews with facility staff, including a Licensed Vocational Nurse, a Registered Nurse Supervisor, and the Director of Nursing, confirmed that no COC documentation was completed for the resident's hospital transfer. The facility's policies require notifying the resident's physician and next-of-kin when there is a change in condition, but this was not adhered to in this case. The lack of documentation could lead to unmonitored changes in the resident's condition, as noted by the staff.
Failure to Accurately Complete PASARR Evaluations
Penalty
Summary
The facility failed to accurately assess and follow through with the Preadmission Screening and Resident Review (PASARR) process for four sampled residents, which is crucial for determining the facility's ability to meet the special needs of residents with serious mental illness, intellectual, and/or developmental disabilities. This deficiency was identified during interviews and record reviews, revealing that the PASARR evaluations were either incorrectly completed or not updated as required. Resident 22 was admitted with diagnoses including anxiety disorder, dementia, and Alzheimer's disease. Despite requiring significant assistance and being on psychotropic medications, the PASARR Level I screening incorrectly indicated that a Level II evaluation was not necessary. The Registered Nurse Supervisor acknowledged the error, stating that a new PASARR should have been submitted. Similarly, Resident 6, diagnosed with major depressive disorder, dementia, and Alzheimer's, had a PASARR Level I that correctly indicated the need for a Level II evaluation, but the Level II was not completed properly. Resident 1, with schizophrenia, mood disorder, and dementia, also had an incorrect PASARR Level I screening, which should have been positive. The Director of Nursing admitted that the PASARR process was not followed correctly for these residents, emphasizing the importance of accurate assessments to ensure appropriate care. The facility's policy requires coordination with the PASARR program to provide care in the most integrated setting, but this was not adhered to, leading to the deficiency.
Failure to Develop Timely Care Plans for Residents
Penalty
Summary
The facility failed to develop a baseline care plan for two residents, Resident 25 and Resident 36, within 48 hours of their admission, as required by policy. For Resident 25, the facility did not address multiple falls and the use of psychotropic medications in the care plan. Despite having a history of falls and being on medications such as Ativan, Rexulti, and Lexapro, the care plan was not updated to reflect these risks and interventions. The care plan for falls was only initiated on 6/6/2024, despite several falls occurring prior to this date, and there was no specific care plan for the psychotropic medications used. Resident 36, who had a history of seizures, did not have a seizure care plan initiated upon admission or after the first seizure episode on 5/1/2024. The care plan for seizures was only initiated on 6/4/2024, leaving a significant gap where no interventions or precautions were documented. This lack of a care plan meant that staff were not provided with guidance on how to manage the resident's seizure disorder, which could have led to inadequate care and increased risk of injury. Interviews with facility staff, including the Director of Nursing and Registered Nurse Supervisors, revealed that care plans should have been updated and initiated promptly to address the residents' needs and risks. The facility's policies on baseline care plans, comprehensive care plans, fall prevention, and seizure precautions were not followed, leading to deficiencies in the care provided to Residents 25 and 36.
Failure to Implement Fall Prevention Policy for High-Risk Resident
Penalty
Summary
The facility failed to implement its fall prevention policy and procedure for a resident identified as high risk for falls. The resident, who had multiple medical conditions including cerebral infarction, hemiplegia, and diabetes, experienced six falls over a period of approximately six weeks. Despite being at high risk for falls, the facility did not develop person-centered interventions or revise the resident's fall risk care plan after each fall. Additionally, the facility did not conduct post-fall assessments or proper neurological checks following the falls. The resident's care plan indicated interventions such as placing the bed against the wall and using floor mats, but these were inconsistently applied and not updated in response to the resident's changing condition. The resident was also on psychotropic medication, which increased the risk of falls, yet the facility failed to identify and address this potential risk factor. The resident's fall risk assessments consistently indicated a high risk for falls, but the care plan was not adequately revised to reflect this risk. Interviews with facility staff revealed that the care plan was not updated for each fall, and the interventions were not consistently documented. The Director of Nursing acknowledged that the care plan should have been updated and revised with each fall, but this was not done. The facility's fall prevention program policy required that each resident be assessed for fall risk and receive care and services according to their individualized level of risk, but this was not effectively implemented for the resident in question.
Failure to Administer Pneumonia Vaccine
Penalty
Summary
The facility failed to ensure that a resident received the pneumonia vaccine, despite multiple physician orders for the vaccination. The resident, who was admitted with several medical conditions including contractures, tachycardia, dysphagia, and anoxic brain damage, was dependent on nursing staff for daily activities and did not have the capacity to make decisions. The resident's medical records indicated physician orders for the pneumococcal vaccine on three separate occasions, yet there was no documentation of the vaccine being administered or offered. The resident was transferred to a General Acute Care Hospital (GACH) due to respiratory distress and was diagnosed with pneumonia on two occasions. The Infection Prevention Nurse (IPN) confirmed the absence of documentation regarding the administration of the pneumonia vaccine and acknowledged the risk of developing pneumonia if the vaccine is not offered or given. The Director of Nursing (DON) also recognized the resident's high risk for pneumonia due to existing medical conditions and expressed uncertainty as to why the vaccine was not administered until much later.
Room Size Deficiency in Multi-Bed Rooms
Penalty
Summary
The facility failed to ensure that 33 of 33 resident rooms met the required space of 80 square feet per resident in multi-bed rooms and 100 square feet for single resident rooms. During a review of the facility's Client Accommodations Analysis form, it was found that all 33 rooms measured less than the required square footage per resident. Specifically, each of the two-bed rooms measured only 143.75 square feet, and one three-bed room measured 220 square feet, all falling short of the regulatory requirements. The Administrator acknowledged awareness of the 80 square feet per resident requirement and had previously approved a room waiver on 7/31/2023. Observations conducted from 6/4/2024 through 6/11/2024 indicated that residents had enough space to move freely within their rooms, with adequate room for the operation and use of wheelchairs, walkers, or canes. Despite the space deficiency, the room size did not affect the nursing care or privacy provided to the residents. The facility's policy and procedure on Resident Rooms, revised on 12/19/2022, stated that resident bedrooms must be designed and equipped for adequate nursing care, comfort, and privacy, and should measure at least 80 square feet per resident in multiple resident bedrooms. The facility had requested and maintained variances from the survey agency for these room variances.
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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