Country Manor Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake View Terrace, California.
- Location
- 11723 Fenton Avenue, Lake View Terrace, California 91342
- CMS Provider Number
- 055002
- Inspections on file
- 41
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Country Manor Healthcare during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and intact cognitive function reported to staff that a staff member pushed him into the restroom, causing pain. Although the incident was disclosed to a CNA, it was not reported to supervisory staff as required by facility policy. Interviews confirmed that the failure to report the suspected abuse promptly could have resulted in ongoing harm, and the facility's abuse reporting procedures were not followed.
A resident with multiple health conditions had not been seen by their Attending Physician (AP) for six months, contrary to the facility's policy requiring visits every 60 days. Instead, a Nurse Practitioner (NP) conducted monthly visits. The resident expressed not having seen the AP for a long time, and the Director of Nursing (DON) confirmed the policy was not followed, highlighting the importance of timely AP visits for health assurance and trust.
A resident with diabetes was not served the prescribed therapeutic diet, as staff allowed extra food portions without notifying the charge nurse. This oversight could lead to elevated blood sugar levels. Interviews revealed a lack of communication and awareness among staff regarding the resident's dietary needs.
Two residents were not treated with dignity during feeding and hydration assistance, as staff stood over them instead of sitting at eye level. Additionally, staff referred to a resident's disposable brief as a diaper, contrary to facility policy, potentially impacting the resident's dignity.
A resident with dementia and muscle weakness was subjected to a pommel cushion restraint without a physician's order, informed consent, or a restraint assessment. Staff were aware of the cushion's use but lacked documentation and authorization, violating the facility's restraint policy.
The facility failed to develop comprehensive care plans for residents, leading to potential delays in care. A resident's care plan lacked the use of a pommel cushion despite a high fall risk, another resident's plan did not address a floor mat for fall prevention, and a third resident's plan failed to include oxygen therapy interventions. Additionally, a wheelchair obstructed a floor mat intended to prevent injury for another resident.
A facility failed to rotate insulin injection sites for several residents, increasing the risk of adverse effects like lipodystrophy. Despite policies and guidelines requiring site rotation, records showed repeated use of the same sites. The DON confirmed the deficiency, acknowledging the potential harm to residents.
The facility failed to maintain ARC/AHA CPR certification for key staff, as required by its policy. Three employees had certifications from the National CPR Foundation, which lacked hands-on training. Interviews revealed a lack of awareness about the need for in-person training. This deficiency could delay emergency care for residents.
The facility failed to maintain a safe environment for two residents by improperly using floor mats intended to prevent fall injuries. A resident's floor mat was incorrectly placed with a wheelchair and overbed table on top, while another resident's mat was obstructed by a wheelchair belonging to a different resident. These practices compromised the mats' effectiveness and increased the risk of injury.
The facility failed to rotate insulin injection sites for several residents, leading to significant medication errors. Despite clear guidelines and policies, insulin was repeatedly administered in the same areas, increasing the risk of adverse effects. This deficiency was confirmed through interviews and record reviews, highlighting a lapse in following professional standards.
The facility did not meet the nutritional needs of 17 residents on puree diets due to improper food texture. Observations revealed that polenta and carrots served were runny and unable to hold their shape, contrary to the facility's standardized recipes and IDDSI guidelines. The Dietary Supervisor and Registered Dietitian acknowledged these issues, emphasizing the importance of following recipes to ensure proper texture and nutrition.
A facility failed to prepare food that conserved flavor and appearance, as seen with a resident who received watery polenta and a frozen salad. The resident expressed dissatisfaction with the food's appearance and taste. The Dietary Supervisor and Registered Dietitian confirmed the issues, noting that poor presentation could affect residents' appetites. The facility's policies required food to be prepared using standardized recipes to maintain quality, but these were not followed.
The facility failed to maintain safe and sanitary food storage and preparation practices, as observed during a survey. Issues included unlabeled food items, improper storage of staff food, and a staff member drinking from an uncovered tumbler in the kitchen. Additionally, wet stacking of pans, dirty ice machine parts, and a cellphone stored in a clean area were noted, all contrary to facility policies and the Food Code 2022.
The facility failed to enforce its policy on storing food brought by family or visitors for residents, due to the lack of designated refrigerator space. The Dietary Supervisor and other staff acknowledged that food for more than one meal was disposed of, as storing it in the kitchen's refrigerator posed a risk of cross-contamination. This led to potential feelings of deprivation among residents, as confirmed by interviews with the LVN and DON.
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. A resident's indwelling catheter drainage bag was observed touching the floor, contrary to facility policy. Enhanced Barrier Precautions were not implemented for another resident, with staff failing to don gowns during high-contact activities. Additionally, a resident's nasal cannula tubing was found touching the floor, risking cross-contamination. These actions were against the facility's infection control policies, putting residents at risk of infection.
The facility failed to obtain informed consent for a COVID-19 vaccine for a resident lacking decision-making capacity, did not consult a physician before withholding the vaccine from another resident, and did not document vaccine education for a third resident. These actions were contrary to the facility's policies and procedures.
A resident with dementia and requiring maximal assistance was given hydration by an unqualified Activities Assistant, contrary to the care plan which specified that only CNAs should assist with feeding and hydration. This was confirmed by facility staff and policy documents, highlighting a failure to adhere to the resident's care plan.
A resident receiving enteral feeding did not have their tube feeding set replaced as required, leading to a deficiency in infection control practices. The facility failed to change the tube feeding formula and water flush bag after 24 hours, as confirmed by staff interviews and facility protocols. This oversight posed a risk of infection and disrupted nutrition delivery.
A resident with chronic respiratory failure and hypoxia did not receive continuous oxygen therapy as ordered, as their oxygen tank was found empty. The facility's staff, including an RN and the DON, acknowledged the oversight, which was contrary to the physician's order and the facility's policy for oxygen therapy.
A facility failed to assess the medical need and risks of bed rail use for a resident with dementia and epilepsy, leading to the use of inappropriate side rails without informed consent. Observations showed a gap between the mattress and side rails, posing an entrapment risk. Staff confirmed the discrepancy between the physician's order and the actual rails used, and the facility did not follow its policy for bed rail assessment and consent.
A resident was administered Celebrex daily without assessing their pain level, contrary to physician orders. The medication was prescribed for moderate pain, but was given even when the resident's pain level was documented as zero. The nurse failed to assess pain or attempt non-drug interventions before administering the medication, as confirmed by the DON.
A facility failed to store a Humalog insulin vial for a resident according to manufacturer's requirements. The vial was found at room temperature without a date indicating when storage began, contrary to guidelines. The Director of Nursing confirmed the vial should have been refrigerated or labeled with a date. This oversight could lead to medication errors due to the administration of expired insulin.
A facility failed to document the offering and review of advance directives for a resident with dementia and other conditions, as required by their policy. The resident's MDS indicated they could communicate effectively, but no advance directive was recorded. The DON and SSD acknowledged the lapse, with the SSD admitting to forgetting the documentation, which is crucial for understanding the resident's end-of-life care preferences.
A resident in an LTC facility received pneumococcal and influenza vaccines without informed consent. The resident, who lacked decision-making capacity, was administered vaccines without the necessary consent from their public guardian. The Infection Preventionist assumed consent was obtained, but the forms were unsigned. The Director of Nursing confirmed the facility's policy was not followed, risking unwanted treatment for the resident.
The facility failed to notify the physician when a resident with an indwelling catheter showed signs of a urinary infection. Despite policies requiring immediate reporting, staff observed changes in the resident's urine output but did not inform the physician, potentially delaying medical intervention.
A resident's urinary indwelling catheter was not secured with a securement device, contrary to the facility's policy. The resident, who had multiple urinary-related diagnoses, was observed without the necessary securement, and staff confirmed the catheter should have been anchored to prevent dislodgement and infection.
Failure to Timely Report Suspected Physical Abuse
Penalty
Summary
The facility failed to report an incident of suspected physical abuse involving a resident with multiple diagnoses, including COPD, schizoaffective disorder bipolar type, and diabetes mellitus. The resident, who had intact cognitive functioning and required staff assistance for daily activities, reported to a registered nurse that a staff member had pushed him into the restroom, causing pain, while he was resisting by holding onto the door frame. The incident was also disclosed to a certified nurse assistant, who acknowledged understanding that such actions could constitute physical abuse but did not report the incident to her supervisor as required. Interviews with staff confirmed that the incident was not reported immediately, and the facility's policy mandates that all employees are required to report suspected abuse, neglect, or exploitation immediately to the administrator and appropriate authorities. The administrator and registered nurse both recognized that the failure to report the incident on the same day as the complaint could result in ongoing harm to the resident. The facility's policy on abuse reporting and investigation was not followed in this case, as the initial report of abuse was not promptly communicated to supervisory staff or external authorities.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the Attending Physician (AP) visited a resident in a timely manner, as required by their policy. The resident, who was admitted with conditions including hypertension, chronic kidney disease, diabetes mellitus, and epilepsy, had not been seen by the AP for six months. Instead, a Nurse Practitioner (NP) conducted monthly visits. The resident expressed during an interview that he had not seen his AP for a long time, indicating a lapse in the required face-to-face visits. The facility's policy mandates that the AP must visit residents at least once every 30 days for the first 90 days following admission, and then at least every 60 days thereafter. However, the AP last visited the resident on 5/17/2024, with subsequent visits conducted by an NP. The Director of Nursing (DON) acknowledged that the policy was not followed, emphasizing the importance of timely AP visits to ensure the resident's health and to build trust. This deficiency had the potential to result in an undetected decline in the resident's medical, health, or psychosocial condition.
Failure to Adhere to Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to ensure that therapeutic diets were served as prescribed by the physician for a resident with schizoaffective disorder, diabetes mellitus, and essential hypertension. The resident was admitted with a physician's order for a controlled carbohydrate diet, regular texture, thin regular liquid consistency, non-fat milk, and large portions with all meals. However, the facility did not adhere to this order, as the resident was allowed to request and receive a second plate of food without the knowledge or approval of the charge nurse, which could lead to elevated blood sugar levels. Interviews with facility staff revealed a lack of communication and adherence to the prescribed diet. A Certified Nursing Assistant (CNA) did not inform the charge nurse when the resident requested additional food, and the CNA was unaware of the resident's diabetic condition. The Dietary Supervisor and a Registered Nurse confirmed that providing extra portions could result in uncontrolled blood sugar levels. The Director of Nursing stated that the facility's policy required CNAs to inform charge nurses of such requests, who would then communicate with the kitchen staff. The facility's policy and procedure for diet orders emphasized the importance of following the physician's orders, which was not done in this case.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of two residents during feeding and hydration assistance. Certified Nursing Assistant 6 assisted a resident with feeding while standing over them, rather than sitting at eye level, which is against the facility's policy for maintaining resident dignity. Similarly, Activities Assistant 1 provided hydration to another resident while standing over them, without being informed of the proper procedure to sit at eye level. Both actions were observed during interviews and were acknowledged by the staff as not aligning with the facility's standards for resident dignity. In another incident, the facility staff failed to use appropriate language when referring to incontinence products for a resident with an indwelling catheter. Treatment Nurse 1 and CNA 2 repeatedly referred to the resident's disposable brief as a diaper, which is considered a dignity issue according to the facility's policy. The staff acknowledged their mistake and the potential negative impact on the resident's self-esteem and dignity. The facility's policies emphasize the importance of treating residents with dignity and respect, including using appropriate language and maintaining eye-level interaction during care. The deficiencies observed in these cases highlight a failure to adhere to these policies, potentially affecting the residents' psychosocial wellbeing.
Improper Use of Restraints Without Authorization
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper authorization and assessment. Specifically, a pommel cushion was used on Resident 60, who was admitted with diagnoses including dementia and generalized muscle weakness, without obtaining a physician's order, informed consent from the resident or their representative, and without completing a restraint assessment. The pommel cushion was intended to prevent the resident from sliding out of the wheelchair due to a history of falls, but it restricted the resident's movement. Observations and interviews revealed that staff, including an Activity Assistant, a Restorative Nursing Assistant, and a Certified Nursing Assistant, were aware of the use of the pommel cushion on Resident 60 but could not specify when it was first used. The Registered Nurse confirmed that there was no physician's order, informed consent, or restraint assessment documented for the use of the pommel cushion. The Director of Nursing also acknowledged that the facility's policy and procedure for the use of restraints were not followed, as evidenced by the lack of necessary documentation and assessments. The facility's policy on the use of restraints, last reviewed in July 2024, clearly states that restraints should only be used for the safety and well-being of residents after alternatives have been tried unsuccessfully, and only with a physician's order and informed consent. The policy also emphasizes that restraints should not be used for staff convenience or to prevent falls. The failure to adhere to these guidelines resulted in the inappropriate use of a restraint device on Resident 60 without proper authorization and assessment.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential delays in necessary care and services. For Resident 60, the care plan did not include the use of a pommel cushion, which was being used to prevent the resident from sliding out of the wheelchair due to a high risk of falls. Despite the resident's history of falls and the use of the cushion being verified by staff, the care plan lacked this critical intervention. Similarly, Resident 17's care plan did not address the use of a floor mat, which was intended to prevent injury from falls. Although the resident was at high risk for falls and the floor mat was observed in use, the care plan had not been updated to reflect this intervention since it was marked as resolved in 2017. This oversight left staff without guidance on the current interventions in place to minimize fall risks. For Resident 57, the care plan included the use of floor mats to decrease injury from falls, but the presence of another resident's wheelchair on the mat compromised its effectiveness. The care plan did not address this issue, potentially placing the resident at risk of injury. Additionally, Resident 3's care plan failed to include interventions for oxygen administration, despite the resident's need for oxygen therapy due to COPD. This omission could lead to a delay in care during episodes of respiratory distress.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating subcutaneous insulin administration sites for four out of five sampled residents. This deficiency was identified during a survey that included interviews and record reviews. The residents involved were receiving insulin for diabetes management, and the failure to rotate injection sites increased the risk of adverse effects such as lipodystrophy and cutaneous amyloidosis. Resident 14, who was admitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and obesity, had insulin administration sites that were not rotated as per the facility's policy and manufacturer's guidelines. The Medication Administration Record (MAR) for several months showed repeated use of the same injection sites, which was confirmed by both a registered nurse and the Director of Nursing (DON) during interviews. The DON acknowledged that the facility's policy and the manufacturer's guidelines required site rotation to prevent tissue damage. Similarly, Residents 37, 56, and 60 also experienced non-rotation of insulin injection sites. The MARs for these residents indicated that licensed nurses administered insulin without rotating the sites, contrary to the facility's policy and standard practices. The DON confirmed these findings and recognized the potential harm caused by this practice, including the development of skin abnormalities at the injection sites. The facility's policies and procedures, as well as the manufacturer's guidelines, clearly stated the importance of rotating injection sites to minimize adverse consequences.
Failure to Maintain Proper CPR Certification
Penalty
Summary
The facility failed to implement its policy and procedure on cardiopulmonary resuscitation (CPR) by not maintaining American Red Cross (ARC) or American Heart Association (AHA) CPR certification for three of five sampled employees. During a review of employee files, it was found that the Activity Assistant and two Certified Nursing Assistants had CPR certifications from the National CPR Foundation, which did not include hands-on training. Interviews with the Activity Assistant and the Director of Staff Development revealed a lack of awareness that CPR training should be hands-on or in-person from ARC/AHA certified providers. The Director of Nursing confirmed that all staff, whether licensed or non-licensed, are required to have CPR certification that includes hands-on training from ARC/AHA certified instructors. The facility's policy and procedure titled 'Emergency Procedure - Cardiopulmonary Resuscitation' indicated that CPR certification should be obtained and maintained through ARC/AHA for key clinical staff members. The failure to adhere to this policy had the potential to delay emergency care for residents who wish to have full treatment in life-threatening situations.
Failure to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, leading to potential risks of injury. For Resident 17, the facility did not properly manage the use of a floor mat intended to prevent injuries from falls. The floor mat was incorrectly placed with the label 'This Side Down' facing up, and both a wheelchair and an overbed table were placed on top of it. This improper placement and use of the floor mat were verified by both a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), who acknowledged that such practices could lead to a slip and fall accident, thereby defeating the purpose of the mat. Resident 17's medical history includes dementia, gait and mobility issues, and a high risk for falls, as indicated by multiple fall risk evaluations. Despite these risks, the care plan for Resident 17 did not include an active intervention for the use of floor mats, and there was no physician's order for the mat. Observations and interviews with staff confirmed that the wheelchair and overbed table were routinely placed on the mat, which could thin the mat over time and reduce its effectiveness in preventing injuries. Similarly, for Resident 57, the facility failed to maintain a clear and safe environment around the resident's bed. Observations revealed that a wheelchair belonging to another resident was consistently placed on top of Resident 57's floor mat, which was intended to minimize injury in the event of a fall. Staff interviews indicated that attempts to remove the wheelchair were unsuccessful due to resistance from the other resident. The Director of Nursing confirmed that the presence of the wheelchair on the mat compromised its function and placed Resident 57 at risk of injury.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. For four of the five sampled residents, the facility did not rotate subcutaneous insulin administration sites as required by professional standards and manufacturer guidelines. This failure was identified during interviews and record reviews, where it was noted that insulin was repeatedly administered in the same areas, increasing the risk of adverse effects such as lipodystrophy and cutaneous amyloidosis. Resident 14, who was admitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and obesity, received insulin aspart and insulin glargine injections without proper site rotation. The Medication Administration Record (MAR) for several months showed repeated use of the same injection sites, which was confirmed by the Registered Nurse and Director of Nursing during interviews. The facility's policy and procedure, as well as the manufacturer's guidelines, were not followed, leading to this significant medication error. Similarly, Residents 37, 56, and 60 also experienced improper insulin administration practices. Their MARs indicated that licensed nurses failed to rotate injection sites, contrary to the facility's policy and professional standards. The Director of Nursing acknowledged these errors, noting that such practices could cause harm to the residents by leading to skin abnormalities. The facility's policies clearly outlined the need for site rotation to prevent adverse consequences, yet these were not adhered to, resulting in the identified deficiencies.
Failure to Meet Nutritional Needs for Puree Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu and did not meet the nutritional needs of 17 out of 96 residents on puree texture diets. On November 5, 2024, during lunch, the polenta served was watery and unable to maintain its shape on the plate. Similarly, on November 6, 2024, the puree carrots were observed to be runny and could not hold their shape. These inconsistencies in food texture were identified through observation, interviews, and record reviews, indicating a failure to follow the facility's standardized recipes and dietary guidelines. The Dietary Supervisor acknowledged that the polenta was runny and emphasized that puree foods should maintain a pudding-like consistency to facilitate ease of eating for residents with chewing and swallowing difficulties. The Registered Dietitian also noted that the puree carrots were watery and suggested that the cook might have added excess water, which could dilute the nutrients. Both the Dietary Supervisor and the Registered Dietitian highlighted the importance of following standardized recipes to ensure the correct texture and nutritional content of puree foods. The facility's standardized recipes and diet manual specify that puree foods should be smooth, free of lumps, and able to hold their shape without weeping. The failure to meet these requirements was documented in the facility's policies and procedures, which mandate the use of approved recipes to conserve nutritive value, flavor, and appearance. The IDDSI guidelines further reinforce these standards, indicating that Level 4 pureed foods should maintain their shape on the plate and not separate into liquid and solid components.
Deficiency in Food Preparation and Presentation
Penalty
Summary
The facility failed to prepare food by methods that conserved flavor and appearance, as observed in the case of Resident 10. The polenta served to Resident 10 was watery and runny, and it was touching other foods on the plate, while the fresh green salad with dressing was served frozen and wilted. These issues were identified during a concurrent observation and interview with Resident 10, who expressed dissatisfaction with the food's appearance and taste, stating that he did not like the food and could not even recognize it. The facility's daily menu indicated that residents on a regular diet were to receive lemon chicken piccata, polenta, spinach au gratin, fresh green salad, gelatin, and milk, but the presentation and quality of the food did not meet these standards. The Dietary Supervisor confirmed during a test tray evaluation that the polenta was watery and the salad was frozen, acknowledging that the tray was not well presented. The Registered Dietitian also emphasized the importance of following standardized recipes to ensure food is appetizing and retains its flavor, noting that poor presentation could lead to residents losing their appetite. The facility's policies and procedures on food preparation, dated July 19, 2024, stated that food should be prepared to conserve nutritive value, flavor, and appearance, using approved and standardized recipes. However, these guidelines were not adhered to, resulting in the observed deficiencies.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Several deficiencies were noted, including the lack of labeling on food items such as garbanzo salad and sherbet, which were not marked with product names. This oversight was acknowledged by the Dietary Supervisor (DS) and Assistant Dietary Supervisor (ADS), who admitted that the labeling process was not followed, potentially leading to the wrong food being served to residents, which could cause allergic reactions. Additionally, staff food items, such as eggs and hash browns, were improperly stored in the preparation area, posing a risk of cross-contamination. The DS confirmed that these items should not have been in the preparation area. Furthermore, a staff member was observed drinking from an uncovered coffee tumbler inside the walk-in refrigerator, which violated the facility's policy against eating and drinking in the kitchen area. This behavior was identified as a potential source of cross-contamination, which could lead to foodborne illnesses among residents. Other issues included wet stacking of domes and pans, which can promote bacterial growth, and the presence of brown and black slimy dirt in the internal parts of an ice machine, indicating inadequate cleaning. The mixer also had dried food residues, suggesting it was not cleaned after use. A staff member's cellphone was found stored on top of a pot in the clean area, which could lead to contamination. These practices were contrary to the facility's policies and the Food Code 2022, highlighting significant lapses in maintaining food safety standards.
Failure to Enforce Food Storage Policy for Resident's Outside Food
Penalty
Summary
The facility failed to enforce its policy and procedures regarding the storage of food brought in by family or visitors for residents. The Dietary Supervisor (DS) acknowledged that while families were allowed to bring food for residents, they were not permitted to bring food for more than one meal due to the lack of designated refrigerator space. The DS expressed concerns about the potential for cross-contamination if such food were stored in the kitchen's refrigerator, which was not a sanitary practice. This lack of proper storage facilities led to the disposal of food brought by families, which could result in residents feeling angry and deprived. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the absence of a designated refrigerator for storing residents' food from outside sources. The LVN suggested the need for a designated refrigerator to prevent food spoilage, while the DON noted that the previous refrigerator in Station 2 was labeled for staff use only. The facility's policy on food from outside sources required monitoring and proper storage of such food, but the lack of designated storage facilities led to the disposal of food, potentially causing residents to feel deprived.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved Resident 16, who had an indwelling catheter drainage bag that was observed touching the floor on multiple occasions. Despite the presence of a privacy bag, the drainage bag was not adequately elevated, which was acknowledged by Certified Nursing Assistants (CNAs) who stated that the bag should not be on the floor to prevent infection. The facility's policy clearly indicated that catheter drainage bags should be kept off the floor to prevent catheter-associated urinary tract infections, yet this protocol was not followed. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for Resident 16, who was at risk of infection due to the presence of an indwelling catheter. Housekeeper 1 and CNA 5 failed to don gowns while performing tasks in the resident's room, despite the presence of an EBP sign indicating the need for gown and glove use during high-contact activities. The Infection Preventionist and Director of Nursing confirmed that the failure to use gowns could lead to the spread of multidrug-resistant organisms (MDROs) and cross-contamination, which was against the facility's policy. Another deficiency was noted with Resident 3, whose nasal cannula tubing was observed touching the floor while connected to the resident. This was confirmed by CNA 6, who acknowledged that the tubing should not be on the floor to prevent cross-contamination and potential infection. The Director of Nursing reiterated that the floor is a potential source of infection, and the facility's policy emphasized the need for ongoing surveillance to prevent healthcare-associated infections. These observations highlight the facility's failure to adhere to its own infection control policies, putting residents at risk of infection.
Deficiencies in COVID-19 Vaccine Administration and Documentation
Penalty
Summary
The facility failed to obtain informed consent prior to administering the COVID-19 vaccine to Resident 16. The resident, who was admitted with chronic obstructive pulmonary disease, metabolic encephalopathy, and benign prostatic hyperplasia, did not have the capacity to make decisions. Despite this, the Infection Preventionist (IP) administered the vaccine without obtaining consent from the resident's public guardian, assuming it had been received during the admission process. This oversight was acknowledged by the IP during a review of the resident's records. For Resident 57, the facility did not offer or clarify the appropriateness of the COVID-19 vaccine administration with the resident's physician. The resident, who had fluctuating capacity to understand and make decisions, was recently hospitalized and had not received the 2024/2025 COVID-19 vaccine. The IP decided against administering the vaccine without consulting the resident's physician, which was outside the IP's scope of practice. This decision was made without the necessary medical consultation, potentially impacting the resident's health. Resident 91 received the COVID-19 vaccine without documented education on the risks and benefits being provided to the resident's representative. The resident, who was admitted with severe sepsis, urinary tract infection, osteomyelitis, and skin infection, did not have the capacity to make decisions. Although verbal consent was obtained, there was no evidence of documented education regarding the vaccine, as required by the facility's policy. This lack of documentation was confirmed during a review of the resident's clinical notes.
Unqualified Staff Providing Hydration
Penalty
Summary
The facility failed to ensure that services were provided by qualified personnel according to the resident's plan of care, specifically for a resident identified as Resident 52. The deficiency was observed when an Activities Assistant (AA) provided hydration to Resident 52, who had a care plan indicating that only certified nursing assistants (CNAs) were responsible for assisting with feeding and hydration. Resident 52, who had diagnoses including dementia and required maximal assistance for activities of daily living, was observed drinking from a cup held by the AA, who was not qualified to provide such assistance. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that only CNAs and licensed nurses were authorized to assist residents with feeding and hydration. The facility's policy and procedure documents also indicated that CNAs were responsible for assisting residents with meals and drinks. The Activities Assistant's job description did not include feeding residents as part of their duties. This oversight had the potential to result in Resident 52 aspirating during the intake of fluids, as the AA was not trained to recognize signs of aspiration.
Failure to Replace Tube Feeding Set in a Timely Manner
Penalty
Summary
The facility failed to ensure appropriate care for a resident receiving enteral feeding, leading to a deficiency in infection control practices. Resident 90, who was admitted with a gastrostomy and required tube feeding due to impaired swallowing and poor oral intake, did not have their tube feeding set replaced as required. Observations revealed that the tube feeding formula and water flush bag were not changed after 24 hours, contrary to the facility's protocol. This oversight was confirmed by RN 1, who acknowledged that the formula and water should be changed every 24 hours to prevent potential gastrointestinal issues. Further interviews with RN 5 and the Director of Nursing highlighted that the entire tube feeding set, including the water bag, should be replaced when the formula is replaced to prevent infection and blockages. The facility's own instructions for use of the enteral feeding pump indicated that the tube feeding set should be replaced after 24 hours to prevent bacterial growth. The failure to replace the tubing set as required posed a risk of infection and disrupted delivery of nutrition and hydration to Resident 90.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide continuous oxygen therapy as ordered for a resident, identified as Resident 13, who was diagnosed with sick sinus syndrome and chronic respiratory failure with hypoxia. The resident was readmitted to the facility with a physician's order for continuous oxygen administration at 2 liters per minute via nasal cannula to maintain oxygen saturation above 92%. However, during an observation, it was found that the resident's oxygen tank was empty, indicating a lapse in the continuous administration of oxygen as prescribed. Interviews with the facility staff, including a Registered Nurse (RN 1) and the Director of Nursing (DON), revealed that the responsibility for ensuring the oxygen tank was not depleted lay with the charge nurses. RN 1 acknowledged that residents dependent on continuous oxygen therapy could experience a drop in oxygen saturation and respiratory complications if the therapy is interrupted. The DON confirmed that the resident should not have run out of oxygen if the order was followed correctly, highlighting a failure to adhere to the facility's policy and procedure for oxygen therapy, which mandates administration as ordered by the physician.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess the medical need and evaluate the risks associated with the use of bed rails for a resident, identified as Resident 17. The resident, who was admitted with diagnoses including dementia, epilepsy, and mobility issues, was at high risk for falls. Despite this, the facility did not obtain a physician's order or informed consent for the use of bed rails, which were intended to aid in mobility and serve as a seizure precaution. The resident's care plan included the use of padded side rails, but the facility did not ensure that the appropriate type of side rails was used, nor did they assess the risk of entrapment. Observations and interviews revealed that the resident was using 1/2 length side rails instead of the 1/4 length rails as ordered by the physician. There was a gap between the mattress and the side rails, which posed a risk of entrapment. Staff members, including a CNA and RN, confirmed the presence of this gap and the potential for injury. The Director of Nursing also acknowledged the discrepancy between the physician's order and the actual side rails in use, as well as the lack of a proper assessment for entrapment risk. The facility's policy required informed consent and an assessment of risks before using bed rails, but these procedures were not followed. The bed safety evaluation forms did not include an assessment for entrapment risk or document any attempts to use less restrictive measures. The facility's failure to adhere to its own policies and procedures regarding bed rail use resulted in a deficiency that placed the resident at risk of injury.
Failure to Assess Pain Before Administering Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not assess the resident's pain level before administering Celebrex, a medication used to decrease pain, on multiple occasions. The resident was given Celebrex daily despite having a documented pain level of zero, which was against the physician's order that specified the medication should only be administered for moderate pain levels between 4 and 6. The report details that the resident was prescribed Celebrex 200 mg to be administered once daily for moderate pain, with non-drug interventions to be attempted first. However, the medication was administered daily without assessing the resident's pain level or attempting non-drug interventions. This was observed during a medication administration where the nurse did not inquire about the resident's pain level before giving the medication. The nurse acknowledged the failure to assess pain and follow the physician's orders, which led to the unnecessary administration of Celebrex. Interviews with the Director of Nursing confirmed that the medication should not have been administered without assessing the resident's pain and trying non-drug interventions first. The facility's policies on medication administration and pain management were not followed, as medications must be administered as prescribed, and pain should be assessed regularly. This oversight placed the resident at risk for adverse effects from unnecessary medication use.
Improper Storage and Labeling of Insulin Vial
Penalty
Summary
The facility failed to store an insulin vial, specifically Humalog, for Resident 49 according to the manufacturer's requirements. During an observation and interview, it was found that the unopened Humalog vial was stored at room temperature without a date indicating when this storage began, contrary to the manufacturer's instructions and facility policy. The vial was supposed to be refrigerated or labeled with a date if stored at room temperature, as it should be discarded after 28 days in such conditions. Licensed Vocational Nurse 3 acknowledged the improper storage and labeling, stating it was unknown when the vial was placed at room temperature, making it unclear when it would expire. The Director of Nursing confirmed that the insulin vial should have been refrigerated or labeled with a date when it was stored at room temperature. The facility's policies and procedures, as well as guides provided by the facility, indicated that insulin vials like Humalog should be stored in a refrigerator or labeled with an opening date if stored at room temperature. The failure to adhere to these guidelines resulted in the potential for medication errors due to the administration of expired insulin, which could lead to ineffective treatment of blood sugar levels for Resident 49.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to maintain proper documentation regarding the offering and review of advance directives for a resident, as per their policy and procedure. Specifically, for one resident with diagnoses including dementia, major depressive disorder, and paranoid schizophrenia, the facility did not document the offering of advance directive information upon admission or during the annual care conference. The resident's Minimum Data Set (MDS) indicated the ability to make themselves understood and understand others, yet it was noted that the resident did not have an advance directive. During interviews, the Director of Nursing (DON) and the Social Services Director (SSD) acknowledged the lapse in documentation. The SSD admitted to forgetting to document the discussion of advance directives for the resident, which is a requirement according to the facility's policy. The policy mandates that advance directives be reviewed annually and documented in the resident's medical record. This oversight could potentially lead to not knowing the resident's wishes regarding end-of-life care and life-sustaining treatments.
Failure to Obtain Informed Consent for Vaccinations
Penalty
Summary
The facility failed to obtain informed consent before administering the pneumococcal and influenza vaccines to a resident, identified as Resident 16, during an Infection Control task. Resident 16 was admitted with several diagnoses, including chronic obstructive pulmonary disease, metabolic encephalopathy, and benign prostatic hyperplasia. The resident's records indicated a lack of capacity to make decisions, yet the Minimum Data Set showed the resident could understand and be understood by others. Despite this, the facility did not secure informed consent from the resident or their public guardian before administering the vaccines. The Infection Preventionist (IP) noted in the clinical records that consent was obtained for both vaccines, but upon review, the consent forms were unsigned and unmarked, indicating no consent was actually obtained. The IP admitted to assuming that consent had been received from the resident's public guardian without verifying it. This oversight led to the administration of vaccines without the necessary informed consent, potentially infringing on the resident's rights and exposing them to unwanted medical treatment. The Director of Nursing (DON) confirmed that the facility's policy and procedures for vaccine administration were not followed. The facility's policies require that informed consent be obtained and documented before administering vaccines, and that residents or their representatives have the right to refuse treatment. The DON acknowledged that the failure to obtain consent could result in harm to the resident from adverse effects or unwanted vaccination, highlighting a significant lapse in following established protocols.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that the physician was notified when a resident had a change in condition. The resident, who was admitted with diagnoses including a urinary tract infection, benign prostatic hyperplasia, and obstructive and reflux uropathy, had an indwelling catheter and was dependent on staff for toileting hygiene. Despite the care plan indicating the need to monitor and report signs of urinary infection, the resident's urine output was noted to be yellow with whitish sediments, and later white, thick, and cloudy, without notifying the attending physician of these changes. During observations, it was found that the resident's indwelling catheter was not secured with a securement device, which could lead to dislodgment and infection. Certified Nursing Assistant and Licensed Vocational Nurse both observed the resident's condition but did not report the change in urine output to the physician. The Director of Nursing confirmed that the facility's policy required the catheter to be secured and any changes in condition to be reported immediately. The facility's policies on urinary catheter care and change in a resident's condition or status were reviewed, indicating that the attending physician should be promptly notified of any adverse changes. However, the staff failed to follow these policies, resulting in the physician not being informed of the resident's change in condition, which had the potential for delayed medical interventions.
Failure to Secure Urinary Catheter
Penalty
Summary
The facility failed to secure a resident's urinary indwelling catheter with a securement device, which is necessary to stabilize the catheter and prevent dislodgement. The resident, who was admitted with diagnoses including urinary tract infection, benign prostatic hyperplasia, and obstructive and reflux uropathy, was observed without a securement device on the catheter. This observation was confirmed by both a Certified Nursing Assistant and a Registered Nurse, who acknowledged that the catheter should have been anchored to prevent potential complications such as dislodgement and infection. During the observation, the resident was found lying in bed with feces in the disposable brief and on the bed cover, indicating a lack of proper hygiene care. The facility's policy on urinary catheter care, reviewed with the Director of Nursing, clearly stated that the catheter should be secured with a leg strap to reduce friction and movement at the insertion site. The failure to follow this policy was confirmed by the Director of Nursing, who acknowledged that the catheter should have been anchored to prevent pulling, accidental dislodgement, and infection.
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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