Culver West Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 4035 Grandview Blvd., Los Angeles, California 90066
- CMS Provider Number
- 055350
- Inspections on file
- 43
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Culver West Health Center during CMS and state inspections, most recent first.
A resident with multiple cardiac and metabolic conditions, impaired cognition, and dependence for ADLs requested a room change due to another resident across the hall who frequently yelled and screamed, disturbing his rest. The resident and his family reported the noise problem and asked a supervisor for a room change, but were told it was not possible due to other residents needing proximity to the nurses’ station. An LVN stated she informed the DON and DSS of the room change request, while the DSS and DON both reported they were unaware of any such request from this resident. Surveyor observations documented the neighboring resident repeatedly yelling loudly with the door often open and no call light activated. The facility’s own room change and noise control policies required honoring resident room change requests, advance notice, documentation, and referral of room change and noise complaints to appropriate leadership, but these processes were not effectively carried out for this resident.
The facility failed to document required inspections of the nurse call system in resident bathrooms and bathing areas, despite a policy requiring weekly checks so that all components are tested at least monthly. A complaint was received alleging a call light had been non-functional for several weeks, and while maintenance logs showed all call lights working in earlier months, there was no documentation of call system checks for later months. The MM confirmed that call lights and the call system should be checked monthly and documented, but acknowledged the absence of records for those periods, placing the facility at risk for a non-functioning call system.
A nurse failed to review a change in transportation arrangements for a resident dependent on hemodialysis, resulting in the resident missing a scheduled dialysis session and being unnecessarily sent to a hospital, where dialysis was not provided due to recent prior treatment. The resident had complex medical needs and typically used gurney transport, but a switch to wheelchair transport was not properly communicated or acted upon by staff.
A resident with moderate cognitive impairment and no representative was allowed to refuse pneumonia, influenza, and COVID-19 vaccinations by signing consent forms, despite lacking decision-making capacity. Staff did not consult the physician, IDT, or Bioethics Committee as required by facility policy, and the DON confirmed that the resident should not have provided informed consent.
A resident with multiple medical conditions was found to have acetaminophen and Dulcolax accessible at the bedside without a physician's order or assessment for self-administration. Staff confirmed that the required assessment and authorization were not completed, and the medications were not stored securely, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions, who was dependent on staff for personal hygiene, was repeatedly observed with dirty fingernails and reported not receiving nail care. Staff acknowledged the issue, and facility policy required such care to maintain dignity, but the resident's nail hygiene needs were not met.
Two residents experienced deficiencies in catheter care and UTI management, including failure to label a catheter bag with the date and time of change, lack of timely physician notification of abnormal urinalysis results, and a significant delay in administering prescribed antibiotics due to unclear communication and documentation lapses.
A resident with a history of renal dialysis, UTI, and diabetes experienced a nine-day delay in receiving prescribed IM Ertapenem for a UTI. The delay resulted from late urine sample collection, lack of timely physician notification of abnormal lab results, and confusion about medication administration, with no evidence that staff followed facility protocols for prompt intervention.
A resident with multiple chronic conditions and intact decision-making ability repeatedly informed staff of her dislike for eggs and sweet foods in the morning, but these preferences were not documented or reflected in her meal tray ticket. As a result, she continued to be served foods she disliked, contrary to facility policy and dietary procedures.
A resident with multiple medical conditions and moderately impaired cognition was served a smaller portion of fresh green salad than required, as a dietary aide used a one-third cup scooper instead of the specified one-half cup. The Dietary Supervisor confirmed the error during observation, and facility policy requires adherence to standardized recipes and portion sizes.
Staff failed to follow infection control protocols by not donning required PPE while providing care to a resident on enhanced barrier precautions and by not labeling an indwelling catheter bag for another resident, despite facility policies and care plans outlining these requirements. These lapses were confirmed through observation, staff interviews, and record review.
A resident with moderate cognitive impairment and no representative was allowed to refuse pneumonia, influenza, and COVID-19 vaccinations without staff consulting the physician, IDT, or Bioethics Committee, despite facility policy requiring such consultation for residents lacking decision-making capacity.
A resident with severe cognitive impairment and multiple medical conditions was found without a working call light within reach, despite requiring significant assistance with daily activities. The resident was observed in pain and unable to summon help due to the nonfunctional call light and inaccessible call bell. Staff interviews and maintenance logs confirmed the issue, and facility policy was not followed regarding call light accessibility.
A deficiency was identified when 38 resident rooms did not meet the federal minimum square footage per resident, with multiple rooms providing only 77 square feet per resident in two-bed rooms and 73 square feet per resident in three-bed rooms. Despite a waiver request and staff reporting no concerns, the measured room sizes did not comply with regulatory standards for resident living space.
A facility failed to maintain AED machines, resulting in delayed emergency response during a resident's cardiac arrest. The AEDs were non-functional, lacking necessary components and with expired batteries. Staff were not trained to use or maintain the AEDs, and there was no clear responsibility for their upkeep, contributing to the deficiency.
A resident with diabetes, hypertension, and dementia experienced moisture-associated skin damage (MASD), but the family was not notified as required by the facility's policy. The lack of documentation and communication was confirmed through interviews and record reviews, highlighting a failure to adhere to procedures for notifying family members of changes in condition.
A resident with severe cognitive impairment and multiple health issues was found with the call light on the floor, out of reach, leading to a near fall. The care plan required the call light to be within reach, but staff failed to ensure this, posing a risk of falls. Interviews with staff confirmed the importance of call light accessibility and prompt response, as outlined in the facility's policy.
The facility failed to investigate and report allegations of physical abuse involving a resident-to-resident altercation within the required 2-hour timeframe. A resident reported being grabbed by another resident, causing discoloration on her arms. The incident was not reported to the Department of Public Health, Ombudsman, or local law enforcement promptly, as required by the facility's policy.
The facility failed to maintain safe and sanitary conditions in food preparation and storage, leading to potential foodborne illness risks. Staff did not wear hairnets properly, perform hand hygiene, or change aprons when necessary. Additionally, a resident had food and drink items left at their bedside for over 14 hours without proper storage or refrigeration, contrary to facility policies.
The facility failed to provide an appropriate bed for a resident, leading to potential pressure injuries, and did not ensure another resident's call light was within reach, risking delays in care. The deficiencies were confirmed through observations and staff interviews.
The facility failed to provide a homelike environment for a resident who had to store personal belongings in boxes on the floor due to insufficient closet space. The resident's belongings were not properly inventoried upon admission, leading to difficulties in locating his possessions and causing distress.
The facility failed to identify and mitigate environmental hazards for a resident with moderately impaired cognition, who was found with an open bottle of shampoo and body wash on her bedside drawer. The liquid could have been mistakenly ingested, leading to potential poisoning and allergic reactions. Staff did not follow the facility's policy on safety and supervision, resulting in this deficiency.
The facility failed to ensure that a resident received continuous feeding of isosource 1.5 as per the physician's order. The resident's tube feeding was found disconnected and spilling on the floor, leading to potential inadequate nutrition. This was confirmed by staff and the facility's policy on gastrostomy feeding.
A resident with a history of heart disease and neuropathy did not receive prescribed pain medication during a night shift, despite requesting it. The LPN admitted to not administering the medication, and the DON emphasized the importance of pain management for resident comfort and quality of life.
The facility failed to provide a functioning call light system for two residents, leading to potential physical and emotional harm. One resident reported a broken call light for five days and was given an ineffective bell, while another resident's call light was out of reach, delaying care. Staff acknowledged systemic issues with the call light system and delays in repairs.
The facility failed to provide adequate storage and conduct inventory for a resident's personal belongings, resulting in the resident storing items in boxes on the floor and reporting missing items. Staff confirmed that the inventory form was not filled out upon admission, leading to difficulties in tracking and locating the resident's belongings.
The facility failed to provide the required 80 square feet per resident in multiple resident bedrooms, affecting 38 rooms. Observations showed sufficient space for general movement and care, but a CNA reported difficulties using a Hoyer lift due to limited space.
Failure to Act on Resident’s Room Change Request Related to Ongoing Noise Disturbance
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to request a room change and to provide appropriate notice and follow-through on that request. One male resident with multiple complex medical conditions, including heart failure, atrial fibrillation, diabetes mellitus, peripheral vascular disease, and general anxiety disorder, was admitted in November and had impaired cognition and dependence on staff for toileting and transfers per his MDS. This resident was housed across the hall from a female resident who had encephalopathy, delusional disorder, anxiety disorder, insomnia, bipolar disorder, chronic kidney disease, and other conditions, and who was known to yell and scream. The facility’s policy stated that room changes would be made when the facility deemed it necessary or when requested by the resident, with documentation in the medical record and involvement of Social Services for inquiries. According to interviews, the male resident and his family member reported that he had complained about the female resident’s constant yelling and screaming, which made it difficult for him to sleep. The family member stated that a supervisor was asked for a room change and responded that a room change was not possible because other residents needed to be closer to the nursing station. The resident himself stated that he had requested a room change about three weeks prior and that no one followed up with him. The LVN reported that multiple residents, including this resident, had complained about the yelling and that the resident requested a room change about two weeks earlier, with the family member calling about one week later to follow up. The LVN stated she informed the DON and the Director of Social Services of the room change request. In contrast, the Director of Social Services stated she was not aware of any complaints from the current room regarding the yelling and screaming and was not aware of any room change request from this resident. The DON stated that any staff member could receive a room change request and that such requests should be reported to the DON and Social Services, but the DON was not aware that this resident had complained or requested a room change. Observations on the survey date documented the female resident repeatedly yelling loudly from her room, sometimes with the door open and without the call light activated, while the male resident’s door was open or slightly open across the hall. The failure of the LVN and/or facility to ensure that the resident’s room change request was effectively communicated, acted upon, and documented resulted in the resident remaining in a room across from a resident who was frequently yelling, contrary to the facility’s room change and noise control policies and the resident’s right to request a room change.
Failure to Document Required Nurse Call System Checks
Penalty
Summary
The facility failed to follow its policy for routine testing and documentation of the nurse call system in resident bathrooms and bathing areas, resulting in missing documentation of required inspections. A complaint was received by the California Department of Public Health alleging that a call light had not been working for four weeks. Review of the maintenance logs for July, August, and September 2025 showed entries indicating all call lights were working, but there was no documentation of call system checks for November and December 2025. During an interview, the Maintenance Manager stated that call lights and the call system are supposed to be checked monthly and documented, and acknowledged that there was no documentation for those two months. The facility’s policy, revised in January 2025, required weekly checking of a proportionate number of nurse call buttons, buzzers, cords, and lights so that each part of the system is checked at least monthly, including verification that the signal lights over residents’ doors, the audible signal at the nurses’ station, and the annunciator lights function properly. This deficient practice placed the facility at risk for a non-functioning call system, as the required testing and documentation process was not followed or recorded for the specified months.
Failure to Review Updated Dialysis Transportation Results in Missed Treatment
Penalty
Summary
A registered nurse failed to review and act upon a change in the transportation method for a resident dependent on hemodialysis, resulting in the resident missing a scheduled dialysis session. The resident, an older adult with multiple complex medical conditions including end stage renal disease, osteomyelitis, heart disease, diabetes, and a stage 4 pressure ulcer, was typically transported to dialysis via gurney due to early morning appointments and personal preference. However, after a change in insurance and transportation arrangements, the Director of Social Services scheduled wheelchair transport and communicated this change through the facility's electronic medical record system. On the day of the scheduled dialysis, the nurse on duty did not review the updated communication regarding the new wheelchair transport arrangement. When the transportation staff arrived with a wheelchair instead of a gurney, the nurse was unaware of the change and the transport staff left without the resident. Subsequent attempts to contact the transportation company were unsuccessful, and the resident ultimately missed the dialysis session. The resident was then sent to a general acute care hospital, where dialysis was not provided because the resident had already received treatment the previous day during a prior hospital visit. The facility's policy required that all pertinent information regarding dialysis care, including transportation details, be documented and available to all caregivers. Despite this, the failure to review and act on the updated transportation method led to a missed dialysis session and unnecessary hospital transfer for the resident.
Failure to Consult IDT or Bioethics Committee for Vaccination Consent in Cognitively Impaired Resident
Penalty
Summary
Staff failed to consult with a physician, the Interdisciplinary Team (IDT), or the facility's Bioethics Committee regarding vaccination decisions for a resident who lacked both decision-making capacity and a representative. The resident, who had diagnoses including adult failure to thrive, anemia, and cholelithiasis, was assessed as moderately cognitively impaired and dependent on staff for daily activities. Documentation showed that the resident did not have the capacity to understand or make medical decisions, as confirmed by both the History and Physical and the BIMS score. Despite this, vaccination consent forms for pneumonia, influenza, and COVID-19 were signed as refusals by the resident, without appropriate consultation or surrogate decision-making. The Director of Nursing acknowledged that the resident should not have signed the informed consent forms and that the required process of involving the physician, IDT, or Bioethics Committee was not followed. Facility policy required treatment consent for non-routine care and outlined the use of the Bioethics Committee to support residents' healthcare decision-making rights, but these procedures were not implemented in this case.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to ensure that a resident had a physician's order and a proper assessment for self-administration of medications left at the bedside. During a record review, it was found that the resident, who had diagnoses including atrial fibrillation, hypertension, neuropathy, osteoarthritis, and difficulty walking, was cognitively intact according to the Minimum Data Set. However, the resident required setup assistance for eating and oral hygiene. Observation of the resident's room revealed bottles of extra strength acetaminophen and Dulcolax in the bedside drawer, accessible while the resident was not present. Interviews with nursing staff confirmed that the resident did not have a physician's order to self-administer these medications, nor had an assessment been completed to determine the resident's capability to do so safely. The facility's policy requires that residents be assessed for cognitive and physical ability and have physician approval before self-administering medications, with such medications stored securely. The medications were not stored in a locked container, and staff acknowledged that this practice was not in accordance with facility policy.
Failure to Provide Routine Nail Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical diagnoses, including hyperlipidemia, anemia, a history of falls, a left arm fracture, and pneumonia, did not receive routine personal hygiene care, specifically nail hygiene. The resident was dependent on staff for personal hygiene, as documented in the Minimum Data Set and medical records. During observations, the resident was seen with black residue under the fingernails on multiple occasions, including while eating breakfast with his hands. The resident reported that staff had not offered to clean or cut his fingernails. Interviews with facility staff confirmed that the resident's nails were dirty and unkempt, and that this was recognized as a dignity issue and a potential source of infection. The facility's policy required that residents be groomed according to their wishes, including nail care, to promote dignity and quality of life. Despite these requirements, the resident did not receive the necessary nail hygiene assistance, resulting in a failure to maintain the resident's dignity and personal hygiene needs.
Deficient Catheter Care and Delayed UTI Response
Penalty
Summary
Two residents experienced deficiencies in care related to urinary catheter management and timely response to urinary tract infection (UTI) symptoms and laboratory findings. For one resident with a history of neuromuscular bladder dysfunction and recurrent UTIs, the indwelling catheter bag was not labeled with the date and time of the last change, as observed by a licensed vocational nurse. The nurse confirmed that labeling is necessary to track changes and prevent complications such as obstruction or infection. Review of the resident's treatment records and facility policy revealed no documentation of when the catheter bag was last changed, and the policy did not specify routine intervals for changing bags. Another resident, dependent on staff for personal care and with a history of renal dialysis, UTI, and diabetes, reported symptoms of dysuria and voiding hesitancy. A physician ordered a urinalysis and culture, but the urine sample was not collected promptly, and the results indicating infection were not immediately communicated to the physician. There was no documentation of a change in condition evaluation or physician notification when the urinalysis returned positive for bacteria. The resident's antibiotic treatment was delayed by nine days due to confusion over the administration route and lack of timely clarification with the physician, despite the presence of symptoms and abnormal laboratory findings. Interviews with nursing staff, the medical director, and the director of nursing confirmed that facility procedures require prompt collection of urine samples, immediate notification of abnormal lab results, and timely initiation of physician-ordered treatments. However, these procedures were not followed, resulting in delayed care and increased risk of complications for the residents involved. Facility policies reviewed also emphasized the need for immediate documentation and communication regarding changes in resident condition and abnormal laboratory values.
Delay in Antibiotic Administration for UTI Due to Lapses in Communication and Protocol
Penalty
Summary
A resident with a history of renal dialysis, urinary tract infection (UTI), and diabetes mellitus experienced a significant delay in receiving prescribed antibiotic treatment for a UTI. The resident first reported symptoms of dysuria and voiding hesitancy, prompting a physician's order for a urinalysis with culture and sensitivity. The urine sample was collected two days after the order, and laboratory results indicating infection were available three days later. However, there was no documented evidence that the abnormal urinalysis results were communicated to the physician or that a change of condition was initiated at that time. The facility received the culture and sensitivity results and obtained a physician's order for Ertapenem, an intramuscular antibiotic, to be administered daily for seven days. Despite this, the first dose of the antibiotic was not given until four days after the order was received. Documentation showed that the delay was due to concerns about a penicillin allergy and confusion regarding the route of administration, but there was no evidence that the physician was notified of these issues or the delay in starting the medication. Interviews with facility staff, including the Registered Nurse Supervisor, Medical Doctor, and Director of Nursing, confirmed that the facility's processes for timely collection of samples, prompt notification of abnormal lab results, and immediate initiation of ordered antibiotics were not followed. The facility's policies required prompt action in response to changes in condition and abnormal laboratory findings, but these procedures were not adhered to, resulting in a nine-day delay from the onset of symptoms to the administration of the prescribed antibiotic.
Failure to Honor Resident Food Preferences in Meal Planning
Penalty
Summary
The facility failed to assess and honor the individual food preferences of a resident with multiple medical diagnoses, including congestive heart failure, COPD, atrial fibrillation, peripheral neuropathy, and a history of repeated falls. Despite the resident having intact cognition and the ability to make decisions, documentation and interviews revealed that her stated dislikes for eggs and sweet foods in the morning were not reflected on her meal tray ticket. The resident reported repeatedly informing staff of her preferences, yet she continued to be served foods she disliked, such as eggs and sweet rolls, which she ate only to avoid hunger. Record reviews showed that the Dietary Supervisor was responsible for visiting new residents to document food preferences and updating these preferences in the resident's health records and meal tray tickets. However, the resident's meal tray ticket did not indicate her specific dislikes, and the last nutritional screening was completed several months prior. Facility policy required quarterly reviews of food preferences, but there was no evidence that the resident's preferences were updated or considered in her meal planning, resulting in a failure to meet her nutritional needs and preferences.
Incorrect Food Portion Served to Resident During Meal Service
Penalty
Summary
The facility failed to serve the correct food portion to a resident during meal service. Specifically, a dietary aide was observed using a one-third cup scooper to serve fresh green salad instead of the required one-half cup scooper, as specified in the facility's Spring Cycle Menu Spreadsheet for that week. The Dietary Supervisor confirmed during the observation that the incorrect scooper was being used and acknowledged that using the wrong portion size could result in residents not receiving the appropriate amount of food. The facility's policy and procedures require standardized recipes and appropriate yields to be maintained and used in preparation. The resident involved had a history of hemiplegia, hemiparesis, essential primary hypertension, and muscle weakness, and was noted to have moderately impaired cognition according to the Minimum Data Set. The resident was admitted and readmitted to the facility with these diagnoses and was determined to have the capacity to understand and make decisions. The dietary aide responsible for serving the meal had participated in a recent in-service education session, as documented in the facility's meeting minutes.
Failure to Follow Infection Control Protocols for PPE Use and Catheter Bag Labeling
Penalty
Summary
Facility staff failed to observe proper infection control measures for two residents. In the case of one resident on enhanced barrier precautions (EBP), a Certified Nurse Assistant (CNA) was observed providing activities of daily living (ADL) care without donning the required personal protective equipment (PPE), specifically a gown, despite signage indicating the need for PPE before entering the room. The CNA stated unawareness of the requirement to continuously wear PPE while providing care to a resident on EBP, and only removed PPE after care was completed. Interviews with the infection prevention nurse and Director of Nursing confirmed that staff are expected to don PPE during physical contact with residents on EBP to prevent the spread of infection. For another resident with an indwelling catheter due to neurogenic bladder and a history of urinary tract infections, the facility failed to ensure the catheter bag was labeled with the date and time of the last change. During observation and interview, a Licensed Vocational Nurse (LVN) confirmed the absence of a label and stated that labeling is necessary to track when the bag was last changed, which is important for monitoring potential complications such as obstruction or infection. The resident's care plan included monitoring for infection and practicing good infection control, but the treatment administration record did not indicate when the catheter bag was last changed. Facility policy and procedures for both PPE use and urinary catheter care were reviewed. The PPE policy outlined the purpose and objectives for gown use, including preventing the spread of infections and exposure to bodily fluids. The urinary catheter care policy indicated that indwelling catheters or drainage bags are not to be changed on routine, fixed intervals, but did not address labeling requirements. These observations and interviews demonstrate lapses in adherence to established infection prevention and control protocols.
Failure to Consult IDT or Bioethics Committee for Vaccination Consent in Incapacitated Resident
Penalty
Summary
The facility failed to ensure that staff consulted with a physician, the Interdisciplinary Team (IDT), or the facility Bioethics Committee regarding vaccination decisions for a resident who lacked both decision-making capacity and a representative. The resident, who had diagnoses including adult failure to thrive, anemia, and cholelithiasis, was assessed as moderately cognitively impaired and dependent on staff for daily activities. Documentation showed that the resident did not have the capacity to understand or make medical decisions, as indicated by both the history and physical and a BIMS score of 10. Despite this, the resident's vaccination consent forms for pneumonia, influenza, and COVID-19 were signed as refusals by the resident, without appropriate consultation with the physician, IDT, or Bioethics Committee. The Director of Nursing confirmed that the resident should not have signed the informed consent due to lack of capacity and that the required consultations did not occur. Facility policies required obtaining treatment consent for non-routine care and outlined the use of the Bioethics Committee to support residents' healthcare decision-making, but these procedures were not followed in this case.
Failure to Provide Accessible and Functional Call Light for Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple complex medical conditions, including an indwelling urethral catheter, hematuria, difficulty walking, type II diabetes mellitus, obstructive and reflux uropathy, benign prostatic hyperplasia, cerebral infarction, and Parkinson's disease, was found without a functioning call light within reach. The resident required significant assistance with activities of daily living and was dependent for toileting hygiene. During observation, the resident was seen in pain and attempted to use the call light, which was not operational. The call bell was found on top of the bedside drawer, out of the resident's reach. Interviews with staff confirmed that the call bell should be accessible to residents at all times to ensure timely assistance, especially in emergencies. The maintenance supervisor was unaware of how long the call light had been nonfunctional, and maintenance logs showed previous notifications about the issue. Facility policy requires that call lights be accessible to residents when in bed, but this was not followed in this instance, resulting in the resident's inability to summon help when needed.
Resident Room Size Below Federal Minimum Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, 38 rooms did not meet the standard of at least 80 square feet per resident in multiple occupancy rooms or 100 square feet for single occupancy rooms. Record review showed that several two-bed rooms measured only 154 square feet (77 square feet per resident), and several three-bed rooms measured 220 square feet (73 square feet per resident). The facility had submitted a waiver request acknowledging these deficiencies, stating that the rooms were used for higher acuity residents and asserting that the arrangement did not adversely affect resident health or safety. Observations conducted over several days indicated that residents had sufficient space to move freely within their rooms, and there was adequate space for beds, side tables, and care equipment. Staff interviews during the survey revealed no concerns regarding room size. However, the documented measurements confirmed that the rooms did not meet the federal minimum space requirements, resulting in a deficiency related to inadequate living and working space for residents and caregivers.
Failure to Maintain AED Machines Leads to Delayed Emergency Response
Penalty
Summary
The facility failed to maintain essential lifesaving equipment, specifically the automated emergency defibrillator (AED) machines, at designated nursing stations. During an emergency resuscitation attempt for a resident, the facility staff discovered that the AED machines were not functional. The AED machines lacked necessary components such as AED pads, and one of the machines did not turn on. Additionally, the batteries for both AED machines were expired, and there were no backup batteries available. This deficiency resulted in delayed lifesaving measures during the resident's emergency resuscitation attempts. The resident involved in the incident was admitted with diagnoses including pneumonia, weakness, and paroxysmal atrial fibrillation. The resident's Physician Orders for Life-Sustaining Treatment (POLST) indicated that resuscitation should be attempted. However, during the emergency, the facility staff were unable to use the AED machines effectively due to their non-functional state. The paramedics, who arrived after the emergency call, confirmed that the AED pads were expired, and the machines were not operational, leading to the resident being pronounced deceased. Interviews with facility staff, including certified nursing assistants, licensed vocational nurses, the director of staffing development, and the director of nursing, revealed a lack of training and awareness regarding the use and maintenance of AED machines. The staff were not trained to use or maintain the AEDs, and there was no clear responsibility assigned for their upkeep. The facility's policy and procedure documents did not include AED maintenance as part of the emergency equipment checks, contributing to the oversight and deficiency in maintaining lifesaving equipment.
Failure to Notify Family of Resident's Change of Condition
Penalty
Summary
The facility failed to notify a resident's family member about a change of condition (COC) as required by their policy and procedures. The resident, who had been initially admitted in 2011 and readmitted in 2024, had diagnoses including diabetes, hypertension, and dementia. A skin assessment on August 6, 2024, revealed moisture-associated skin damage (MASD), but the family member was not informed of this condition. Interviews with the family member and facility staff confirmed the lack of notification, and a review of records showed no documentation of the MASD in the change of condition or nursing progress notes. The facility's policy, revised in September 2023, mandates that licensed nurses notify the primary physician, family, and responsible party of any non-life-threatening change of condition. However, the Treatment Nurse and Director of Nursing acknowledged that the family was not informed, which could prevent them from participating in the resident's care plan. The deficiency violated the family member's right to be informed about the resident's care and had the potential to result in inadequate care and services.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the facility's policy and procedures. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, respiratory failure, bronchiectasis, weakness, difficulty walking, and Alzheimer's disease, was observed in bed with the call light on the floor behind the bed. The resident expressed a need for assistance with a diaper change and was unable to locate the call light, which led to an attempt to get up and nearly resulted in a fall. The resident's care plan indicated a risk for falls due to balance problems, impaired cognition, and noncompliance with using the call light. The care plan specified that the call light should be kept within reach and that staff should respond promptly to requests for assistance. During an observation, a CNA confirmed that the call light was on the floor and acknowledged the danger posed by the call light being out of reach, as residents might try to get up and potentially fall. Interviews with facility staff, including a CNA, an LVN, and the DON, revealed that all staff were aware of the importance of keeping call lights within reach and responding to them promptly. The DON admitted not knowing how the call light ended up behind the bed but emphasized the necessity of having call lights accessible to residents to prevent falls and ensure timely assistance. The facility's policy on call light answering, revised recently, reiterated the requirement for call lights to be within reach and answered quickly.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to investigate and report allegations of physical abuse involving a resident-to-resident altercation within the required timeframe. Resident 1, who had intact cognition and was independent with activities of daily living, reported that another resident, Resident 2, had grabbed her arms, causing discoloration. This incident was not reported to the Department of Public Health, Ombudsman, or local law enforcement within the mandated 2-hour window as per the facility's policy and procedures titled Abuse and Crime Reporting effective 9/11/2023. Licensed Vocational Nurse 1 (LVN 1) was informed of the incident by Resident 1 around 3 A.M. and texted the administrator but did not report the incident to the police, SSA, or the Ombudsman. The administrator received the text around 6 A.M. and subsequently notified the police at 9:30 A.M., the Ombudsman at 10:03 A.M., and the Department of Public Health at 10:00 A.M., all of which were beyond the required 2-hour reporting window. The facility's Director of Staff Development confirmed that the abuse should have been reported immediately within 2 hours to ensure the safety of the resident and prevent additional emotional harm. The failure to report the incident promptly had the potential to place Resident 1 at risk for further abuse and delayed the onsite inspection by the Department of Public Health. The facility's policy clearly stated that any employee with a reasonable suspicion of a crime against a resident must report the incident within 2 hours to the appropriate authorities. The administrator acknowledged that the incident should have been reported within the required timeframe to ensure immediate investigation and resident safety.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in food preparation and storage, leading to potential foodborne illness risks for residents. During a kitchen tour, it was observed that staff did not wear hairnets properly, leaving hair exposed, which could contaminate food. Additionally, staff did not perform hand hygiene or change aprons when transitioning from handling dirty dishes to clean dishes, increasing the risk of cross-contamination. Interviews with staff confirmed these practices were against the facility's policies and could lead to infections among residents. In another instance, a resident was found with multiple food and drink items left at their bedside for over 14 hours without proper storage or refrigeration. The resident confirmed that the items had been there since the previous night. The Infection Prevention Nurse and Director of Nursing acknowledged that such practices could lead to food spoilage and potential health risks for the resident. The facility's policy stated that food meant for refrigeration should not be stored in residents' rooms unless being consumed immediately. The facility's policies and procedures were reviewed, indicating that food services employees must follow hygiene and sanitary practices to prevent foodborne illnesses. These policies included wearing hairnets, performing hand hygiene, and changing aprons when necessary. The failure to adhere to these policies was observed and confirmed through staff interviews, highlighting significant lapses in maintaining food safety standards in the facility.
Failure to Provide Appropriate Bed and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide an appropriate bed for a resident, leading to potential pressure injuries. The resident, who was admitted with type 2 diabetes and morbid obesity, had intact cognition and required assistance for hygiene, dressing, and toileting. Despite the resident's complaints about the bed being too short and causing pressure on his feet, the issue was not addressed by the staff, including the social worker and maintenance personnel. The resident's height was documented as 73 inches, which exceeded the length of the bed, leading to discomfort and potential pressure ulcers as confirmed by the Licensed Vocational Nurse and Director of Nursing. Additionally, the facility failed to ensure that another resident's call light was within reach, which is crucial for communication and timely assistance. This resident, who had epilepsy, asthma, schizophrenia, and hemiplegia, was observed lying in bed with the call light hanging against the wall, out of reach. The resident expressed difficulty in reaching the call light due to her condition. The Certified Nurse Assistant confirmed that the call light should be within reach to prevent delays in care, which could lead to poor outcomes or unnecessary hospitalization. The Director of Nursing emphasized the importance of having the call light within reach for all residents to ensure timely care and prevent potential medical complications. The facility's policy on answering call lights also mandates that the call light should be easily accessible to residents when they are in bed. The failure to adhere to this policy was evident in the case of the resident with multiple medical conditions, highlighting a significant lapse in ensuring resident safety and communication.
Failure to Provide Homelike Environment Due to Improper Inventory of Resident's Belongings
Penalty
Summary
The facility failed to provide a homelike environment for Resident 38, who was observed storing personal belongings in boxes on the floor. Resident 38, who has type 2 diabetes and morbid obesity, was admitted to the facility and has intact cognition but requires assistance with hygiene, dressing, and toileting. During an interview, Resident 38 expressed frustration about missing clothes and the lack of assistance from staff in organizing his belongings. Certified Nurse Assistant 1 confirmed that there was not enough space in the closet, leading to the resident's belongings being stored in boxes, which is not a homelike environment. The CNA also mentioned that an inventory of the resident's belongings should be done upon admission, but this was not completed for Resident 38, leading to difficulties in locating his possessions. Further interviews with staff, including a Licensed Vocational Nurse, Social Worker, Registered Nurse, and the Director of Nursing, revealed that the facility's policy requires an inventory of residents' belongings upon admission. However, this procedure was not followed for Resident 38, resulting in the misplacement of his belongings and contributing to a non-homelike environment. The facility's policy on personal property emphasizes the importance of documenting and investigating any complaints of missing items, but this was not adhered to in this case, causing distress to the resident.
Failure to Identify and Mitigate Environmental Hazards
Penalty
Summary
The facility failed to assess and identify environmental hazards and risk factors for accidents for one of the residents. Resident 35, who has a history of diabetes mellitus, chronic obstructive pulmonary disease (COPD), pneumonia, and congestive heart failure (CHF), was found with an open one-gallon bottle containing a strawberry pink-colored liquid on her bedside drawer. The resident, who has moderately impaired cognition, stated that the bottle was not hers and she did not know what the liquid was. The liquid was later identified by a Licensed Vocational Nurse (LVN) as shampoo and body wash used by the facility for bathing residents. The LVN acknowledged that the bottle should have been tightly capped and not left at the bedside, as a confused or wandering resident could mistakenly ingest it, leading to potential poisoning and allergic reactions. The Director of Nursing (DON) confirmed that staff are required to observe and assess the environment for safety when entering and exiting residents' rooms. The facility's policy on safety and supervision of residents emphasizes the importance of preventing accidents by considering environmental hazards and individual resident risk factors. However, this policy was not followed in the case of Resident 35, leading to the identified deficiency.
Failure to Ensure Continuous Tube Feeding for Resident
Penalty
Summary
The facility failed to ensure that Resident 65 received continuous feeding of isosource 1.5 as per the physician's order. Resident 65, who was admitted with diagnoses including moderate protein-calorie malnutrition, dysphagia, and gastro-esophageal reflux disease, had a physician's order for continuous feeding via a gastrostomy tube at 65 cc per hour. However, during an observation, the tube feeding was found to be disconnected from the resident and spilling on the floor, indicating that the resident was not receiving the prescribed nutrition. This was confirmed by a Licensed Vocational Nurse who acknowledged that the feeding pump was running but not connected to the resident's g-tube, which could lead to inadequate nutrition and calories for the resident. Further interviews with the Quality Assurance and Director of Nursing confirmed that the tube feeding needs to be connected to the resident's g-tube to ensure adequate nutrition and calories. The facility's policy and procedures for gastrostomy feeding also indicated that the feeding formula should be connected to the tube. The failure to connect the feeding tube as ordered had the potential to cause inadequate nutrition for Resident 65, which could lead to weight loss and dehydration.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to ensure timely pain management for Resident 33, who was admitted with diagnoses including atherosclerotic heart disease, autonomic neuropathy, and heart failure. Despite having an active physician order for Oxycodone HCL 10 mg every 6 hours as needed for pain, the medication was not administered during the 11 PM to 7 AM shift on 4/16/24. Resident 33 reported requesting the pain medication at 3 AM but did not receive it, resulting in unnecessary pain. The Medication Administration Record and Individual Resident's Controlled Drug Record confirmed that no pain medication was given during that shift. Licensed Vocational Nurse 3 admitted to not administering the pain medication as requested, acknowledging that it should have been given to ensure the resident's comfort. The Director of Nursing emphasized the importance of pain management for resident comfort, quality of life, and functionality. The facility's policy on pain management, which requires staff to assess and manage pain using a consistent approach, was not followed in this instance, leading to the deficiency.
Deficient Call Light System
Penalty
Summary
The facility failed to provide a functioning call light system for two residents, leading to potential physical and emotional harm. Resident 37, who had multiple diagnoses including Type 2 Diabetes, lung transplant, heart failure, and major depressive disorder, reported a broken call light for five days. Despite informing staff, the resident was given a bell that staff could not hear effectively, causing frustration and anger. The maintenance supervisor acknowledged the issue, citing an old call light system and delays in obtaining parts for repairs. The Director of Nursing confirmed that malfunctioning call lights were reported but could not specify the time required to fix them, acknowledging the potential health consequences of delayed assistance. Resident 29, diagnosed with epilepsy, asthma, schizophrenia, and hemiplegia, was found with a call light out of reach. The resident, who required substantial assistance and was unable to move independently, stated she could not reach the call light. A Certified Nurse Assistant confirmed that the call light should have been within reach and acknowledged that its unavailability could delay care and result in poor outcomes. The Director of Nursing reiterated the importance of ensuring call lights are reachable to prevent delays in care, which could worsen the resident's medical condition. The facility's policies and procedures emphasized the importance of maintaining functional call light systems and ensuring they are within residents' reach. However, the observations and interviews revealed that these policies were not effectively implemented, leading to deficiencies in resident care. The maintenance log and staff interviews highlighted systemic issues with the call light system and delays in addressing reported malfunctions, contributing to the residents' inability to promptly alert staff to their needs.
Failure to Provide Adequate Storage and Inventory for Resident Belongings
Penalty
Summary
The facility failed to provide adequate storage and conduct inventory for personal belongings for Resident 38, resulting in a non-homelike environment. Resident 38, who has type 2 diabetes and morbid obesity, was observed storing personal belongings in several boxes on the floor. The resident complained about missing personal items, including sweatpants, and stated that staff were unhelpful in locating these items. Certified Nurse Assistant 1 confirmed that there was insufficient closet space, leading to belongings being stored in boxes, and acknowledged that the inventory form was not filled out upon admission. This was corroborated by Licensed Vocational Nurse 1, who found no admission inventory in the resident's medical chart. Further interviews revealed that the facility's policy requires an inventory of residents' belongings upon admission, but this was not followed for Resident 38. The Social Worker and Director of Nursing both emphasized the importance of this inventory for tracking and investigating missing items. The failure to complete the inventory form and provide adequate storage led to Resident 38 feeling upset and reporting lost belongings, which compromised the resident's sense of a homelike environment.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 38 out of the 38 resident rooms. Specifically, 30 rooms consist of 2 beds each, providing only 77 square feet per resident, and 8 rooms consist of 3 beds each, providing only 73 square feet per resident. This deficiency was identified through observation, interview, and record review. The facility had previously submitted a Request for Room Size Waiver, indicating that the room sizes would not interfere with daily nursing care or the safety of the residents. However, the waiver did not meet the federal regulation requirements of 80 square feet per resident for multiple resident rooms and 100 square feet for single resident rooms. During multiple observations, it was noted that residents had ample space to move freely inside the rooms, and there was sufficient space for beds, side tables, and resident care equipment. However, during an interview with a Certified Nurse Assistant (CNA), it was revealed that the limited space in the rooms made it difficult to use a Hoyer lift for residents whose beds were close to the window. This indicates that while the rooms appeared to have enough space for general movement and care, specific care activities requiring more space were hindered by the room sizes not meeting federal regulations.
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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