Del Amo Gardens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 22419 Kent Avenue, Torrance, California 90505
- CMS Provider Number
- 555706
- Inspections on file
- 22
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Del Amo Gardens Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility's QAA and QAPI committees did not implement corrective actions for systemic issues in monitoring weight loss, reporting falls with major injury, and implementing pressure injury preventive measures. The DON acknowledged the need for improvement in these areas.
The facility failed to ensure RNAs were competent in performing PROM exercises, leading to potential harm for two residents with hypertonicity. RNA 1 performed exercises too quickly, causing pain and resistance. The DSD admitted RNA competencies were not assessed, and performance evaluations for nursing staff were not conducted, compromising resident safety.
The facility failed to document the administration of controlled substances for three residents, leading to discrepancies between the CDR and MAR. A resident with anxiety did not have lorazepam administration recorded, while two other residents with pain management needs had tramadol administration unrecorded. Staff interviews confirmed the importance of matching documentation to ensure proper medication administration.
A facility exceeded the acceptable medication error rate, reaching 14.81% due to failures in following physician orders for three residents. A resident received amlodipine without a required blood pressure check, another was given undissolved MiraLAX and amlodipine without a blood pressure check, and a third received metformin without food. The errors were acknowledged by staff, and the DON confirmed the importance of adhering to orders and guidelines.
The facility failed to follow dietary guidelines for residents on mechanical soft and ground diets, serving improperly sized Chicken Alfredo and broccoli. Five residents on a chopped diet received large food pieces, while 17 residents on a ground diet were served chopped instead of ground food, contrary to the production guides. This was due to a misunderstanding by the cook, as confirmed by the dietary supervisor and registered dietitian.
The facility failed to ensure safe food storage and preparation practices, risking foodborne illnesses. Nutritional supplements and chicken were stored without thaw dates, and expired thickened water was not discarded. These actions violated facility policy and FDA guidelines.
A resident's privacy was compromised during a wound care dressing change due to inadequate privacy curtains that did not fully cover the care area. Staff interviews confirmed awareness of the issue, and the facility's policy emphasized the importance of respecting residents' private space.
Two residents with severe cognitive impairments were found to be living in a room with peeling paint and exposed walls, which did not provide a homelike environment. Staff interviews confirmed the issue, and the facility's policy emphasized the need for a homelike setting.
A resident with severe cognitive impairment and legal blindness experienced an unwitnessed fall resulting in a right hip fracture, requiring surgery and hospitalization. The incident was not reported to the CDPH, delaying an investigation. Despite the facility's policies requiring reporting of such events, the DON did not report the fall, citing unreliable information from the resident's cognitively impaired roommate.
A resident with multiple health issues, including diabetes and chronic kidney disease, experienced a significant change in condition with the progression of a pressure injury from Stage I to Stage II. Despite this, the facility failed to complete a significant change in status assessment (SCSA) as required. The MDSC acknowledged the oversight, and the DON emphasized the importance of SCSA in addressing specific resident problems.
The facility failed to ensure accurate MDS documentation for two residents, leading to potential negative effects on their care plans. One resident's MDS inaccurately documented a Stage III pressure ulcer, while the resident only had a resolved Stage II ulcer. Another resident's MDS incorrectly recorded an unplanned discharge to a hospital, instead of a discharge to a private home with home health services. These discrepancies were confirmed by staff interviews and record reviews.
The facility failed to update care plans for two residents, one after discontinuation of OT services and another following hypoglycemic events. This oversight could lead to confusion and inadequate care, as the care plans did not reflect the residents' current needs and conditions.
A resident with diabetes experienced two hypoglycemic events, and the facility failed to conduct IDT meetings to address these incidents. During the second event, the emergency response system was not activated despite the resident being unresponsive after interventions. The facility did not clarify insulin orders with the physician, leading to a deficiency in maintaining the resident's highest level of practicable functioning.
A resident at moderate risk for pressure injuries developed a Stage II ulcer due to the facility's failure to implement timely care interventions, including repositioning and using a low air loss mattress. The use of bath towels instead of incontinence pads contributed to skin shearing, and poor communication among staff regarding the resident's nutritional needs and pressure injury progression further exacerbated the situation.
A resident with right-sided hemiplegia and hemiparesis was not provided with the recommended resting hand splint and hand roll splint, as advised by OT. Instead, rolled-up towels were used in the resident's hands, and PROM exercises were performed at a fast speed, causing discomfort. The Director of Rehabilitation confirmed the splints were not issued due to time constraints, and the Director of Nursing acknowledged the Rehabilitation Department's responsibility for splint assessment and issuance.
A resident experienced significant unplanned weight loss due to the facility's failure to monitor and report decreased oral intake and implement effective interventions. Despite having a care plan, the staff did not notify the physician of the resident's condition, leading to continued weight loss. The resident, with multiple health issues and severe cognitive impairment, was dependent on staff for daily activities and had poor food intake, which was not adequately addressed by the facility.
A resident with severe cognitive impairment and dysphagia was given a peanut butter and jelly sandwich instead of a pureed diet, contrary to physician and speech therapist recommendations. The dietary manager admitted the oversight, acknowledging the risk of aspiration and choking due to the inappropriate meal. The facility's policy required adherence to prescribed diets, which was not followed in this case.
A facility failed to accurately document a resident's occupational therapy (OT) discharge recommendations and range of motion (ROM) status. The resident, with right-sided hemiplegia and hemiparesis, was evaluated by OT for a decline in ROM. The OT evaluation recommended splints for the resident's hands, but the discharge summary inaccurately documented the resident's tolerance for wearing them. The Director of Rehabilitation admitted to the documentation errors, which could cause confusion and harm. The Director of Nursing stressed the importance of accurate documentation to ensure necessary care and services.
A resident at high risk for pressure ulcers developed a deep tissue injury on the right heel due to the facility's failure to ensure regular turning, repositioning, and offloading. Despite being non-ambulatory and bedfast, the resident was not consistently repositioned every two hours, leading to the progression of a Stage 1 pressure ulcer to a DTI. The facility's care plan lacked specific interventions for repositioning and offloading, contributing to the preventable injury.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Corrective Actions for Systemic Issues
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to implement corrective actions for systemic issues identified in the monitoring of weight loss, reporting of falls with major injury, and implementation of pressure injury preventive measures. During an interview, the Director of Nursing (DON) acknowledged that the QAA committee discusses monthly falls, pressure injuries, and weight loss, but recognized a need for improvement in these areas. A review of the facility's policy and procedures indicated that the purpose of QAPI/QAA activities is to identify and correct quality deficiencies and improve the quality of care, quality of life, and resident safety.
Inadequate Competency and Performance Evaluations in LTC Facility
Penalty
Summary
The facility failed to ensure that Restorative Nursing Aides (RNA) were competent in performing passive range of motion (PROM) exercises for residents, which led to potential harm and pain for the residents involved. Specifically, RNA 1 was observed performing PROM exercises at a very fast speed on two residents, both of whom had conditions that required careful handling. Resident 2, who had right-sided hemiplegia and hypertonicity in both arms, experienced pain and resistance during the exercises. Similarly, Resident 18, who had right-sided hemiplegia and hypertonicity in the right arm, also experienced pain and requested the exercises to stop. The Director of Rehabilitation confirmed that PROM exercises should be performed slowly for residents with hypertonicity to avoid causing pain and further muscle contraction. However, RNA 1 continued to perform the exercises quickly, leading to discomfort and potential harm to the residents. The Director of Staff Development (DSD) admitted that competencies for RNAs were not being conducted, and there was no clear responsibility for ensuring RNA competencies were assessed. This lack of oversight and training contributed to the improper execution of PROM exercises. Additionally, the facility failed to conduct performance evaluations for nursing staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, as per the facility's policy. The Director of Nursing acknowledged the importance of annual performance evaluations to ensure staff competency and safe delivery of care. The absence of these evaluations further highlighted the facility's failure to assess and maintain the necessary skills and competencies of its staff, potentially compromising resident safety.
Failure to Document Controlled Substance Administration
Penalty
Summary
The facility failed to accurately account for the administration of controlled substances for three residents, leading to discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). For Resident 31, the facility did not document the administration of lorazepam 0.5 mg on two occasions, despite the medication being removed from the CDR. This resident, who was dependent on staff for all activities of daily living and had a diagnosis of anxiety disorder, did not have the administration of the medication recorded on the MAR, as confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). Similarly, for Resident 46, who had diagnoses including diabetes mellitus and osteomyelitis, the administration of tramadol 50 mg was not documented on the MAR, although it was removed from the CDR. The resident's care plan required the administration of analgesics as ordered, but the lack of documentation on the MAR meant that the administration could not be confirmed. An LVN acknowledged that the discrepancy could lead to confusion about whether the medication was given. For Resident 12, who had severe cognitive impairment and a diagnosis of a wedge compression fracture, the administration of tramadol 50 mg was also not documented on the MAR, despite being removed from the CDR. This discrepancy was noted by an LVN, who expressed concern that it could result in the medication being administered again or not at all, potentially leading to increased pain for the resident. Interviews with nursing staff highlighted the importance of matching documentation on the CDR and MAR to ensure proper medication administration and prevent issues such as drug diversion or duplicate therapy.
Medication Administration Errors Exceeding Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below the 5% threshold, resulting in a 14.81% error rate during medication administration for three residents. Resident 29 was administered amlodipine without the required blood pressure check, which was a physician-ordered parameter to determine whether the medication should be held or administered. The Licensed Vocational Nurse (LVN) acknowledged the oversight, recognizing the potential for blood pressure changes that could lead to falls or injuries. Resident 48 also received amlodipine without a prior blood pressure check, contrary to the physician's orders. Additionally, the LVN failed to properly dissolve MiraLAX powder before administration, allowing the resident to consume it in an undissolved state. The Director of Nursing (DON) confirmed the necessity of adhering to physician orders and manufacturer specifications to prevent adverse effects such as dizziness or falls. Resident 42 was given metformin without food, despite the physician's order to administer it with meals to mitigate side effects like nausea and upset stomach. The Registered Nurse (RN) admitted to not following the order, and the DON reiterated the importance of administering medications as prescribed to avoid potential side effects. The facility's policies on medication administration were not followed, contributing to the medication errors observed.
Failure to Follow Dietary Guidelines for Mechanical Soft and Ground Diets
Penalty
Summary
The facility failed to adhere to the standardized recipes for the lunch menu on 11/19/2024, specifically for residents on mechanical soft chopped and ground diets. Five residents on a mechanical soft chopped diet received Chicken Alfredo with broccoli that was not chopped appropriately, with chicken pieces measuring 1.5 inches and broccoli florets at 2 inches, contrary to the required half-inch size. Additionally, 17 residents on a mechanical soft ground diet were served chopped Chicken Alfredo instead of the required ground consistency, as per the food production guides. Observations and interviews revealed that the cook misunderstood the dietary requirements, preparing the same chopped Chicken Alfredo for both chopped and ground diets. The dietary supervisor confirmed the inconsistency in food sizes and acknowledged the risk of choking due to large food pieces. The registered dietitian and speech therapist emphasized the importance of proper food texture for residents with limited chewing ability, highlighting the facility's failure to follow its policy and procedure for mechanical soft and ground diets.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, which could potentially lead to foodborne illnesses among residents. During an observation, it was found that nutritional supplements labeled to be stored frozen and used within 14 days of thawing were not monitored for their thaw dates. Specifically, a box of 30 single-serve cartons of vanilla-flavored high-protein nutrition supplements and another box of sugar-free chocolate high-calorie nutrition supplements were stored in the walk-in refrigerator without any thaw date. The Dietary Supervisor acknowledged that there should be a date on the supplements to monitor when they were thawed and when they should be discarded. Additionally, a large tray of boneless chicken thighs was observed thawing on the bottom rack of the walk-in refrigerator without a thaw date. The Dietary Supervisor and a cook confirmed that the chicken was removed from the freezer but failed to mark the thaw date, which is necessary to ensure safe storage and cooking. Furthermore, a bottle of thickened water stored in the reach-in refrigerator was found to have exceeded its storage period, as indicated by the manufacturer's use-by date. The Dietary Supervisor and a dietary aide confirmed that the thickened water was expired and should have been discarded. These lapses in food storage and preparation practices were contrary to the facility's policy and the 2022 U.S. Food and Drug Administration Food Code, which require proper labeling, dating, and monitoring of refrigerated food.
Privacy Violation During Wound Care
Penalty
Summary
The facility failed to maintain the right to privacy for a resident during a wound care dressing change. The privacy curtains in the resident's room were not long enough to cover the entire room, only providing a barrier between the resident and their roommate. This deficiency was observed during a wound dressing change for a resident with multiple medical conditions, including diabetes mellitus, chronic kidney disease, and severe cognitive impairment. The resident was dependent on staff for various activities of daily living and was at risk of developing pressure injuries. Interviews with facility staff, including a Certified Nursing Assistant and a Treatment Nurse, revealed that the issue with the short privacy curtains had been ongoing, with staff acknowledging the need for curtains to fully cover the resident's care area to ensure privacy and dignity. The Director of Nursing also confirmed the necessity for privacy curtains to cover the entire care area during personal care provision. The facility's policy on dignity and respect emphasized the importance of respecting residents' private space and property at all times.
Failure to Maintain Homelike Environment Due to Peeling Paint and Exposed Walls
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents, as evidenced by peeling paint and exposed walls in their shared room. Resident 1, who was initially admitted with dementia, hemiplegia, and hemiparesis, and Resident 49, admitted with metabolic encephalopathy and dementia, both had severe cognitive impairments and were dependent on staff for activities of daily living. During observations, the room was noted to have peeling yellow paint and cracked walls above the baseboards, which did not reflect a homelike environment. Interviews with facility staff, including a CNA and the Maintenance Supervisor, confirmed the condition of the room and acknowledged that it did not meet the standards of a homelike environment. The Director of Nursing also stated that the room should not have chipped paint or dirty walls, as this could potentially affect the residents' dignity and mood, violating their rights to a homelike environment. The facility's policy on maintaining a homelike environment emphasized the responsibility of all staff to address such issues promptly.
Failure to Report Unwitnessed Fall Resulting in Injury
Penalty
Summary
The facility failed to report an unwitnessed fall of a resident, which resulted in a right hip fracture requiring surgical repair and hospitalization, to the California Department of Public Health (CDPH). The resident, who had severe cognitive impairment and was legally blind, was found on the floor by a CNA. The fall was unwitnessed, and the resident was transferred to a General Acute Care Hospital for treatment. Despite the severity of the injury, the incident was not reported to the state agency, delaying an investigation by CDPH. The resident had a history of falls and was dependent on staff for most activities of daily living due to severe cognitive impairment and legal blindness. On the morning of the fall, the resident was found sitting on the floor between the beds, complaining of hip pain. An x-ray confirmed a right hip fracture, and the resident underwent surgery. Interviews with staff revealed that the fall was unwitnessed, and the resident's roommate, who was also cognitively impaired, could not provide reliable information about the incident. The facility's policies on fall management and reporting unusual occurrences were reviewed, indicating that unusual events, such as unwitnessed falls resulting in injury, should be reported. However, the Director of Nursing did not report the fall, citing the roommate's unreliable account. This oversight resulted in a failure to comply with state reporting requirements, as the fall was not reported to CDPH, preventing timely investigation and intervention.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to ensure that a significant change in status assessment (SCSA) was completed for a resident who experienced a significant change in condition. The resident, who had multiple diagnoses including diabetes mellitus, chronic kidney disease, and pulmonary hypertension, was admitted with a diagnosis of moderate protein-calorie malnutrition. The resident's Minimum Data Set (MDS) dated 11/2/2024 indicated severe cognitive impairment and dependency on staff for various activities of daily living. Additionally, the resident was at risk for pressure injuries and had developed a Stage 1 pressure injury. Despite these conditions, the Minimum Data Set Coordinator (MDSC) did not complete an SCSA when the resident's pressure injury progressed to Stage II, as noted in the Pressure Sore Management Record dated 11/11/2024. The MDSC acknowledged that the SCSA should have been triggered by the presence of two major changes, such as weight loss and pressure injury. The Director of Nursing (DON) confirmed the importance of completing an SCSA to address specific problems. The facility's policy indicated that an SCSA is appropriate when there are two or more areas of decline or improvement, or if the Interdisciplinary Team (IDT) determines it would benefit the resident. This oversight had the potential to impact the resident's care and treatment.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the Minimum Data Set (MDS) assessments for two residents, leading to potential negative effects on their care plans. For one resident, the MDS inaccurately documented a Stage III pressure ulcer, while the resident only had a Stage II pressure ulcer that had resolved. This discrepancy was identified during interviews with the Treatment Nurse and the MDS Coordinator, who confirmed the miscoding. The resident had been readmitted to the facility after surgery with a Stage II pressure ulcer, which was resolved, and no further wound care was being provided. For another resident, the MDS inaccurately recorded an unplanned discharge to a Short-Term General Hospital, whereas the resident was actually discharged to a private home with home health services. This error was identified during a review of the resident's discharge summary and confirmed by the MDS Coordinator. The Director of Nursing Services emphasized the importance of accurate MDS documentation to ensure appropriate care and services for residents. The facility's policy on the accuracy of assessments requires that the MDS reflect the resident's status during the observation period, capturing only occurrences within that timeframe.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for two residents, leading to potential negative impacts on their care. For Resident 2, the Occupational Therapy (OT) services were discontinued as per a physician's order, but the care plan was not updated to reflect this change. The Director of Rehabilitation confirmed that the care plan still indicated ongoing OT services, which was inaccurate. This oversight could lead to confusion and inappropriate care for Resident 2, who had severe cognitive impairments and functional limitations. Resident 46 experienced a significant change in condition due to hypoglycemic events, yet the care plan was not revised accordingly. Despite a physician's order to decrease the insulin dosage following a hypoglycemic episode, the care plan was not updated to reflect this change. The Minimum Data Set Coordinator acknowledged that the care plan should have been revised to prevent further hypoglycemic events. The failure to update the care plan after the resident's condition changed could have serious implications for the resident's health. The facility's policy and procedure require that comprehensive care plans be developed, reviewed, and revised by the interdisciplinary team, especially after any assessment or change in condition. However, in both cases, the care plans were not updated as required, indicating a lapse in following the facility's established procedures. This deficiency in care planning could lead to inadequate care and potential harm to the residents involved.
Failure to Conduct IDT Meetings and Activate Emergency Response
Penalty
Summary
The facility failed to conduct an Interdisciplinary Team (IDT) meeting after a resident experienced two hypoglycemic events. The resident, who had a history of diabetes mellitus and osteomyelitis, experienced confusion and cold, clammy skin, with blood glucose levels dropping to 42 mg/dL and 34 mg/dL on separate occasions. Despite these events, the IDT meetings were not held to discuss potential causes and revise care plans to prevent recurrence. Additionally, the facility did not activate the emergency response system when the resident remained unresponsive after interventions during the second hypoglycemic event. The resident's blood glucose was 34 mg/dL, and after administering glucagon, it only rose to 49 mg/dL. The resident was still not verbally responsive, and the emergency response system was not activated, which could have led to a delay in care. The facility's policy indicated that care and services should maintain the resident's highest level of practicable functioning. However, the failure to clarify insulin orders with the physician and the lack of IDT meetings after the hypoglycemic events demonstrated a deficiency in adhering to this policy. The Director of Nursing Services acknowledged that the emergency response system should have been initiated and that IDT meetings should have been conducted to address the hypoglycemic events.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident who was assessed at moderate risk for developing pressure injuries. The resident, who had intact skin upon admission, developed a Stage I pressure injury on the coccyx area, which progressed to a Stage II injury. The facility did not implement the resident's care plan in a timely manner, specifically delaying the use of a low air loss mattress and failing to reposition the resident to offload pressure from the coccyx area. The resident's care plan included interventions such as turning and repositioning every two hours, using a low air loss mattress, and providing nutritional support. However, these interventions were not initiated promptly, and the resident's pressure injury worsened. Additionally, the facility used bath towels instead of incontinence pads, which contributed to skin shearing and further compromised the resident's skin integrity. The resident's severe cognitive impairment and dependency on staff for mobility and hygiene further complicated the situation. Interviews with staff revealed that the resident's poor food intake and refusal of a mechanical soft diet were not adequately addressed, and there was a lack of communication regarding the progression of the pressure injury. The use of bath towels instead of appropriate incontinence products was identified as a practice that could lead to skin breakdown. The facility's failure to properly reposition the resident and use appropriate incontinence care measures contributed to the development and progression of the pressure injury.
Failure to Provide Recommended Splints for Resident
Penalty
Summary
The facility failed to provide a resting hand splint for the left arm and a hand roll splint for the right hand to a resident, as recommended by Occupational Therapy (OT). The resident, who was admitted with right-sided hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage, was at high risk for contracture development due to increased muscle tone and a tendency to hold both hands in fists. Despite the OT's recommendation for splinting to maintain joint integrity and manage muscle tone, the splints were never issued to the resident. Observations revealed that the resident was lying in bed with rolled-up towels in both hands instead of the recommended splints. The Restorative Nursing Aide (RNA) was unaware of any orders for splints and used towel rolls to prevent the resident's nails from digging into her palms. The RNA provided passive range of motion (PROM) exercises at a fast speed, causing the resident to moan and grimace in pain. The Director of Rehabilitation confirmed that the splints were not issued due to a lack of time to assess the resident for appropriate splint wear time before discharge from OT services. The Director of Nursing stated that the Rehabilitation Department was responsible for assessing and issuing splints. The facility's policies indicated that treatment and services should be provided to maintain or improve each resident's range of motion and prevent further decline unless clinically unavoidable. The failure to issue the recommended splints potentially contributed to the resident's risk of range of motion decline and contracture development.
Failure to Prevent Unplanned Weight Loss in a Resident
Penalty
Summary
The facility failed to prevent significant unplanned weight loss in a resident, identified as Resident 25, who experienced a 9.2% weight loss over three months and a 10.5% loss over six months. The staff did not adequately monitor the resident's oral intake or notify the physician of the significant weight loss in a timely manner. Despite having a care plan in place to address altered nutrition and hydration status, the facility did not effectively implement interventions to prevent further weight loss. Resident 25 was admitted with multiple diagnoses, including diabetes mellitus, chronic kidney disease, and moderate protein-calorie malnutrition. The resident was dependent on staff for daily activities and had severe cognitive impairment. Despite being on a prescribed diet and receiving nutritional supplements, the resident's food intake was consistently low, ranging from 0% to 50% of meals consumed. The care plan required monitoring of weight and food intake, but the staff failed to document and report significant changes to the physician as required. Interviews with staff revealed a lack of communication and follow-up regarding the resident's declining condition. The CNA responsible for feeding the resident did not notify the charge nurse of low food intake, and the LVN and RN acknowledged the resident's poor eating habits but did not take appropriate action. The RD was not aware of the continued weight loss despite interventions and had not personally assessed the resident. The facility's policies on nutrition and notification of change were not followed, contributing to the resident's ongoing weight loss and risk of malnutrition.
Failure to Provide Appropriate Pureed Diet
Penalty
Summary
The facility failed to ensure that a resident on a pureed diet received food consistent with their diet order and according to the pureed menu recipe. The resident, who had severe cognitive impairment and was dependent on staff for various activities, was observed consuming a peanut butter and jelly sandwich, which is not part of a pureed diet. This was contrary to the physician's order and the speech therapist's recommendation for a pureed diet due to the resident's dysphagia and diabetes mellitus. The resident's care plan indicated a need to monitor and report signs of dysphagia, yet the dietary manager admitted that the resident was not receiving the correct diet. The dietary manager acknowledged that the peanut butter and jelly sandwich was not appropriate for the resident's pureed diet and that the facility should have requested another speech therapy evaluation to ensure the resident's safety. The speech language pathologist confirmed that the resident's diet should be pureed and that a peanut butter and jelly sandwich could pose a risk of aspiration. The facility's policy and procedure on therapeutic diets stated that residents should receive foods in the appropriate form as prescribed by the physician. However, the dietary manager did not verify the resident's diet, leading to the resident receiving an inappropriate meal. This oversight had the potential to put the resident at high risk for aspiration and choking, as the facility did not adhere to the prescribed diet and recommendations.
Inaccurate Documentation of OT Recommendations and ROM Status
Penalty
Summary
The facility failed to ensure accurate documentation of clinical records for a resident, specifically regarding occupational therapy (OT) discharge recommendations and range of motion (ROM) status. The resident, who was admitted with diagnoses including right-sided hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage, was evaluated by OT due to a decline in ROM in both hands. The OT evaluation recommended the use of a resting hand splint on the left hand and a hand roll on the right hand for 4 hours on and 4 hours off to maintain joint integrity and manage muscle tone. However, the OT discharge summary inaccurately documented that the resident could tolerate wearing both splints for 4 hours, despite only tolerating 30 minutes at the time of discharge. The Director of Rehabilitation (DOR), who conducted the OT evaluation, confirmed that the documentation of contractures in both hands was inaccurate, as the resident did not have contractures. The DOR admitted to mistakenly documenting the recommendation for the splints' wear time due to a lack of attention while writing the discharge summary. This inaccurate documentation could potentially cause confusion and harm, as it did not accurately reflect the resident's current level of function and needs. The Director of Nursing (DON) emphasized the importance of accurate documentation in a resident's clinical record, as it reflects the resident's status and ensures the provision of necessary care and services. The facility's policy and procedure on documentation, as well as the OT job description, highlight the responsibility of accurately charting patient care services and evaluating patient progress. The failure to accurately document the resident's condition and OT recommendations had the potential to negatively impact the provision of necessary care and services for the resident.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident who was at high risk for developing pressure ulcers. The resident, who was non-ambulatory and bedfast, was admitted with multiple diagnoses including hemiplegia, hemiparesis, and malnutrition. Despite being assessed as high risk for pressure ulcers, the resident developed a deep tissue injury (DTI) on the right heel, which evolved from a Stage 1 pressure ulcer. The facility did not ensure the resident was turned and repositioned every two hours, nor did they maintain offloading of the right heel to prevent constant pressure. Interviews and record reviews revealed that the resident's care plan included interventions such as repositioning and the use of a pressure-reducing device, but these were not consistently implemented. Documentation showed numerous instances where the resident was not turned or repositioned as required. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) acknowledged that the resident's pressure ulcer was avoidable and attributed its development to poor nutrition, immobility, and constant pressure on the heel. The facility's failure to reassess the resident's condition and update the care plan with necessary interventions contributed to the progression of the pressure ulcer. The Director of Nursing (DON) confirmed that the resident was not consistently turned and repositioned, as indicated by the documentation survey reports. The facility's policy emphasized the importance of repositioning and relieving constant pressure for residents at risk of pressure ulcers. However, the resident's care plan did not include specific interventions for repositioning and offloading the right heel after the DTI was identified. This lack of adherence to standard nursing practices and the facility's policy resulted in the resident developing a preventable pressure ulcer.
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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