Driftwood Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 4109 Emerald St, Torrance, California 90503
- CMS Provider Number
- 555114
- Inspections on file
- 40
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Driftwood Healthcare Center during CMS and state inspections, most recent first.
A resident with schizophrenia and severe cognitive impairment was prescribed psychoactive medications, but informed consent was obtained from a family member instead of the court-appointed Conservator, as required. Facility staff were unaware of the Conservator's status, resulting in the Conservator not being informed or able to make decisions about the resident's care.
A resident with severe cognitive impairment and a diagnosis of schizophrenia was discharged to a family member without involving the court-appointed Conservator in the discharge planning process. Facility staff were unaware of the Conservatorship and conducted discharge planning with the family member instead, contrary to facility policy requiring the Responsible Party's involvement.
Staff failed to accurately monitor and document washing machine hot water temperatures, instead recording a standard value without measurement, and lacked training and policies for proper temperature checks. Laundry water temperatures were only recorded on weekdays, with no monitoring on weekends, creating a risk for inadequate infection control for all residents.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not obtain food from approved sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
Two residents experienced deficiencies in medical record documentation: one resident's diagnosis list failed to include a depressive mood disorder despite physician notes and prescribed antidepressants, while another resident's MAR incorrectly showed administration of Naloxone, which was not given. These errors were confirmed by staff interviews and record reviews, and were inconsistent with facility policy requiring complete and accurate documentation.
Nursing staff did not ensure a call light was within reach for a resident with functional quadriplegia who was dependent on staff for all care. The resident was unable to call for help and relied on his roommate to contact staff, despite care plan and facility policy requirements to keep the call light accessible and provide adaptive devices as needed. Multiple staff confirmed the resident could not access the call light, resulting in unmet needs.
A resident with severe cognitive impairment was without a personal blanket for three months after the item went missing. The family reported the missing blanket to multiple CNAs and charge nurses, but the information was not relayed to the SSD as required by facility policy. This resulted in a lack of timely investigation and action to locate or replace the item.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to medication management.
A resident with multiple medical and mental health diagnoses, including PTSD and anxiety, was admitted and later prescribed psychotropic medications, but the PASRR Level 1 screening was inaccurately completed, failing to identify the presence of a serious mental illness and omitting the need for a Level 2 screening. The DON confirmed that the screening should have been updated after changes in the resident's condition and medication regimen, in accordance with facility policy.
Two residents did not have care plans addressing their specific needs—one with impaired hearing and another with PTSD and psychotropic medication use. Staff and record reviews confirmed the absence of required care plan components, despite facility policy mandating person-centered, trauma-informed care planning.
A medication listed on the Ekit index as potassium chloride was found to be replaced with nitrofurantoin tablets during a nurse's observation, despite facility policy requiring pharmacists to verify Ekit contents and perform monthly inventories. This discrepancy was confirmed by both nursing and pharmacy staff.
A resident receiving Apixaban, an anticoagulant, was not monitored or documented for signs and symptoms of bleeding as required by the care plan and facility policy. Nursing staff, including an LVN and RN, confirmed that this monitoring was not performed or recorded on the MAR, and the DON acknowledged the deficiency.
The facility did not follow its abuse prevention policy by failing to suspend two CNAs involved in an alleged abuse incident. This lapse placed all residents at risk, including a cognitively intact resident with schizophrenia and cerebral infarction who was dependent on staff for care. The DON and RN Supervisor confirmed that the required protocol to remove and suspend staff pending investigation was not followed.
A resident with dementia was discharged without her personal belongings, as required notifications and procedures for returning personal effects to her responsible party or family member were not followed. The resident arrived at a new care facility with only the clothes she was wearing, and staff failed to ensure her inventory of personal items was properly managed and returned according to facility policy.
A resident with dementia and impaired decision-making capacity was discharged to a B&C facility without proper discharge planning, notification, or involvement of the responsible party or family member. Required documentation, assessments, and communication were not completed, resulting in the resident being transferred and later passing away at another facility without her family’s knowledge.
A resident with significant cognitive and physical impairments was found with unexplained bruising and swelling to the forehead and eye. Staff could not determine the cause of the injury, and although the facility's policy required reporting such injuries of unknown origin to CDPH and other authorities, this was not done in a timely manner. The DON was unaware of the reporting requirement, resulting in a delay that prevented timely investigation by state authorities.
A resident with multiple comorbidities and cognitive impairment was found with a forehead injury, black eye, and swelling. Although medical care was provided and the physician and family were notified, no investigation was conducted to determine the cause of the injury or to rule out abuse or neglect, contrary to facility policy.
A resident with intact cognitive skills reported being sexually abused by another resident with moderate cognitive impairment. The incident was captured on video, but staff initially dismissed the report, questioning the resident's account. The facility's abuse prevention policy was not effectively implemented, as staff failed to take immediate action to investigate or report the incident.
A resident reported inappropriate conduct by another resident, confirmed by video surveillance, but the facility failed to conduct a thorough investigation by not interviewing other residents. Despite evidence of the incident, the investigation was limited to the involved residents and their roommates, neglecting to gather information from other potentially affected residents. The Director of Nursing admitted the investigation was not thorough, highlighting a gap in the facility's response to abuse allegations.
A resident with multiple health conditions was discharged from an LTC facility without proper discharge planning or documentation. The resident left without medications or follow-up instructions, and staff failed to document necessary communications or obtain a signed discharge form. The facility's policy on discharge planning was not followed, leading to an uncoordinated discharge process.
A resident with cognitive impairments was found smoking unsupervised near the facility's parking lot, without a smoking apron or safe disposal means, contrary to the care plan and facility policies. Staff interviews revealed a lack of supervision and awareness, leading to a deficiency in maintaining a safe environment.
A facility failed to ensure accurate documentation in an OT Discharge Summary Note, leading to a deficiency. An OT incorrectly documented that a resident tolerated a washcloth in her left hand, instead of the right hand, potentially affecting the resident's care plan. The resident had generalized muscle weakness and was dependent on staff for ADLs. The error was confirmed by the OT and highlighted the importance of accurate records for effective communication among the care team.
A facility failed to invite a resident's designated advocate to an IDT meeting, despite the resident's request for their involvement due to forgetfulness. The resident, with conditions like diabetes and muscle weakness, was unable to understand the meeting discussions and refused to sign documents without the advocate's consultation. Staff interviews revealed a lack of awareness about the advocate's role, and facility policies on resident rights and care planning were not followed.
Two high-risk residents in an LTC facility were using wheelchairs with malfunctioning locks, posing a fall risk. Despite being reported, maintenance issues were not promptly addressed, and staff were unaware of the problems. The facility's policy lacked clear guidelines for interim measures and maintenance timeframes, leading to oversight and potential safety risks.
A facility failed to provide a resident's medical records to their legal representative within the required timeframe, delaying the resident's appeal against an insurance denial. Despite multiple requests, the facility did not release the records, citing confidentiality. The resident, who required assistance due to medical conditions, believed the facility omitted crucial information. Staff interviews revealed a lack of clarity in the facility's policy on record disclosure.
A facility failed to retain and submit accurate medical records for a resident, leading to a denial of insurance coverage for continued stay. The resident, who required assistance with daily activities and had severe medical issues, did not have necessary clinical documents submitted to the insurance provider. The Social Services Representative did not include critical information about the resident's inability to self-administer insulin, and the facility's documentation retention policy was not followed.
A resident was unable to return to her original room after a brief hospitalization due to the facility moving another resident into her room, despite a policy to hold the bed for seven days. The resident, who had respiratory failure and an embolism, was transferred to a GACH for shoulder pain and returned after 11 hours, only to find her room occupied. This led to her experiencing frustration and sadness.
A facility failed to provide the correct diet consistency for residents with dysphagia, serving them regular bread instead of minced and moist as prescribed. This oversight involved several staff members, including the Dietary Supervisor and a Licensed Vocational Nurse, who did not ensure the correct food consistency was provided. The residents, who had various medical conditions requiring a modified diet, were at risk due to this failure.
The facility failed to clean the ice machine per manufacturer guidelines, affecting 83 residents. Observations showed the ice machine's trim was dirty, confirmed by staff interviews emphasizing the importance of cleanliness to prevent contamination. The facility's policy required regular cleaning, but this was not followed, risking microorganism growth and illness.
The facility failed to document the annual review of dietary department policies, as required by the QAA and QAPI teams. Interviews with the Dietary Supervisor and Administrator revealed that the Manual Signature/Approval Form and Information/Record Manual sign-in sheets lacked titles indicating which policies were reviewed. The facility's policy stated that reviews should occur annually, but there was no documentation for 2022.
The QAA and QAPI at the facility failed to identify deficiencies in dietary staff competencies and meal tray assessments, leading to residents not receiving appropriate therapeutic diets and being at risk of choking. The DON noted that the Dietary Supervisor should have reported the issue to the Administrator.
The facility failed to ensure staff competency in serving physician-prescribed dysphagia diets, resulting in several residents receiving incorrect food textures that posed a risk for aspiration and choking. Despite clear dietary orders, staff served sandwiches on regular bread instead of the required minced and moist consistency. Interviews revealed a lack of adherence to dietary standards and facility policies.
The facility failed to ensure timely follow-up appointments for dental and podiatry evaluations for two residents, leading to delays in necessary care. One resident experienced dental pain requiring urgent follow-up, which was overlooked by the Social Service Director. Another resident needed podiatry services for toenail debridement, but staff failed to communicate the request effectively, resulting in a delay. Interviews revealed inadequate management of specialist appointment scheduling, contrary to facility policies.
The facility failed to ensure dietary staff were competent in preparing and serving physician-prescribed dysphagia diets. Several residents received inappropriate meals that did not meet the required minced and moist consistency, placing them at risk for aspiration and choking. Observations and interviews revealed a lack of adherence to the facility's diet manual and policies, with staff misunderstanding the dietary requirements.
A facility failed to document the discussion and provision of written information regarding advance directives for a resident with severe cognitive impairment and significant medical conditions. The resident's POLST form lacked documentation of their wishes for medical care. Interviews with staff confirmed the absence of an advance directive or documentation that it was offered, despite the facility's policy requiring such information to be provided upon admission.
A resident with cognitive impairments, including Fetal Alcohol Syndrome and autistic disorder, was inappropriately asked to sign a binding arbitration agreement without assessing their mental capacity. Facility staff confirmed the resident's inability to understand or consent, yet the agreement was signed without a legal representative's involvement, violating facility policy.
The facility failed to convene an IDT meeting to discuss a resident's hearing loss, pending audiologist appointment, and requested hearing aids. Despite the resident's awareness and ability to communicate, the facility did not follow up on necessary audiology appointments or provide updates to the resident and their responsible party, leading to frustration and potential psychosocial decline for the resident.
A facility failed to ensure a resident with hearing loss received a timely audiology appointment after an otolaryngologist ordered an audiogram. Despite the order being made months earlier, the resident had not received the audiogram, leading to frustration and a potential decline in psychosocial health. The Social Services Assistant and Registered Nurse Supervisor acknowledged the failure to follow up on the appointment.
Failure to Obtain Informed Consent from Court-Appointed Conservator for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that the court-appointed Conservator, assigned by the Los Angeles County Office of the Public Guardian, was informed of the risks and benefits of psychoactive medications prescribed to a resident with schizophrenia and severely impaired cognition. Instead, informed consent for the use of Quetiapine Fumarate and Aripiprazole was obtained from the resident's family member (FM), not the Conservator, despite documentation indicating the Conservator was the legal decision-maker for the resident. The resident was dependent on staff for all activities of daily living and had a diagnosis of schizophrenia with severe cognitive impairment, as documented in the Minimum Data Set and admission records. Record review showed that the facility's policy required identification of a surrogate decision-maker, including public guardians, to provide informed consent for treatment. However, the Director of Nursing acknowledged that staff were unaware of the Conservator's appointment and obtained consent from the FM instead. As a result, the Conservator was not informed about the resident's prescribed psychoactive medications and was unable to make decisions regarding the resident's care, contrary to legal and facility policy requirements.
Failure to Involve Court-Appointed Conservator in Discharge Planning
Penalty
Summary
Facility staff failed to ensure that the court-appointed Conservator, designated as the Responsible Party (RP) for a resident with severe cognitive impairment and a diagnosis of schizophrenia, was involved in the resident's discharge planning. The resident was dependent on staff for all activities of daily living, and the facility's records indicated that the Conservator had been appointed prior to the discharge event. Despite this, discharge planning discussions and decisions were conducted with a family member who was not the legal Conservator. The discharge was executed per the family member's request, and the resident was released into the family member's care without the involvement or consent of the Conservator. Facility staff, including the Social Services Director and Director of Nursing, stated they were unaware of the Conservatorship at the time of discharge, as this information was not provided upon admission. The facility's policy required that discharge planning involve the IDT, the resident, and the Responsible Party, but this protocol was not followed in this case.
Failure to Monitor and Document Laundry Water Temperatures for Infection Control
Penalty
Summary
The facility failed to prevent the spread of infection for all 91 residents by not ensuring accurate and consistent monitoring of washing machine hot water temperatures. Staff responsible for recording the temperatures on the Washer Water Temperature Log admitted to not actually measuring the water temperature, but instead were instructed by previous supervisors to write down 160 degrees Fahrenheit daily, regardless of the actual temperature. Additionally, staff reported that they had not received training on how to properly monitor or document the water temperature. Further review revealed that the laundry hot water temperature was only recorded Monday through Friday, with no monitoring occurring on weekends. The Maintenance Supervisor confirmed that there were no existing policies or procedures for monitoring the washing machine temperatures, and that accurate temperature checks are important for regulatory compliance and infection control. These lapses in monitoring and documentation had the potential to affect all residents in the facility.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in noncompliance with regulations regarding the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling protocols. The report does not provide further details regarding specific events, individuals involved, or the condition of any residents at the time of the deficiency.
Failure to Maintain Accurate Medical Records and Medication Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation for two residents, resulting in deficiencies related to medical records and medication administration. For one resident with a diagnosis of depression, the medical diagnosis list did not include any depressive mood disorder, despite multiple physician progress notes and medication orders indicating treatment for depression and anxiety. The resident was prescribed sertraline for depression and alprazolam for anxiety, and both the primary and psychiatry doctor progress notes referenced depression as part of the resident's medical history. The Director of Nursing confirmed that the diagnosis list should have reflected a depressive mood disorder, as accurate documentation is necessary for staff to understand the resident's current condition and provide appropriate care. For another resident, the Medication Administration Record (MAR) for a specific month inaccurately indicated that the resident received a dose of Naloxone, a medication used to reverse opioid overdose, when in fact the medication was not administered. The order for Naloxone was present as needed for opioid overdose, but a registered nurse confirmed that the resident did not receive the medication and that its administration was mistakenly documented. The Director of Nursing acknowledged this as a documentation error and emphasized the importance of correct medication administration records to prevent errors in care. Both deficiencies were identified through observation, interview, and record review, and were found to be inconsistent with the facility's policy and procedures, which require medical records to be complete and accurate. The facility's own policies stress the need for standardized, legible, and descriptive documentation to ensure the highest quality and accuracy in resident care records.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
Nursing staff failed to ensure that the call light device was within reach for a resident who was functionally quadriplegic and dependent on staff for all activities of daily living. During observation, the call light was found next to the resident's lower right hip, out of reach, and the resident reported being unable to call for help, instead relying on his roommate to summon assistance. The resident's care plan specifically indicated that the call light should be kept within reach and that staff should monitor and anticipate his needs. Interviews with the resident, his roommate, a CNA, an RN, and the DON confirmed that the resident could not access the call light and that this prevented his needs from being addressed promptly. Review of the resident's medical records showed diagnoses of functional quadriplegia, hypotension, and multiple muscle contractures, with documentation that he had the capacity to understand and make decisions but was dependent on staff for all care. Facility policy required that the call alert device be placed within the resident's reach and that adaptive devices be provided for those unable to use the standard system. Despite these requirements, the resident was not provided with an accessible call light or adaptive device, resulting in a failure to reasonably accommodate his needs and preferences.
Failure to Timely Investigate and Report Missing Resident Belongings
Penalty
Summary
The facility failed to investigate a claim of missing belongings for a resident with severe cognitive impairment, resulting in the resident missing a blanket for three months. The resident, who had diagnoses including muscle weakness and dementia, was dependent on the facility for daily living and support. The family member reported the missing blanket to multiple certified nursing assistants and charge nurses, but the information was not relayed to the social services director (SSD) as required by facility policy. The SSD only became aware of the missing item after a significant delay, despite the family providing photographic evidence that the blanket had been in the facility. Facility policy required that all inquiries regarding lost or stolen items be reported immediately to the administrator or designee, and that a search for the missing property begin right away. However, the nursing staff did not follow this procedure, resulting in a lack of timely investigation and action. Both the SSD and the director of nursing (DON) confirmed that missing items should be reported within a day or two, but this did not occur, leading to a prolonged period during which the resident was without her personal belonging.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Failure to Accurately Complete PASRR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately. The resident was admitted with diagnoses including metabolic encephalopathy, rhabdomyolysis, post-traumatic stress disorder (PTSD), and anxiety. Upon review, the resident's PASRR Level 1 screening was marked as negative, indicating no serious mental illness, and therefore a Level 2 screening was not conducted. However, the resident had documented mental health diagnoses and was prescribed psychotropic medications for depression and anxiety, which were not reflected in the PASRR screening. Further review revealed that the PASRR Level 1 screening did not acknowledge the resident's mental health conditions, as question nine regarding serious diagnosed mental disorders was incorrectly answered "NO." The Director of Nursing confirmed that this should have triggered a Level 2 screening and that a status change review should have been completed when new psychotropic medications were started. The facility's policy requires the MDS Coordinator to ensure PASRR updates are completed according to guidelines, including after significant changes in status, which was not followed in this case.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Hearing Loss and PTSD
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, resulting in deficiencies related to unmet medical and psychosocial needs. For one resident with a history of muscle weakness, type 2 diabetes mellitus, and major depressive disorder, the facility did not develop a care plan addressing the resident's impaired hearing. Despite documentation and staff acknowledgment of the resident's hearing loss, no care plan was initiated to guide staff in providing appropriate care for this condition. Another resident, admitted with diagnoses including post-traumatic stress disorder (PTSD), anxiety, opioid use disorder, and muscle weakness, did not have a care plan that addressed PTSD or the use of psychotropic medications for mood disorders. The resident's care plan lacked goals and interventions specific to PTSD and did not include monitoring or management strategies for prescribed psychotropic medications such as sertraline and alprazolam. Staff interviews confirmed the absence of these care plan components and emphasized the importance of such plans for safe and effective care. Facility policy required that baseline and comprehensive care plans be developed upon admission and updated to address all identified needs, including trauma-informed care and the use of psychotropic medications. However, record reviews and staff interviews revealed that these requirements were not met for the two residents, resulting in a failure to provide person-centered care as outlined in facility procedures.
Mismatch Between Emergency Kit Medication List and Contents
Penalty
Summary
The facility failed to ensure that the medication listed on the oral medications' Emergency kit (Ekit) index matched the medication actually present in the Ekit. During an observation and interview with a registered nurse, it was found that slot number 25 in the Ekit, which was supposed to contain potassium chloride 20 mEq, instead contained four tablets of nitrofurantoin 50 mg. The registered nurse stated that the pharmacist is responsible for verifying Ekit contents upon delivery, and that discrepancies could lead to medication errors or delays. The dispensing pharmacist confirmed that the on-duty pharmacist should verify Ekit contents against the list and that any discrepancies should result in the Ekit being returned to the pharmacy. Review of facility policy indicated that the consultant pharmacist is required to monitor and inventory emergency kits at least every 30 days for completeness and expiration dating.
Failure to Document Monitoring for Anticoagulant Therapy
Penalty
Summary
Nursing staff failed to document monitoring for signs and symptoms of bleeding on the medication administration record (MAR) for a resident who was prescribed Apixaban, an anticoagulant. The resident had multiple diagnoses, including hypotension, hyperlipidemia, and atrial flutter, and was dependent on staff for all activities of daily living. The care plan required monitoring and documentation of bleeding every shift due to the use of Apixaban, but this was not completed or recorded on the MAR as required. During interviews, both the LVN and RN confirmed that monitoring for bleeding and bruising was not being documented, and the Director of Nursing acknowledged that this documentation should have been present on the MAR. Review of facility policy indicated that licensed nurses are required to monitor and document for signs and symptoms related to high-risk medications, including Apixaban, and to inform the attending physician of any findings. The lack of documentation indicated that the required monitoring was not performed.
Failure to Suspend Staff Following Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its written abuse prevention policy and procedure by not suspending two Certified Nurse Assistants (CNAs) who were involved in an alleged abuse incident. According to the facility's policy, any employee suspected of abuse should be immediately removed from resident care and suspended pending the outcome of an investigation. However, the Director of Nursing (DON) acknowledged that the CNAs were not suspended as required by the policy, despite being aware of the allegation and the policy's stipulations. This deficiency affected all 94 residents in the facility, as the failure to suspend the involved staff placed all residents at risk of abuse. The incident specifically involved a resident with diagnoses including schizophrenia and cerebral infarction, who was cognitively intact but dependent on staff for daily care activities. The Registered Nurse Supervisor confirmed that staff involved in abuse allegations should not be allowed to work until the investigation is complete, but this protocol was not followed in this case.
Failure to Return Resident's Personal Belongings at Discharge
Penalty
Summary
A resident with dementia, who was unable to make consistent and reasonable decisions and had a family member as a surrogate decision maker, was discharged from the facility without her personal belongings. The resident's inventory of personal effects, which included clothing, glasses, a phone, and other personal items, was not signed or acknowledged by the resident, her responsible party, or family member at the time of discharge. Interviews revealed that both the family member and responsible party were only informed of the discharge on the day it occurred and were not notified about the disposition of the resident's belongings. The facility's own policies required staff to prepare an inventory at discharge, provide a copy to the resident or representative, and obtain a signature, but this was not done. Upon arrival at the new care facility, the resident had only the clothes she was wearing, a list of medications, and an insurance card, with no other personal items provided. The receiving facility owner confirmed that the resident arrived without any belongings. Facility staff interviews indicated that it was the responsibility of the registered nurse supervisor and social services director to ensure notification and proper handling of personal effects, but this process was not followed. The facility's policies also required reasonable steps to protect and return personal property to residents or their representatives upon discharge, which was not adhered to in this case.
Failure to Ensure Safe and Appropriate Discharge for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia and lacking decision-making capacity was appropriately discharged. The resident was transferred to a Board and Care (B&C) facility without an Interdisciplinary Team (IDT) discharge meeting, prior discharge planning, or providing the resident’s Responsible Party (RP) and/or Family Member (FM) with a Notice of Proposed Discharge/Transfer 30 days prior to the transfer. There was no assessment of the resident at the time of transfer, no confirmation that the B&C facility received the resident’s contact information, and no medication or personal effects inventory list was sent with the resident. Documentation was incomplete, with missing signatures and contradictory information regarding whether discharge instructions and medication lists were provided to the RP or FM. The resident’s medical records indicated a diagnosis of dementia and depression, with assessments showing the resident was unable to make consistent and reasonable decisions and required assistance with activities of daily living. The care plan identified impaired cognitive function and the need for communication with the family and caregivers. Despite these needs, the discharge process did not involve the RP or FM, and there was no evidence of a completed discharge planning IDT meeting. The RP and FM were only informed of the discharge on the day it occurred, and neither was provided with the resident’s discharge location or adequate information about the transfer. After discharge, the resident was transferred from the B&C facility to an Extended Care Facility (ECF) and subsequently passed away without the knowledge of the RP or FM. Interviews with facility staff confirmed that required notifications and documentation were not completed, and the facility’s own policies regarding discharge planning and communication were not followed. The lack of proper discharge planning and communication resulted in the resident being discharged without the involvement or knowledge of her legal representatives, and her whereabouts and condition remained unknown to her family until after her death.
Failure to Timely Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who was observed with a discoloration on her forehead, a black eye, and swelling, to the California Department of Public Health (CDPH) as required. The resident, who had diagnoses including chronic kidney disease, dementia, hypertension, and schizophrenia, was dependent on staff for most activities of daily living and lacked the capacity to make decisions. On the morning of the incident, staff observed the resident with new bruising and swelling, but no staff member witnessed the event or could explain how the injury occurred. The resident's medical provider and family were notified, and medical interventions such as a skull x-ray and neurological checks were ordered. Multiple staff interviews revealed that the injury was first noticed during a shift change, with no prior documentation of trauma or incident. Staff members, including CNAs and RNs, stated they did not know how the injury happened, and some speculated it may have been caused by the resident hitting her head on the bed rails, though this was unwitnessed. The facility's own policy defined injuries of unknown source as those not observed or explained and considered suspicious due to their extent or location. Despite this, the required reporting to CDPH and other authorities was not completed in a timely manner. The Director of Nursing (DON) confirmed during interviews that she was unaware of the obligation to report the injury as an incident of unknown origin. Facility policies reviewed indicated that such injuries should be reported to state agencies within specified timeframes and that thorough investigations should be conducted. However, the lack of timely reporting prevented CDPH from investigating the injury promptly, constituting a failure to follow regulatory requirements for reporting suspected abuse, neglect, or injuries of unknown origin.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and respond appropriately to an injury of unknown origin for one resident who was observed with discoloration on her forehead, a black eye, and eye swelling. The resident, who had diagnoses including chronic kidney disease, dementia, and schizophrenia, was dependent on nursing staff for most activities of daily living and lacked capacity to make decisions. On the morning of the incident, a CNA observed the discoloration, and the resident's physician and family were notified. Orders were given for a skull x-ray, skin monitoring, and neurological checks, but no investigation was initiated to determine the cause of the injury or to rule out abuse or neglect. Interviews with nursing staff and the DON confirmed that the injury was unwitnessed and that no formal investigation was conducted, despite facility policy requiring immediate investigation of injuries of unknown source. The facility's policies also required reporting such incidents to appropriate authorities and conducting thorough investigations, including interviews with staff and residents. The lack of investigation into the resident's injury constituted a failure to follow these policies and procedures.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. Resident 1, who had intact cognitive skills and the capacity to make decisions, reported that Resident 2 entered her room, unfastened her incontinent brief, and touched her private area. This incident occurred without the staff's knowledge, and Resident 1 felt scared and helpless. The facility's video surveillance confirmed that Resident 2, who had moderate cognitive impairment and lacked decision-making capacity, entered and exited Resident 1's room multiple times on the night of the incident. The staff's response to the incident was inadequate. When Resident 1 reported the abuse to RN 1, she was met with skepticism and was not believed. RN 1 did not take immediate action to investigate or report the incident. Similarly, when Resident 1 informed CNA 1 and LVN 1 about the incident, they also questioned the validity of her account, suggesting she might have been dreaming. The staff's failure to take Resident 1's report seriously and to act promptly contributed to the deficiency. The facility's policy on abuse prevention was not effectively implemented in this case. The policy stated that the facility does not condone any form of abuse and that the administrator is responsible for ensuring a safe environment. However, the staff's inaction and disbelief in Resident 1's report indicate a failure to adhere to these policies. The Director of Nurses was not present during the incident and only became aware of it after it was reported to her, highlighting a lack of immediate oversight and response to the situation.
Plan Of Correction
Free from Abuse and Neglect CFR(s): 483.12(a)(1) Corrective action: • On 3/17/25 Resident 1 was placed with a 1:1 sitter to make the resident feel secure and safe. • On 3/17/25 Resident 2 was on 1:1 staff to monitor his whereabouts. • Torrance Police were notified on 3/17/25. Officer Garcia spoke to Resident 2 to investigate the alleged sexual abuse. • Resident 1 was sent to Torrance Memorial Medical Center ER on 3/18/25 for further evaluation. Resident came back the same day with no unusual symptoms and trauma reported. • Resident 2 was sent to LADMC on 3/18/25 for evaluation and no longer resides in the Facility. • Resident 1 was seen and evaluated by the Psychiatrist on 3/19/25. Resident had verbalized to the psychiatrist that she is coping well and feels safe in the Facility. Resident 1 was monitored for anxiety. IDT was initially done on 3/18/25 with spouse. Follow-up IDT with Resident 1 and spouse on 3/21/25 regarding the outcome of the investigation, giving emphasis on Resident 2 being no longer in the facility. A copy of the video was sent to Torrance police for evidence, and additional interventions were done by the facility to prevent other residents from entering Resident 1’s room. Both Resident 1 and spouse had verbalized satisfaction and felt safe in the facility. How to identify potentially affected others: • On 3/25/25, all Department managers interviewed the Resident assigned to their ambassador rounds, asking if another resident, specifically describing the profile of Resident 2, entered their room. There was no other resident who entered their room. • SSD and DON interviewed all current residents from rooms 1-26 on 3/25/25, and there was no other resident affected by the same deficient practice. Based on the Department Managers' interviews as well as a preview of video surveillance, no other Resident was affected by this concern. Measures/Systemic change: • The Administrator gave in-service to 11-7 staff on 3/18/25 regarding Abuse reporting. • The Administrator gave in-service to all Department Managers on 3/18/25 regarding Abuse. • RN Supervisor 1 was given 1:1 in-service on 3/20/25 by DON regarding Abuse, giving emphasis on making sure that the alleged victim will feel safe and immediately providing another staff to stay with the resident. • The Administrator and DON gave 1:1 in-service to Supervisor 1 on 3/24/25 regarding Abuse, emphasizing on identifying alleged abuse and ensuring the resident's safety by assuring and keeping the victim safe. Disciplinary action was given to Supervisor 1. • The Administrator and DON gave 1:1 in-service to CNA 1 on 3/21/25 regarding abuse, emphasizing making sure that the victim of alleged abuse will not be left alone and that staff must immediately inform a supervisor. • DON gave in-service to Nursing staff on 3/18/25, 3/20/25, 3/21/25 regarding Abuse Prevention and Management, emphasizing the importance of making the victim feel safe and secure by having one staff with the resident. • Dietary Supervisor gave in-service to kitchen staff on 3/18/25 regarding Abuse. • Rehab Director gave in-service to Rehab staff on 3/21/25 regarding Abuse. Evening Hallway Monitoring was initiated on 3/22/23 from 9 PM to 7 AM. The RN Supervisor will assign staff to make rounds on the hallways to ensure that no resident attempts to enter other residents' rooms and to check any closed rooms. Nursing staff will document any findings every 30 minutes in the log between 9 PM and 7 AM. The scheduler will assign nursing staff 30 minutes of their time for rounds. The assigned staff will be designated in the sign-in sheets. Medical Records and/or Designee will audit the binder daily for charting and documentation for completion weekly. Findings will be discussed in daily clinical meetings for necessary action. QAPI was initiated on 4/5/25 regarding Abuse. Monitoring: • The DON will review the Evening Hall Monitoring Audit report for accuracy. Any negative trends will be discussed and reported in the monthly QA & A meeting for further intervention and compliance. Completed on 4/10/25
Inadequate Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of inappropriate conduct by one resident towards another. Resident 1 reported that Resident 2 entered her room and touched her private parts, an incident confirmed by video surveillance. Despite this confirmation, the facility did not interview other residents to determine if Resident 2 had a pattern of entering other residents' rooms, which was a critical oversight in the investigation process. Resident 1, who had intact cognitive skills, reported the incident to multiple staff members, including a registered nurse and a certified nursing assistant, but felt that her claims were not taken seriously. The video footage showed Resident 2, who had moderate cognitive impairment and lacked decision-making capacity, entering and exiting Resident 1's room multiple times on the night of the incident. Despite this evidence, the facility's investigation was limited to interviews with the involved residents and their roommates, neglecting to gather information from other potentially affected residents. The Director of Nursing acknowledged that the investigation was not thorough, as it did not include interviews with all interviewable residents to check for similar incidents. This failure to conduct a comprehensive investigation could lead to unrecognized acts of abuse, as the facility's policy requires prompt reporting and thorough investigation of abuse allegations. The deficiency highlights a significant gap in the facility's response to allegations of abuse, as they did not fully adhere to their own policies and procedures.
Plan Of Correction
Investigate / Prevent / Correct Alleged Violation CFR(s): 483.12(c)(2)-(4) Corrective action: On 3/20/25 the Administrator reviewed video footage for other random nights (3/7/25 and 3/16/25) with DHS Surveyor and there was no evidence of resident 2 entering into any other resident's room. In addition, on 3/22/25, the Administrator and DON reviewed video footage on additional evenings (3/10/25, 3/12/25 and 3/14/25) and there was no evidence of any resident entering another resident's room. How to identify potentially affected other: On 3/25/25 all Department managers interviewed the Resident assigned to their ambassador rounds asking if another resident and specifically describing profile of Resident 2 entered their room. There was no other resident who entered their room. SSD and DON interviewed all current residents from room 1-26 on 3/25/25 and there was no other resident affected from the same deficient practice. Based on the Department Managers interview as well as preview of video surveillance, no other Resident was affected by this concern. Measures/Systemic change: The Administrator was given 1:1 in-service by Governing Board Member on 4/6/25 regarding Abuse Investigation giving emphasis on conducting thorough investigation to include interviewing other residents. The DON was given 1:1 in-service by the Administrator on 4/7/25 regarding Abuse Investigation giving emphasis on conducting thorough investigation to include interviewing other residents. The Administrator gave in-service to Department Managers on 4/7/25 regarding Abuse Investigation, giving emphasis on conducting thorough investigation to include interviewing other residents. On 4/9/25 the SOC 341 was updated that includes steps to follow for immediate action, SOC 341 Forms, Interview Forms, Local Law enforcement number and Cover sheets for CDHP and Ombudsman for reporting. On 4/9/25 and 4/10/25 DON gave in-service to the Department Manager regarding the SOC 341 Binder in case they will be the assigned Manager of the Day for the weekend. On 4/9/25 DON gave in-service to RN supervisor regarding the SOC 341 Binder giving emphasis on immediate action and steps to do during alleged abuse incidents giving emphasis on interviewing alleged victim, alleged abuser, roommates and other residents who are involved and or affected with the incident within 24 hours of the incident. The Administrator and or designee will review any video footage as necessary within 72 hours of the incident. Other Residents who are affected and or involved with the incident will be interviewed by the Administrator and or Designee within 5 days of investigation. The Administrator and or designee will provide a written report of the results of all abuse investigation and appropriate action taken to CDPH or local laws within 5 working days of the reported allegation. Monitoring: When there is an alleged abuse incident, the Supervisor will conduct thorough interviews with staff, residents involved as well as other residents that could have been affected by the allegation. The Administrator and DON will utilize available equipment and tools to investigate thoroughly. Results will be documented, discussed and reported in the monthly QA & A meeting for further intervention and compliance. Completion Date: 4/10/25
Failure in Discharge Planning and Documentation
Penalty
Summary
The facility failed to ensure proper discharge planning and documentation for a resident who was discharged without prior planning or instructions. The resident, who had a history of paraplegia, anxiety disorder, major depressive disorder, cannabis dependence, and psychoactive substance-induced psychotic disorder, was admitted to the facility earlier in the month. Despite being capable of making reasonable and consistent decisions, the resident was discharged without receiving necessary discharge instructions or documentation. The discharge process was inadequately handled, as evidenced by the lack of a signed Notice of Proposed Transfer and Discharge form and the absence of documented discharge instructions. The resident was discharged without medications, as per the physician's order, and was not provided with a list of medications, prescriptions, or follow-up appointments. Interviews with staff revealed that the discharge was unplanned, and the resident insisted on leaving the facility despite the lack of medications. The staff failed to document the communication with the resident or his refusal to sign the discharge form. The facility's policy required discharge planning to begin upon admission, with the interdisciplinary team reviewing the resident's progress and determining a discharge date. However, this process was not followed, and the resident's discharge was not properly coordinated between the nursing and social services departments. The Director of Nursing and the Administrator acknowledged the importance of thorough discharge planning and documentation, which was not achieved in this case.
Plan Of Correction
Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix) Corrective action: Resident 1 no longer resides in the facility. Notice of Proposed transfer & Discharge was corrected on 3/6/25 and Faxed to Ombudsman. Late Entry for telephone order and documentation was done by RN supervisor 2 on 3/6/25. SSD called Texas Police on 3/26/25 to do a wellness check regarding Resident 1. They were unable to provide information regarding the resident's whereabouts. There wasn't anyone home at the time of their visit. How to identify potentially affected other: • On 3/21/25 Medical Records conducted an audit for Discharges from January 01, 2025, to March 21, 2025, for completion of Discharge order, Notice of Proposed Transfer, Discharge Planning, Enteract (If applicable) and Discharge notes. No other resident was found affected with the same deficient practice. Measures/Systemic change: • RN supervisor 3 was given Disciplinary Action and 1:1 in-service on 3/5/25 by DON giving emphasis on making sure that Steps for Discharge Process is done with instruction, Health teachings and Verbalization of understanding with resident's signature or Responsible Party. • RN Supervisor 2 was given Disciplinary Action and 1:1 In-service on 3/6/25 by DON Regarding Discharge Process giving emphasis on documenting and writing Telephone Order per MD's instruction for Discharges. To make sure Discharge Planning will be initiated. • License Nurses were given in-service and Re-education by Director of Nursing regarding Discharge Process on 3/6/25, 3/7/25, 3/8/25, 3/11/25 and 3/12/25 with emphasis on appropriate documentation on proposed Transfer, making sure that resident or Responsible Party will sign Discharge Instructions with Health Teachings Provided upon Discharge. • QAPI was initiated on 3/6/25 regarding Transfer and Discharges. • License nurse was given in-services by DON regarding QAPI on 3/6/25, 3/7/25, 3/8/25, 3/11/25 and 3/12/25. • The Administrator gave 1:1 in-service to Medical Records Director regarding audit on all Discharge charts on 3/7/25. • The Administrator gave 1:1 in-service to SSD on 3/24/25 regarding Discharge Process giving emphasis in Initiating Discharge Planning, Documentation and follow-up with Discharge Resident. Monitoring: • Medical Records Designee will audit the PCC, daily Discharges for charting and documentation for completion weekly. Findings will be discussed in daily clinical meeting for necessary action. • DON will review the Discharge Audit report for accuracy. Any negative trends will be discussed and reported in the monthly QA & A meeting for further intervention and compliance. Completed on 3/26/25 F 660
Resident Smoking Supervision Deficiency
Penalty
Summary
The facility failed to ensure adequate supervision for a resident while smoking, leading to a deficiency in maintaining a safe environment. Resident 5, who was admitted with conditions including cerebrovascular disease, right side hemiplegia, and glaucoma, was observed smoking unsupervised near the facility's parking lot. The resident, who was forgetful and unable to make reasonable decisions, was seen without a smoking apron or a safe receptacle for cigarette disposal. Despite the care plan indicating the need for supervision and the use of protective measures, the resident was left alone, posing a risk of burn injuries. Interviews with facility staff revealed a lack of awareness and supervision regarding Resident 5's smoking activities. A Licensed Vocational Nurse mentioned that smoking supplies were kept at the nursing station and provided to residents when needed, but the resident was still found smoking alone. A Certified Nursing Assistant admitted to being unaware of the resident's unsupervised smoking due to being occupied with other duties. The Director of Nursing acknowledged that all staff were responsible for ensuring resident safety during smoking. The facility's policies required smoking to occur in designated areas with appropriate safety measures, which were not adhered to in this instance.
Plan Of Correction
Free of Accident Hazard / Supervision / Devices CFR(s): 483.25(d)(1)(2) Corrective action: • The body check was done on Resident 5 on 3/6/25 RN Supervisor and Tx nurse with no indication of cigarette burns and other skin issues associated with smoking. • SSD spoke with Resident 5 and Brother on 3/7/25 regarding Smoking Policies giving emphasis that cigarettes and lighter will be kept by LN, smoking schedule that is supervised by staff. How to identify potentially affected other: • RN supervisor made rounds on 3/6/25 and there was no other resident smoking. • Medical Records audited current residents who desired to smoke and non-compliance regarding facility's smoking policy was audited on 3/21/25 to ensure that smoking assessment & care plan are updated and revised in resident's record. No issues were identified. Measures/Systemic change: • License Nurses and Certified Nurse Assistant was given in-service by Director of Nursing regarding Smoking Resident on 3/6/25, 3/7/25, 3/7/25, 3/8/25, 3/11/25 and 3/12/25 giving emphasis on following smoking schedule, making sure that all cigarette & lighter should be kept by LN, smoking resident should be assessed with care plan and should be supervised by assigned staff at all times. • IDT was done on 3/24/25 by SSD to all current residents who smoke giving emphasis on smoking schedule with staff to supervised and all cigarette & lighter should be kept by LN. Monitoring: • Nursing staff will monitor daily rounds on their shift to ensure "no cigarette lighter permitted in the resident's room for the resident who desire to smoke. Any issues identified will be corrected. • The SSD will conduct random weekly rounds for 1 month, then 3 months and then quarterly thereafter or until compliance is reached and ongoing as needed to ensure the appropriate storing of cigarette, lighter for the resident who desired to smoke. Any issues identified will be corrected. • DON and or designee will randomly check for compliance. • Audit review the Smoking progress report, will be discussed and reported in the monthly QA & A meeting for further intervention and compliance. Completion Date: 3/26/25
Inaccurate Documentation in OT Discharge Summary
Penalty
Summary
The facility failed to ensure accurate documentation in the Occupational Therapy (OT) Discharge Summary Note for a resident, leading to a deficiency. The OT documented that the resident tolerated a thin hand-rolled washcloth in her left hand for four hours without irritation or skin breakdown, when it should have been documented for the right hand. This error was identified during a review of the resident's records and confirmed by the Occupational Therapist (OT 1) during an interview. The resident, who was admitted with generalized muscle weakness and had moderately impaired cognition, was dependent on facility staff for Activities of Daily Living (ADLs). The inaccurate documentation had the potential to affect the resident's plan of care and treatment, as it could lead to miscommunication and confusion within the care team. The Director of Rehabilitation and the Director of Nursing both emphasized the importance of accurate records to ensure proper communication among the interdisciplinary team and to monitor for any complications or decline. The facility's policy and procedure on medical record content require that records be accurate, timely, and complete, which was not adhered to in this instance.
Failure to Include Resident's Advocate in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's designated advocate was invited to participate in the Interdisciplinary Team (IDT) meeting to discuss and revise the resident's care plan. The resident, who had diagnoses including diabetes mellitus, generalized muscle weakness, and Charcot's arthropathy, had expressed a desire for their advocate to be involved in all IDT meetings due to forgetfulness. However, during an IDT meeting, the advocate was not invited, and there was no documentation indicating that the advocate was notified of the meeting. The Director of Nursing (DON) and Social Worker Representative (SWR) conducted the meeting with the resident, who was unable to understand the discussions and refused to sign documents without consulting the advocate. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's preference for advocate involvement. The DON was unaware that the advocate was listed as a care conference person and assumed it was acceptable to proceed without them since the resident was their own decision-maker. The Medical Records Director (MRD) acknowledged that the advocate was supposed to be involved in all IDT meetings, but there was no specific recollection of when this was communicated. The facility's policies on resident rights and comprehensive person-centered care planning emphasize the inclusion of residents and their representatives in care planning decisions, which was not adhered to in this instance.
Failure to Maintain Functional Wheelchair Locks for High-Risk Residents
Penalty
Summary
The facility failed to ensure that wheelchairs used by two high-risk residents were properly maintained and functional, specifically regarding the locking mechanisms. Resident 3, who had a history of falls and required assistance with mobility, was using a wheelchair with a non-functional left lock. Despite being reported to the Director of Maintenance, the issue was not addressed promptly, leaving the resident at risk of falling during transfers. The CNA assisting Resident 3 was unaware of the malfunction, and the Registered Nurse was not informed of the issue during shift changes, indicating a breakdown in communication and maintenance protocols. Resident 4, who also had a high fall risk due to severe cognitive impairment and mobility issues, was using a wheelchair with a problematic right lock. The Licensed Vocational Nurse and Physical Therapist both struggled to secure the lock, and the resident was unable to operate it independently. Despite attempts to educate the resident on using the wheelchair, the complexity of the locking mechanism was beyond their capability. The Director of Rehabilitation was informed of the issue but did not ensure immediate corrective action, and the Director of Maintenance was only reminded of the problem on the day of the survey. The facility's policy on wheelchair maintenance lacked specific guidelines for interim measures while repairs were pending and did not specify a timeframe for addressing maintenance issues. The Administrator believed it was sufficient for nursing staff to assume the locks were functional, while the Director of Nursing emphasized the importance of verifying wheelchair stability to prevent falls. This discrepancy in expectations and the absence of a clear protocol contributed to the oversight and potential risk to the residents' safety.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a copy of medical records upon written request from an authorized legal representative for one of the sampled residents, which violated the resident's right to obtain a copy of their medical record. This deficiency delayed the resident's appeal to their Health Insurance Provider's decision to deny coverage for their stay at the facility. The resident, who was cognitively intact, required assistance with personal hygiene and had medical conditions including Diabetes Mellitus, generalized muscle weakness, and Charcot's arthropathy. The resident's legal representative had requested records from the facility multiple times since June 2024, believing that the facility was omitting information that could support the resident's continued stay. Despite these requests, the facility did not provide the requested records, which included monthly authorizations and clinical notes from various specialists. The Social Worker Representative, responsible for submitting records to the insurance provider, stated that the documents were confidential and had not been released to the legal representative. Interviews with facility staff revealed a lack of clarity and communication regarding the release of records. The Medical Records Director acknowledged the request but did not have access to the records submitted to the insurance provider. The facility's policy on the disclosure of protected health information did not specify a timeframe for submitting records to authorized requestors, contributing to the delay in fulfilling the request.
Failure to Retain and Submit Accurate Medical Records
Penalty
Summary
The facility failed to retain, accurately document, and systematically organize medical records for a resident, leading to potential stress and fear for the resident due to the lack of necessary documentation for continued insurance coverage. The resident, who was cognitively intact, required assistance with various activities of daily living and had significant medical issues, including diabetes mellitus and a severe diabetic foot infection. Despite these needs, the facility did not provide the necessary clinical documents to the health insurance provider, which resulted in the denial of payment for the resident's continued stay. The resident's endocrinology assessment indicated an inability to self-administer insulin due to severe neuropathy, a critical piece of information that was not submitted to the insurance provider. The Social Services Representative, responsible for submitting clinical records, failed to include this vital information and did not understand how to interpret the clinical notes. The facility's Medical Records Director and other staff were unaware of what documents had been sent to the insurance provider, and the resident's legal representative had repeatedly requested these records without success. Interviews with facility staff revealed a lack of communication and understanding regarding the submission of medical records. The Social Services Representative, who had recently changed roles, did not consult with nursing staff or the Director of Nursing to ensure accurate documentation was sent to the insurance provider. The facility's policy on documentation retention was not followed, as the endocrinology After Visit Summary was not retained in the resident's chart, contributing to the deficiency.
Failure to Hold Bed for Resident After Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was able to return to her original room upon readmission from a General Acute Care Hospital (GACH). The resident, who had been admitted to the facility with diagnoses including respiratory failure and embolism of the right femoral vein, was transferred to the GACH for right shoulder pain. The facility had a policy in place to hold a resident's bed for up to seven days upon transfer to a hospital, as indicated in the Bed Hold Agreement form signed by the resident. However, upon her return to the facility after approximately 11 hours, the resident was placed in a different room because another resident had been moved into her original room during her absence. The resident expressed frustration and sadness about not being able to return to her original room, as confirmed during an interview with her. The Director of Nursing (DON) explained that the decision to place the resident in a different room was due to the facility's action of moving another resident into her room while she was at the GACH. This action was contrary to the facility's policy and procedure, which stated that the bed should be held for seven days if the resident or their representative elected to hold the bed within 24 hours of transfer.
Failure to Provide Correct Diet Consistency for Residents with Dysphagia
Penalty
Summary
The facility failed to ensure that residents on a dysphagia minced and moist diet received food consistent with their prescribed diet orders. Specifically, seven residents were served a ground pimento cheese salad sandwich on regular white bread, which was not minced or moist as required by their diet orders. This oversight occurred during meal preparation and tray validation, where the Dietary Supervisor, cook, and Licensed Vocational Nurse did not ensure the correct food consistency was provided. The residents involved had various medical conditions, including dysphagia, dementia, and other health issues that necessitated a modified diet to prevent choking and aspiration. Despite having clear physician orders and care plans indicating the need for a minced and moist diet, the facility's dietary staff did not follow the appropriate procedures. The Registered Dietician and other staff members failed to recognize the discrepancy between the diet orders and the food served, leading to the incorrect meal being provided to the residents. Observations and interviews revealed that the dietary staff relied on a dietary spreadsheet that did not align with the facility's diet manual, which clearly stated that soft bread should be avoided for residents on a minced and moist diet. The staff's misunderstanding and lack of adherence to the prescribed diet orders resulted in the residents receiving meals that posed a risk to their health and safety.
Ice Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain cleanliness of the ice machine as per the manufacturer's guidelines, affecting 83 out of 85 sampled residents. During an observation, the Maintenance Supervisor demonstrated that the ice machine's soft black durometer trim was not clean, as evidenced by a white tissue paper turning brown after wiping the trim. This observation was supported by interviews with the Environmental Services Supervisor and the Infection Preventionist nurse, who both emphasized the importance of keeping the ice machine clean to prevent contamination and illness among residents. The facility's policy and procedure for housekeeping of ice machines, dated January 12, 2012, required that the ice machine be cleaned according to the manufacturer's guidelines. The manufacturer's manual specified that exterior cleaning should be done as often as necessary to maintain cleanliness and efficient operation. However, the facility did not adhere to these guidelines, leading to the potential risk of microorganism growth and foodborne illness for residents, staff, and visitors consuming ice from the machine.
Failure to Document Annual Review of Dietary Policies
Penalty
Summary
The facility failed to provide annual documentation for the Quality Assessment Assurance Committee (QAA) and Quality Assurance Performance Improvement (QAPI) team signatures to verify the review of their dietary department policies. During an interview and record review with the Dietary Supervisor (DS), it was found that the Manual Signature/Approval Form dated 1/3/23 did not have a title indicating which policies were being reviewed. The DS mentioned that policies are reviewed when the company informs them of new policies, but could not specify how often these reviews occur. In a separate interview and record review with the Administrator (ADM), it was revealed that the Information/Record Manual sign-in sheets dated 1/2/2024 and 1/3/2024 also lacked titles indicating which policies were reviewed. The ADM acknowledged that policies and procedures are supposed to be reviewed at least annually, but there was no sign-in sheet for 2022 to confirm the review of dietary policies. The facility's policy and procedure document titled 'Review of Policies and Procedures' dated 1/1/2014, indicated that the facility reviews its manuals annually, but this was not adhered to.
Failure in Dietary Staff Competency and Meal Tray Assessment
Penalty
Summary
The Quality Assessment Assurance Committee (QAA) and Quality Assurance Performance Improvement (QAPI) at the facility failed to identify and address deficiencies in the skills competencies of the dietary staff and the assessment of residents' meal trays. This oversight led to residents not receiving the appropriate meal trays as prescribed by their physicians, which placed them at risk of not adhering to their therapeutic diets and potentially choking on their food. The Director of Nursing (DON) acknowledged that the Dietary Supervisor should have noticed the incorrect diets being provided and reported this issue to the Administrator. The facility's policy and procedure for the QAPI Program, dated 9/19/2029, outlines the implementation of a program designed to monitor and evaluate the quality of resident care and resolve identified problems. However, the program failed to ensure that the dietary staff's competencies were assessed and that residents' meal trays were correctly prepared according to their dietary orders. This failure was identified during an interview with the DON and a review of the facility's policy, highlighting a gap in the facility's quality assurance processes.
Inadequate Staff Competency in Dysphagia Diets
Penalty
Summary
The facility failed to ensure that nursing staff, including LVNs and CNAs, were competent in understanding and implementing physician-prescribed diets for residents with dysphagia. This deficiency was observed when seven out of eight sampled residents received a lunch tray containing a ground pimento cheese salad sandwich served on regular white bread, which did not meet the required minced and moist consistency for their dysphagia diets. The incorrect food consistency placed these residents at risk for aspiration, choking, and potentially life-threatening conditions. The report details the medical histories and dietary requirements of the affected residents, all of whom had diagnoses that included dysphagia and other conditions such as dementia, cerebral infarction, and diabetes. Each resident had specific dietary orders for a dysphagia mechanical soft texture with ground food, as documented in their care plans and physician's orders. Despite these clear instructions, the facility's staff failed to provide the appropriate food texture, as evidenced by the observation of meal trays containing unmodified bread with crusts. Interviews with facility staff revealed a lack of awareness and adherence to dietary standards. CNA 4 acknowledged that meal trays with incorrect consistencies should be returned to the kitchen, while LVN 4 did not recognize the issue with the sandwiches served. The Director of Nursing (DON) confirmed that the licensed nurses and CNAs should have identified and corrected the food texture discrepancies. The facility's policies and procedures, which outline the responsibilities of dietary staff, CNAs, and licensed nurses in ensuring correct meal consistencies, were not followed, leading to this deficiency.
Delayed Follow-Up Appointments for Dental and Podiatry Care
Penalty
Summary
The facility failed to ensure timely follow-up appointments for dental and podiatry evaluations for two residents, leading to delays in necessary care. Resident 51, who has a history of Type 2 Diabetes Mellitus, chronic kidney disease, severe protein-calorie malnutrition, legal blindness, and end-stage renal disease, experienced dental pain in teeth numbers 14, 16, and 18. Despite a physician order for dental consultation and a dentist's recommendation for urgent follow-up appointments for endodontic and oral surgery referrals, the Social Service Director admitted to overlooking the referral, resulting in a delay in addressing the resident's dental pain. Similarly, Resident 56, diagnosed with muscle weakness and gait abnormalities, required routine foot care due to thickened, elongated toenails with subungual debris and pain. Although a podiatric consultation recommended further assistance for toenail debridement, the resident's request for podiatry services was not communicated effectively by the staff. The CNA forgot to inform the charge nurse, and the LVN did not conduct a thorough assessment of the resident's toenails, leading to a delay in podiatry care. Interviews with facility staff, including the Director of Nursing and the Social Worker Director, revealed that the responsibility for scheduling specialist appointments was not adequately managed. The facility's policies on foot care and oral healthcare emphasize the importance of timely referrals and documentation, but these were not followed, resulting in delays in necessary medical services for the residents.
Inadequate Preparation of Dysphagia Diets
Penalty
Summary
The facility failed to ensure that dietary staff, including the registered dietician, dietary supervisor, cook, and dietary aide, were competent in preparing and serving physician-prescribed diets for residents with dysphagia. On a specific date, seven out of eight sampled residents on a dysphagia minced and moist diet received a lunch tray containing a ground pimento cheese salad sandwich that was not prepared according to the required minced and moist consistency. The sandwich was served on regular slices of white bread with crust, which is not suitable for residents on this diet, placing them at risk for aspiration, choking, and potentially life-threatening conditions. The report details the medical history and dietary requirements of the affected residents, all of whom had diagnoses including dysphagia and other conditions such as dementia, cerebral infarction, and diabetes. Each resident had specific dietary orders for a dysphagia mechanical soft texture with ground food, which were not followed. Observations and interviews revealed that the dietary staff did not adhere to the facility's diet manual and policies, leading to the inappropriate preparation and serving of meals. Interviews with the dietary staff, including the cook and dietary aide, indicated a lack of understanding and oversight in following the correct procedures for preparing the minced and moist diet. The registered dietician acknowledged the error after reviewing the facility's diet manual, which clearly stated that soft bread should be avoided unless modified to a fine, moist consistency. The dietary supervisor and registered dietician initially believed the sandwich was appropriate based on the dietary spreadsheet provided by corporate, highlighting a disconnect between corporate guidelines and the facility's diet manual.
Failure to Document Advance Directive Discussion for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident's medical records were updated to reflect the discussion and provision of written information regarding advance directives. This deficiency was identified for one of the three sampled residents, who was admitted with severe cognitive impairment and significant medical conditions, including encephalopathy, intracerebral hemorrhage, and heart failure. The review of the resident's records revealed that the section for advance directives in the Physician Orders for Life-Sustaining Treatment (POLST) form was left blank, indicating a lack of documentation about the resident's wishes for medical care. Interviews with facility staff, including a Registered Nurse Supervisor, the Social Services Director, and the Director of Nursing, confirmed the absence of an advance directive or documentation that it was offered to the resident. The staff acknowledged the importance of having an advance directive documented in the medical record for legal purposes and to ensure that the resident's healthcare wishes are known and respected, especially given the resident's cognitive impairment. The facility's policy and procedure on advance directives required that written information be provided to residents upon admission, but this was not followed in the case of the resident in question.
Failure to Assess Mental Capacity Before Signing Arbitration Agreement
Penalty
Summary
The facility failed to assess the mental capacity of a resident before having them sign a binding arbitration agreement. The resident, who was admitted with diagnoses including Fetal Alcohol Syndrome and autistic disorder, was found to be cognitively impaired and unable to complete a Brief Interview for Mental Status (BIMS). Despite this, the resident signed the arbitration agreement without the signature of a legal representative. The facility's policy requires that the agreement be explained in a manner the resident understands, which was not adhered to in this case. Interviews with facility staff, including a Licensed Vocational Nurse, a Registered Nurse Supervisor, and the Director of Nursing, confirmed that the resident was only alert to their name and did not have the mental capacity to sign consents. The Business Office Manager Assistant, who was responsible for offering the arbitration agreement, admitted to not checking the resident's medical chart for mental capacity before obtaining the signature. This oversight led to the resident signing the agreement without a proper understanding of its implications.
Failure to Convene IDT Meeting and Follow Up on Audiology Appointments
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) meeting was convened to discuss the status of a resident's hearing loss, pending audiologist appointment, and requested hearing aids. This deficiency involved a resident who was admitted with diagnoses including unspecified hearing loss and major depressive disorder. Despite the resident's awareness and ability to communicate, albeit with difficulty, the facility did not follow up on the necessary audiology appointments or provide updates to the resident and their responsible party (RP). This led to frustration and potential psychosocial decline for the resident. The resident's records indicated a history of hearing loss and a recommendation for an audiogram following an ENT visit. However, there was no documentation of communication between the facility, the resident, and the RP regarding the ENT visit or hearing assessments. The Social Services Assistant (SSA) admitted to being aware of the resident's ENT visit outcome but failed to follow up on the audiology appointment or convene an IDT meeting to discuss the resident's needs. This lack of communication and follow-up resulted in a delay in care and services for the resident. The Registered Nurse Supervisor (RNS) confirmed that the resident's records lacked any indication of communication about the ENT visits or hearing assessments. The facility's policies required the social services department to maintain contact with the resident's family and involve them in care planning. However, these policies were not followed, leading to a delay in the resident receiving necessary services to improve their hearing and potentially exacerbating their depression.
Failure to Ensure Timely Audiology Appointment for Resident
Penalty
Summary
The facility failed to ensure that a resident with hearing loss received a timely audiology appointment after an otolaryngologist ordered an audiogram. Despite the order being made on January 5, 2024, the resident had not received the audiogram as of May 8, 2024. The resident, who has a history of depression and difficulty hearing, had been requesting hearing aids for several years. The Social Services Director did not provide updates regarding the audiology appointment or hearing aids, leading to frustration for the resident and their representative. The Social Services Assistant, who took over the responsibilities in February 2024, acknowledged the failure to follow up on the audiology appointment. The Registered Nurse Supervisor confirmed that the facility did not follow up on the audiology appointment, resulting in a delay in the resident receiving needed services to improve hearing. The facility's policies and procedures indicated that social services should refer residents to an audiologist if needed and provide medically related social services to maintain and improve residents' well-being. However, these procedures were not followed in this case.
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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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