Fountain Valley Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Fountain Valley, California.
- Location
- 11680 Warner Avenue, Fountain Valley, California 92708
- CMS Provider Number
- 555328
- Inspections on file
- 40
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Fountain Valley Post Acute during CMS and state inspections, most recent first.
A resident did not receive oxygen therapy as ordered, with the oxygen concentrator set above the prescribed rate and the nasal cannula applied by a CNA instead of a licensed nurse. The nasal cannula was not stored according to infection control policy, and the resident's MDS was inaccurately coded, failing to reflect ongoing oxygen use.
A resident who lacked decision-making capacity experienced an unwitnessed fall, and the required shift-by-shift monitoring for 72 hours post-incident was not documented by licensed nurses as per facility policy. Nursing staff and the DON confirmed the absence of this documentation in the medical record.
A facility failed to report a staff-to-resident abuse allegation in a timely manner, as required by their policy. A resident, unable to make medical decisions but able to communicate needs, reported multiple allegations after an unwitnessed fall, including an accusation against a male CNA. Despite being aware of the incident, the SSD and DON did not ensure the allegation was reported to the appropriate authorities, risking the allegation going unreported and uninvestigated.
A facility failed to investigate an alleged abuse incident involving a resident who reported an unwitnessed fall and injury, claiming a male CNA attacked her. Despite the facility's policy requiring thorough investigation of all abuse allegations, the DON chose not to investigate, citing the resident's fixation on a former employee. This inaction posed a risk of unidentified abuse and unprotected residents.
The facility failed to provide safe respiratory care for several residents, including improper use and storage of CPAP machines, nasal cannulas, and nebulizer masks. Orders for oxygen administration were not followed, and equipment was not stored in a sanitary manner, potentially affecting residents' respiratory health.
The facility did not follow the prescribed menu for residents on pureed diets, as the pureed fresh green salad with dressing was not served to 20 residents. Instead, a V8 juice puree was used as a substitute without prior notification. The FSD and RD confirmed the menu was not followed, and the substitution was not documented in advance. This oversight had the potential to impact the nutritional intake of the residents.
The facility failed to follow food safety and sanitation guidelines, with expired poultry found in the refrigerator and unclean kitchen utensils. The FSD confirmed the expired food needed to be discarded, and utensils were not maintained properly, posing a risk for foodborne illnesses among 132 residents.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident was found with the call light on the floor, needing help to change a wet diaper, while another resident's call light was out of reach on a wheelchair, requiring assistance to cut bread. CNAs confirmed the call lights' locations and provided the necessary help.
A facility failed to conduct a PASARR Level I screening for a readmitted resident with a history of mental health issues, as required by policy. The resident was on medications for schizophrenia and depression, yet the necessary screening to identify potential needs for specialized services was not performed. Staff interviews confirmed the oversight.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. A resident with an indwelling urinary catheter lacked a care plan for EBP, while another resident with an oxygen order had no care plan for its use. A resident on a LAL mattress and another with a midline catheter also lacked appropriate care plans. Additionally, a resident's oxygen therapy was administered at a lower rate than prescribed, indicating a failure to adhere to the care plan.
A resident who required a communication board in Vietnamese to communicate care needs was not provided with one, despite the facility's policy to arrange for such aids. Observations and interviews confirmed the absence of the necessary communication board, which hindered effective communication between the resident and staff.
The facility failed to provide appropriate pressure ulcer care for three residents at high risk for skin breakdown. A resident was found on a LAL mattress with an incorrect pressure setting for her weight, and there was no physician's order for its use. Two other residents were on LAL mattresses without specific directions for settings, lacking physician's orders and care plans. This indicates a failure to provide necessary care and services to promote skin healing and prevent pressure ulcers.
The facility failed to ensure that disposed narcotic count sheets were signed by two licensed nurses, as required by their policy. On a specific date, tramadol and chlordiazepoxide were placed in the narcotic box, but the log was only signed by one nurse. This oversight was confirmed by RN 1 and the DON, highlighting a potential for medication diversion.
The facility failed to ensure two residents were free from unnecessary drugs. One resident was prescribed amitriptyline and bupropion without monitoring target behaviors, and interviews revealed no verbalization of sadness. Another resident was prescribed Zoloft without documented behaviors of sadness or non-pharmacological interventions. The facility's policy required documentation and non-pharmacological interventions, which were not followed.
A facility's medication error rate was found to be 12%, exceeding the acceptable threshold of 5%. This was due to errors by LVNs in administering medications. One LVN failed to instruct a resident to close their eyes for the required time after administering eye drops, while two other LVNs did not check residents' bowel patterns before administering a stool softener, contrary to physician orders.
The facility failed to ensure safe storage and management of medications, with expired drugs found in the Central Supply Room and medication carts, and medications left at residents' bedsides without proper authorization. Unattended and unlocked medication carts were also observed, and medications for discharged residents were not disposed of properly. These deficiencies were confirmed by staff and posed risks for unsafe medication administration.
Two residents did not receive the appropriate mechanically altered diets as ordered by their physicians. One resident was served a regular diet instead of a mechanical soft diet, despite having dysphagia, while another resident did not receive the milk and coffee specified on her diet card. These oversights were confirmed by staff and pose risks to the residents' health.
A resident was not provided with the required assistive eating device during meals, as observed during a lunch observation. The resident used regular utensils despite having a physician's order and care plan intervention for built-up utensils. The facility's policy mandates that such devices be recorded on meal tickets, which was not done in this case. Staff interviews confirmed the oversight.
The facility did not follow its policy on educating staff and visitors about safe food handling for food brought in from outside, risking foodborne illness for residents. Interviews revealed that while general food handling training was provided, specific education on handling outside food was lacking. The DON confirmed the absence of such education despite encouraging families to bring food.
The facility failed to maintain infection control by not implementing Enhanced Barrier Precautions (EBP) for residents with indwelling catheters and midline IVs, as observed in two residents. Staff did not wear PPE during care activities, and there were no EBP signs or supplies outside the residents' rooms. Additionally, the facility did not conduct adequate infection surveillance, failing to include residents with signs of infection not on antimicrobials in reports, and did not document pathogens in infection reports. An indwelling urinary catheter drainage bag was found on the floor in a resident's room, further indicating lapses in infection control.
The facility failed to educate and offer pneumococcal vaccinations to six residents, as per its policies. Five residents did not receive educational materials about the vaccine's risks and benefits, confirmed by the IP and DON. Additionally, one resident's responsible party was not offered the PPSV 23 vaccine following the PCV13, contrary to CDC guidelines. These omissions were verified through medical record reviews and interviews, putting residents at risk for pneumococcal infections.
The facility failed to educate and offer the COVID-19 vaccine to six residents as per its policies. Five residents did not receive educational materials about the vaccine's risks and benefits, confirmed by the IP. Additionally, another resident's responsible party was not offered the seasonal COVID-19 vaccine, despite the resident's capacity to make decisions. These deficiencies were verified through interviews and medical record reviews.
A facility failed to assess a resident for self-administration of medication, as required by its policy. A resident was observed using Vicks vapor rub for headaches without a physician's order or a documented care plan and assessment. A nurse confirmed the absence of these necessary documents, highlighting a deficiency in the facility's adherence to its self-administration policy.
The facility failed to maintain dignity for two residents during meal assistance. Both residents, who were severely cognitively impaired, were assisted with meals by staff who stood at the bedside instead of sitting at eye-level, as required by facility policy. This was confirmed by the staff involved and acknowledged by the facility's administration.
A resident reported receiving an opened mail package, which violated the facility's policy on mail privacy and security. The Central Supply Clerk mistakenly opened the package, thinking it was hers, and later apologized to the resident. The incident caused discomfort to the resident, who had the capacity to understand and make medical decisions.
The facility failed to provide adequate care for pressure ulcers for two residents. One resident's skin was not assessed upon readmission, and no care plan was developed for their coccyx wound. Another resident's care plan was not updated to reflect a Stage 3 pressure injury, and they received wound treatment with medication belonging to another resident, risking contamination or incorrect dosage.
The facility failed to implement their policy to ensure the immediate reporting of an abuse allegation involving a CNA. A resident alleged that a CNA had hit him during a shower, but the incident was not reported to the Administrator or DON until two days later. The failure to report the abuse allegation immediately compromised the resident's protection and violated the facility's abuse prevention policy.
Failure to Ensure Proper Oxygen Administration and Accurate Documentation
Penalty
Summary
The facility failed to ensure that a resident received appropriate respiratory care as ordered by the physician. Specifically, the resident had a physician's order for oxygen via nasal cannula at 2 LPM every shift, with instructions to notify the physician if oxygen saturation dropped below 88%. However, observations revealed that the oxygen concentrator was set at 2.5 LPM, not the ordered 2 LPM. Additionally, a CNA applied the nasal cannula to the resident instead of a licensed nurse, contrary to facility policy and staff statements that only licensed nurses should administer oxygen to ensure correct settings. The nasal cannula was also not stored in an oxygen storage bag as required for infection control. Further review showed that the resident's Minimum Data Set (MDS) was not accurately coded to reflect that the resident was on continuous oxygen therapy, despite documentation and staff verification that the resident was receiving oxygen. Oxygen saturation readings were recorded as being taken on room air on multiple occasions, which did not align with the physician's order for continuous oxygen. These findings were confirmed through interviews with the CNA, LVN, and DON, as well as review of the resident's medical record and facility policies.
Failure to Document Post-Fall Monitoring for a Resident
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete following a fall incident. Specifically, after an unwitnessed fall with no evidence of injury, the required documentation of the resident's condition monitoring every shift for 72 hours was not completed. The facility's policy required licensed nurses to record information related to changes in a resident's condition and to continue monitoring and documenting the resident's status every shift for 72 hours after such an event. However, a review of the resident's progress notes revealed missing documentation for several shifts during the required monitoring period. Interviews with nursing staff confirmed that the expectation was to assess and document the resident's condition every shift for 72 hours post-fall. Both RN 3 and RN 4 acknowledged that the necessary documentation was not present in the medical record, and the DON verified these findings. The resident involved had no capacity to understand or make decisions, as noted in their medical history, further emphasizing the importance of thorough monitoring and documentation after the fall.
Failure to Report Abuse Allegation in a Timely Manner
Penalty
Summary
The facility failed to implement its abuse policy and procedures by not reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. Specifically, the facility did not report in a timely manner an allegation of staff-to-resident abuse involving a resident who had an unwitnessed fall resulting in injury. The resident, who was unable to make medical decisions but could communicate needs, reported multiple allegations regarding the cause of the fall, including an accusation that a male CNA attacked her. Despite these allegations, there was no documented evidence that the abuse allegation was reported to the local State and Federal agencies as required by the facility's policy. Interviews with facility staff, including the Social Services Director (SSD) and the Director of Nursing (DON), confirmed that they were aware of the incident and acknowledged that the allegation should have been reported as abuse. The SSD, a mandated reporter, verified the incident occurred and should have been reported, while the DON was made aware of the allegation on the day it occurred but did not ensure it was reported. This failure to report the abuse allegation in a timely manner had the potential for the abuse allegation to go unreported and uninvestigated.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse policy and procedure (P&P) related to the investigation of physical abuse for one resident. The facility's P&P requires that any incident or allegation of abuse be thoroughly investigated by the administrator, with specific steps including reviewing documentation, interviewing involved parties, and submitting a report to the State Survey Agency within five working days. However, in the case of one resident, this protocol was not followed. The Director of Nursing (DON) was aware of the resident's allegation of abuse but decided not to investigate, citing the resident's fixation on a male CNA who no longer worked at the facility. The resident in question had an unwitnessed fall resulting in injury and reported three different allegations regarding the incident, including an attack by a male CNA. Despite the facility's protocol requiring an investigation of all abuse allegations, the DON acknowledged that no investigation was conducted. This failure to investigate posed a risk for potential abuse to remain unidentified and for residents to go unprotected.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by multiple deficiencies observed during a survey. Resident 793's physician's order for the use of a CPAP machine was not followed, and the resident was not utilizing the CPAP machine as ordered. Additionally, the resident's nasal cannula was not stored in a sanitary manner. The medical record review revealed that there was no follow-up regarding obtaining the CPAP machine, and the physician was not notified about the resident not using the CPAP machine. Resident 5's nasal cannula was not changed according to facility procedures, and the nebulizer mask storage bag was not labeled per facility policy. Resident 57's CPAP and nebulizer mask were not stored in a sanitary manner when not in use, and Resident 72's nebulizer mask was also not stored properly. Resident 595's oxygen tubing was not labeled or stored in a respiratory bag, and there was no signage indicating oxygen in use outside the resident's room. Resident 43 was not administered continuous oxygen as per the physician's order, and Resident 110's nasal cannula was found lying on the floor. The facility also failed to administer oxygen as per the physician's order to Resident 68 and did not change the nasal cannula oxygen tubing weekly. Resident 63 did not have a storage bag for the oxygen, and the storage bag for the nebulizer was not labeled and dated as per the facility's policy. These failures had the potential to affect the respiratory health and well-being of the residents in the facility, as they did not adhere to the facility's policies and procedures for respiratory care and infection prevention.
Failure to Follow Prescribed Menu for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on pureed diets, as observed during a survey. Specifically, the pureed fresh green salad with dressing was not served to 20 residents, including two residents whose lunch trays were missing this item. Instead, a V8 juice puree was used as a substitute without prior notification to the residents. The facility's Food Service Director (FSD) and Registered Dietitian (RD) confirmed that the menu was not followed, and the substitution was not documented in advance as required by the facility's policies. The deficiency was further highlighted by the fact that the pureed fresh green salad was not prepared due to a lack of stock and issues with the blending process. The FSD and RD acknowledged that the V8 juice was not part of the original menu and that the menu had not been updated to reflect this change. Additionally, the residents' medical records indicated a preference for salad, which was not honored due to the substitution. This oversight had the potential to impact the nutritional intake of the residents on pureed diets.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by the presence of expired food items in the kitchen. Specifically, two bins containing thawed poultry were observed in the walk-in refrigerator with use-by dates that had already passed. The Food Service Director (FSD) confirmed that the turkey was supposed to be used the day prior but was not, and both the turkey and chicken needed to be discarded. This oversight posed a risk for foodborne illnesses among the 132 residents who received food prepared in the facility's kitchen. Additionally, the facility did not ensure that kitchen utensils were maintained in a clean and usable condition. Observations revealed a melted and heavily used rubber spatula, a chipped rubber spatula, and a melted handle of a metal spatula stored in the kitchen. Furthermore, a ladle with brown residues was found stored with other clean utensils. These findings were verified by the FSD, indicating a failure to comply with the USDA Food Code requirements for maintaining food-contact surfaces and utensils in a safe and sanitary condition.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, which could potentially delay the residents from receiving timely care. Resident 394 was found awake with his call light on the floor, unable to call for assistance. He expressed the need for help to change his wet diaper. CNA 7 confirmed the call light was on the floor and assisted the resident. Similarly, Resident 132 was observed searching for her call light, which was out of reach on a wheelchair next to her bed. She needed assistance to cut her toasted bread. CNA 4 acknowledged the call light's location and verified the situation.
Failure to Conduct PASARR Screening for Readmitted Resident
Penalty
Summary
The facility failed to ensure that a resident, who was readmitted, had a Level 1 PASARR screening. This screening is crucial for identifying individuals with mental disorders, intellectual disabilities, or related disorders, and determining if they require further evaluation or specialized services. The facility's policy mandates that all individuals be screened per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. However, upon review, it was found that the resident's medical record lacked evidence of a PASARR Level I screening upon their readmission. The resident in question had a history of mental health issues, as indicated by physician orders for medications such as Risperdal for schizophrenia and Trazodone and Escitalopram for depression. Despite these indicators, the PASARR screening was not conducted upon the resident's readmission. Interviews with facility staff confirmed that the screening was overlooked, and it was acknowledged that a PASARR Level I screening should have been completed at the time of readmission.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. Resident 34, who had an indwelling urinary catheter, did not have a care plan developed for evidence-based practice (EBP) despite having physician orders related to catheter management. This oversight was confirmed by an LVN who acknowledged the absence of a care plan for EBP, which was expected for residents with indwelling catheters. Resident 63, who lacked the capacity to make decisions, had a physician order for oxygen administration, but no care plan was developed to address this need. An LVN verified the absence of a care plan for oxygen use, which should have included interventions and goals for maintaining the resident's oxygen saturation levels. Similarly, Resident 76, who was observed lying on a low air loss (LAL) mattress, did not have a care plan for its use, as confirmed by another LVN. Resident 743, who had a midline catheter, also lacked a care plan for EBP, despite having physician orders for monitoring and maintaining the IV site. An LVN confirmed the absence of a care plan for EBP, which was expected for residents with midline catheters. Additionally, Resident 43's care plan for continuous oxygen therapy was not implemented correctly, as the resident received oxygen at a lower rate than prescribed. This discrepancy was verified by an LVN, highlighting a failure to adhere to the care plan for respiratory management.
Failure to Provide Communication Board in Resident's Language
Penalty
Summary
The facility failed to provide a communication board in the resident's language, which was necessary for effective communication of care needs. Resident 60, who was capable of understanding and making decisions, required a communication board in Vietnamese to communicate with the facility staff. Despite the facility's policy to arrange for interpreters or alternate means of communication, such as communication boards, there was no Vietnamese communication board available for Resident 60. During observations and interviews, it was confirmed that Resident 60 did not have access to a communication board in their language. The CNA was observed using hand gestures to communicate, which led Resident 60 to ask the surveyor in Vietnamese about the CNA's intentions. Both the DON and LVN verified the absence of a Vietnamese communication board, acknowledging that it should have been provided to facilitate communication between Resident 60 and the staff.
Inappropriate Use of Low Air Loss Mattresses for Residents
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents at high risk for skin breakdown. Resident 76 was found lying on a low air loss (LAL) mattress with a pressure setting inappropriate for her weight, as the setting was between 660 to 750 pounds, while the resident weighed 285.3 pounds. The Director of Nursing (DON) adjusted the setting to 290 pounds after verifying the resident's weight. Additionally, there was no physician's order for the use of the LAL mattress for Resident 76, which is required by the facility's policy. For Residents 43 and 62, the facility failed to ensure the use of LAL mattresses with specific directions for settings. Resident 43 was observed on a LAL mattress without a physician's order or a care plan specifying the appropriate settings. Similarly, Resident 62, who was at risk for skin breakdown, was on a LAL mattress without a physician's order for its use and settings. The lack of specific orders and care plans for the LAL mattresses for these residents indicates a failure to provide necessary care and services to promote skin healing and prevent pressure ulcers.
Failure to Ensure Dual Signatures on Narcotic Disposal Logs
Penalty
Summary
The facility failed to ensure that the disposed narcotic count sheets were signed by two licensed nurses, as required by their policy and procedure for discarding and destroying controlled medications. During an interview and document review, it was found that on a specific date, 30 pieces of tramadol, nine pieces of tramadol, and 30 pieces of chlordiazepoxide were placed inside the narcotic box, but the Controlled Drugs Log was only signed by one licensed nurse. This oversight was confirmed by RN 1, who acknowledged the discrepancy in the signing process. Further verification by the Director of Nursing (DON) confirmed that the Controlled Drugs Log should have been signed by both an RN and another licensed nurse. The DON stated that the pharmacy consultant and RN are responsible for collecting the controlled medications from the narcotic box for destruction. The failure to have two signatures on the narcotic count sheets had the potential for medication diversion, as it did not comply with the facility's policy and procedure, which is designed to prevent such occurrences.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs, as observed through a combination of interviews, medical record reviews, and policy reviews. Resident 29 was prescribed amitriptyline and bupropion hydrochloride for depression and smoking cessation, respectively. However, the facility did not identify specific target behaviors to monitor for these medications, nor did they document any episodes of the behaviors that these medications were intended to address. Interviews with the Director of Nursing (DON), a Licensed Vocational Nurse (LVN), and a Certified Nursing Assistant (CNA) revealed that Resident 29 had not verbalized sadness or depression, which were the stated reasons for the prescriptions. For Resident 38, the facility did not document specific behaviors of sadness before prescribing Zoloft, nor did they implement non-pharmacological interventions prior to or during the use of the medication. The facility's policy required the identification and documentation of medical symptoms that warrant the use of psychotropic medications, as well as the implementation of non-pharmacological interventions. An interview with the Assistant Director of Nursing (ADON) confirmed the lack of documentation and non-pharmacological interventions for Resident 38.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 12%. This deficiency was identified through several incidents involving Licensed Vocational Nurses (LVNs) and their administration of medications. LVN 2 did not instruct Resident 22 to close their eyes for the required one to two minutes after administering Systane eye drops, as per the facility's policy and procedure (P&P). This oversight was confirmed during an interview with LVN 2, who acknowledged the deviation from the prescribed method. Additionally, LVN 4 and LVN 1 failed to adhere to the facility's P&P regarding the administration of docusate sodium, a stool softener. Both LVNs did not check the bowel patterns of Residents 12 and 97, respectively, for loose stools before administering the medication, despite physician orders to hold the medication in such cases. These lapses were confirmed through interviews and medical record reviews, where both LVNs acknowledged their failure to verify the residents' bowel conditions prior to medication administration.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and management of medications and supplies, as observed in multiple areas. In the Central Supply Room, expired medications and supplies were found, including acetaminophen, fish oil, antifungal creams, and moisturizing lotions without manufacturing or expiration dates. Medication carts were also found to contain expired medications, such as antifungal creams and aspirin without expiration dates, and medications belonging to discharged residents. Additionally, medication carts were left unlocked and unattended, posing a risk for unauthorized access. Several residents were directly affected by these deficiencies. For instance, an antifungal cream was found at the bedside of a resident with severe cognitive impairment, who was not a candidate for self-administration of medications and had no physician's order for the cream. Another resident had A&D ointment left at their bedside, which staff confirmed should not have been there. Furthermore, medications for residents who had been discharged were not disposed of properly, including controlled substances that should have been destroyed or returned to the pharmacy. The facility's policies and procedures for medication storage were not followed, as evidenced by the presence of expired and improperly stored medications. The Director of Nursing and other staff members verified these findings during interviews and observations. The failure to adhere to these policies resulted in the potential for unsafe administration of medications and compromised the safety and sanitary conditions of medication storage areas.
Failure to Provide Physician-Ordered Diets
Penalty
Summary
The facility failed to ensure that two nonsampled residents received the appropriate mechanically altered diets as ordered by their physicians. Resident 14 was observed to be served a regular texture diet instead of the prescribed mechanical soft diet, which was confirmed by the speech therapist and the food service director. The medical records indicated that Resident 14 had a physician's order for a regular diet with mechanical soft texture due to dysphagia, a condition that makes swallowing difficult. Despite this, the resident was not provided the correct diet, posing a risk of aspiration and unmet nutritional needs. Similarly, Resident 132 was not served the milk and coffee as ordered on her diet card. During breakfast, Resident 132 reported that she was served cereal without the accompanying milk and coffee, which was confirmed by a CNA. The diet card for Resident 132 specified the provision of 4 ounces of low-fat milk and black coffee, which were not provided. This oversight in meal service indicates a failure in the facility's food and nutrition services to adhere to physician-ordered diets.
Failure to Provide Assistive Eating Device
Penalty
Summary
The facility failed to provide a nonsampled resident, identified as Resident 53, with an assistive eating device during mealtimes, as required by the facility's policy and the resident's care plan. During a lunch observation, Resident 53 was seen feeding himself using regular utensils with his right hand, without the built-up utensils that were ordered by a physician on 5/16/24 and documented in the resident's care plan initiated on 4/23/24. The meal ticket for Resident 53 did not indicate the need for built-up utensils, contrary to the facility's policy that such devices should be recorded on tray cards and diet profiles. An interview with RNA 1 confirmed the use of regular utensils, and the Food Service Director (FSD) acknowledged the findings.
Failure to Educate on Safe Food Handling for Outside Food
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the safe handling of food brought in by family and visitors for residents. The policy, revised in March 2022, required family and visitors to be educated on safe food handling practices, including safe cooling, reheating, and preventing cross-contamination. However, the facility did not ensure that staff responsible for handling such food, or the family and visitors themselves, were educated on these practices. This oversight posed a risk of foodborne illness to residents consuming food from outside sources. Interviews with facility staff revealed gaps in the implementation of the policy. A CNA described her process for handling outside food, which included cooling hot food before refrigeration, but there was no mention of formal training on safe food handling. The Food Service Director (FSD) and Director of Staff Development (DSD) confirmed that while in-services were provided to kitchen and floor staff regarding general food handling, no specific education was given to staff or family/visitors about handling food brought in from outside. The Director of Nursing (DON) acknowledged the lack of education provided to family and visitors, despite encouraging them to bring food for residents, as long as it complied with therapeutic diets.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain infection control as evidenced by several deficiencies related to the implementation of Enhanced Barrier Precautions (EBP) and infection surveillance. Residents with indwelling urinary catheters and midline IV catheters, such as Residents 34 and 743, were not placed on EBP as per the facility's policies and procedures. Observations revealed that there were no EBP signs or personal protective equipment (PPE) supplies outside their rooms, and staff did not wear PPE when performing care activities that required close contact. Interviews with staff confirmed the lack of adherence to EBP protocols, which are crucial for preventing the transmission of infectious diseases. The facility also failed to conduct adequate surveillance of infections among residents who exhibited signs and symptoms of infection but were not on antimicrobials. The Infection Preventionist (IP) acknowledged that these residents were not included in the surveillance report, which hindered the ability to track and monitor potential infections. Additionally, the facility's Monthly Infection Surveillance Reports for September and October 2024 did not document the organisms or pathogens involved in infections, contrary to the facility's policy. This omission prevented the identification of patterns or clusters of infections and impeded efforts to manage antimicrobial use effectively. Furthermore, the facility did not maintain proper infection control practices in Resident 38's room, where an indwelling urinary catheter drainage bag was found on the floor, and a urinal with urine was hanging from a trash can. These observations were verified by a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON) acknowledged the findings. These lapses in infection control practices put residents at increased risk of infection and disease transmission.
Failure to Educate and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that six residents were educated and offered the pneumococcal vaccination as per the facility's policies and procedures. Specifically, the facility did not provide educational materials regarding the risks and benefits of the pneumococcal vaccine to five residents. This omission was confirmed during interviews with the Infection Preventionist (IP) and the Director of Nursing (DON), who acknowledged that the Vaccine Information Statement (VIS) should have been provided to the residents to inform them about the vaccine's risks, benefits, and possible reactions. Additionally, the facility did not offer the PPSV 23 vaccine to the responsible party of one resident who had previously received the PCV13 vaccine, as recommended by the CDC guidelines. This oversight was verified during a medical record review and interview with the IP. These failures put the residents at risk for infection and transmission of pneumococcal infections, as the facility did not adhere to its own policies regarding vaccination education and administration.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that six residents were educated and offered the COVID-19 vaccination as per the facility's policies and procedures. Specifically, the facility did not provide educational materials outlining the risks and benefits of the COVID-19 vaccine to five residents. This omission was confirmed during interviews and medical record reviews, where it was noted that the Vaccine Information Statement (VIS) for COVID-19, which provides detailed information about the vaccine, was not given to these residents. The Infection Preventionist (IP) acknowledged that the educational materials should have been provided to the residents to inform them about the vaccine's risks, benefits, and potential side effects. Additionally, the facility failed to offer the seasonal COVID-19 vaccine to the responsible party of another resident, despite the resident having the capacity to understand and make decisions. The resident's immunization record showed that the last COVID-19 vaccine was administered over two years ago, yet there was no evidence in the medical record that the seasonal vaccine was offered. This oversight was also confirmed by the IP during an interview and medical record review.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medications and had an appropriate order and care plan in place before self-administering medication. The facility's policy and procedure for self-administration of medications, dated February 2021, requires an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration is safe and clinically appropriate. During an observation on November 4, 2024, a blue jar of Vicks vapor rub was seen on the overbed table of a resident, who applied it to her head for headaches. The resident did not have a physician's order for the use of Vicks vapor rub, nor was there a care plan or self-administration assessment documented. A registered nurse confirmed these findings, indicating a lapse in following the facility's policy.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote dignity and respect for two residents during meal assistance. For Resident 103, who was severely cognitively impaired with a BIMS score of 00, the CNA was observed standing at the bedside while assisting with meals, contrary to the facility's policy that requires staff to be seated at eye-level with residents. This observation was confirmed by the CNA, who acknowledged that staff should be sitting down to ensure they are at the same level as the resident. Similarly, for Resident 116, who also had a BIMS score of 00 indicating severe cognitive impairment, the LVN was observed standing while assisting with meals. The LVN confirmed that she should have been seated to maintain the resident's dignity. The facility's policy on meal assistance emphasizes the importance of not standing over residents during meal assistance to ensure their comfort and dignity. The Administrator, DON, and Regional Quality Assurance Nurse acknowledged these findings during an interview.
Resident's Mail Privacy Breach
Penalty
Summary
The facility failed to ensure the privacy and security of a resident's mail, as per their policy. During a resident council meeting, a resident reported receiving an opened mail package, which caused discomfort. The facility's policy on mail delivery, dated May 2024, aims to ensure that all residents receive their mail promptly and securely, maintaining their privacy and dignity. The resident, who had the capacity to understand and make medical decisions, was admitted and readmitted to the facility on unspecified dates. An interview with the Central Supply Clerk revealed that she mistakenly opened the resident's mail package, thinking it was her own, as she frequently received packages for the facility. Upon realizing the mistake, she delivered the opened package to the resident and apologized, confirming that the package had been opened by staff before reaching the resident.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for two residents. For the first resident, the facility did not assess the resident's skin upon readmission, despite a reported coccyx wound. The medical records lacked documentation of a comprehensive skin assessment, and there was no care plan developed to address the coccyx wound, even though a physician's order for wound care was present. For the second resident, the facility did not revise the care plan to address a Stage 3 pressure injury, which was identified by a wound care physician. The care plan only addressed a Stage 2 pressure injury, and there was no update to reflect the more severe condition. Additionally, during a wound care treatment observation, it was found that the resident received wound treatment with medication that belonged to another resident, raising concerns about potential contamination or incorrect dosage. These deficiencies indicate that the facility did not adhere to its policies and procedures regarding skin assessments and care plan updates, potentially compromising the care and healing of the residents' pressure injuries.
Failure to Report Abuse Allegation Immediately
Penalty
Summary
The facility failed to implement their policy and procedure to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Specifically, the facility staff did not immediately report an abuse allegation involving a CNA to the facility's Administrator or DON for one of the residents reviewed for abuse. This failure was identified through interviews, medical record reviews, and a review of the facility's policy and procedure on abuse prevention. The incident involved Resident 1, who alleged that CNA 1 had hit him during a shower. Despite the allegation, CNA 1 continued to interact with Resident 1, and the abuse was not reported to the appropriate authorities until two days later by the Social Service Coordinator. On the day of the incident, CNA 1 reported Resident 1's aggressive behavior to RN 1 but did not mention the abuse allegation. CNA 2, who overheard the allegation, took over Resident 1's care but also did not report the incident, assuming CNA 1 had already informed RN 1. The DON was only made aware of the allegation two days later by the Social Service Coordinator, who discovered the abuse claim while reviewing Resident 1's progress notes. The facility's failure to immediately report the abuse allegation and remove the alleged perpetrator from the schedule compromised the resident's protection and violated the facility's abuse prevention policy.
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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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