Garden Crest Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 909 Lucile Ave., Los Angeles, California 90026
- CMS Provider Number
- 055161
- Inspections on file
- 43
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Garden Crest Rehabilitation Center during CMS and state inspections, most recent first.
A resident with DM and dementia returned from a GACH with a new right elbow fracture, right arm splint and sling, and discharge instructions for orthopedic follow-up and a right posterior long arm splint. Nursing documentation showed the readmission and new fracture, but there was no evidence the attending physician was notified of the readmission, new diagnosis, or right arm device. The DON stated nurses are expected to notify physicians of readmissions and changes in condition, and the treatment nurse acknowledged she did not notify the physician because she forgot, contrary to facility policy requiring communication of assessment findings and obtaining admission orders.
A resident with severe cognitive impairment and multiple comorbidities was sent to the hospital after staff noted inability to move the right arm and severe pain, and later returned with an arm splint/immobilizer and sling for a suspected elbow fracture. On readmission, staff observed the right arm device and later its removal after an X‑ray reportedly ruled out fracture, but no comprehensive assessment was completed, no PCP order was obtained for use and monitoring of the right arm device, no resident‑centered care plan was developed or implemented for the device, and no monitoring of its use was documented, contrary to facility policy and stated expectations for post‑hospital readmissions.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
A resident with severe cognitive impairment and multiple chronic conditions did not receive an accurate Joint Mobility Assessment (JMA) because the physical therapist relied solely on observation and staff interviews, without performing passive range of motion (PROM) or physically assessing the resident. Both the Director of Rehab and DON confirmed that PROM is necessary for an accurate JMA, and facility policy requires complete and objective documentation of services provided.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified during the survey.
The facility did not maintain an area free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in injuries. After the incident, a CNA overheard the resident accuse staff of pushing her, but this allegation was not recognized or reported as abuse by the LVN until the following day due to miscommunication. As a result, the required notification to the SSA and Ombudsman was delayed beyond the mandated two-hour window.
A resident with multiple chronic conditions and intact decision-making capacity was not properly informed or involved in their discharge planning. Although the care plan and facility policy required resident participation and communication, documentation showed only the family was contacted, with no evidence that the resident was included in the process.
A resident was placed in isolation without a physician's order upon readmission to the facility, despite testing negative for Influenza A. Staff interviews confirmed the lack of an active order and acknowledged the potential negative effects of isolation. Facility policies emphasize the need for physician orders and the use of the least restrictive measures.
The facility failed to ensure staff performed proper hand hygiene, as observed with a CNA handling trash and touching high-touch areas, an RN entering a resident's room without hand hygiene, and a housekeeping staff member entering a room after touching a mop bucket. Staff interviews confirmed awareness of the importance of hand hygiene in preventing infections.
The facility failed to submit accurate Payroll-Based Journal (PBJ) data for the 3rd quarter of 2024, as required by their policy. The previous payroll staff submitted the PBJ in August, but omitted the rehabilitation department. Despite resubmitting the report in October, the Administrator could not confirm the original submission date due to a lack of documentation. This resulted in inaccurate reporting of direct care staffing information.
The facility failed to provide emergency dialysis kits at the bedside for residents on hemodialysis, as observed in three residents with end-stage renal disease. Despite care plans requiring monitoring and immediate intervention for complications, the necessary emergency supplies were missing. The absence of these kits was confirmed by staff, including a registered nurse and the DON, who acknowledged the risk of delayed treatment during emergencies.
A resident with a documented DNR order was administered CPR against their wishes when found unresponsive. The POLST, signed by the resident's family member, was not honored due to the absence of a code status order in the electronic health record. Facility policies on POLST and DNR orders were not followed, and the resident's dignity was compromised.
A facility failed to include a resident's preferred activities, such as reading, in their care plan, despite the resident's dependence on others for mobility and their expressed interest in reading materials. The resident, who had no cognitive impairment, was observed reading a magazine in bed and reported limited access to reading materials. The Activity Director acknowledged the oversight, noting the care plan should have been updated to reflect the resident's interests.
Two residents in an LTC facility did not receive necessary assistance with ADLs, leading to deficiencies in care. One resident, with paraplegia, was left unattended for over an hour after requesting a diaper change, while another resident, dependent on staff for oral hygiene, showed signs of neglect with dry lips and unclean teeth. Staff interviews and documentation revealed inconsistencies in care provision and record-keeping.
A facility failed to conduct a monthly drug regimen review for a resident on psychotropic medications, as required by policy. The resident, diagnosed with major depressive disorder and bipolar disorder, did not have their medications reviewed for three months. The pharmacist did not send a list of reviewed residents with no recommendations, leading to missing documentation. The DON confirmed the oversight, acknowledging the risk of potential medication interactions.
The facility failed to properly label and date food items, including a pitcher of apple juice and multiple cups of juice and milk, in accordance with professional standards. This was observed during a kitchen tour and follow-up visit with the Dietary Supervisor, who acknowledged the importance of labeling to prevent foodborne illness. The facility's policy requires refrigerated and dry foods to be labeled and dated, which was not adhered to, placing residents at risk.
The facility failed to meet the required 80 square feet per resident in 14 rooms, potentially impacting safe nursing care and privacy. Measurements confirmed the deficiency, although feedback from residents and staff varied. One resident felt the room was tight, while another had no issues. An LVN reported no complaints and stated room change requests were addressed promptly.
A resident with dementia and other conditions was prescribed Meclizine for dizziness, but the facility failed to develop a person-centered care plan or monitor the medication's effects. The resident received Meclizine on a scheduled basis for nearly three months without appropriate interventions or monitoring, contrary to facility policies requiring comprehensive care plans and monitoring for changes in condition.
A facility failed to conduct a pain assessment for a resident with chronic pain syndrome after a change in condition involving pain in the head, chest, and hip. Despite the resident's fluctuating cognitive capacity and transfer to a hospital for further evaluation, the required pain assessment was not completed, as confirmed by the DON. This oversight was against the facility's policy, which mandates assessments upon significant changes in condition.
A resident with dementia, chronic pain syndrome, and Type II diabetes was administered Meclizine 25 mg four times a day for dizziness from June to August without any recommendations for change from the Pharmacy Consultant (PC). The PC failed to notice the continuous prescription during monthly reviews, leading to potential risks of adverse side effects. The Director of Nursing confirmed the lack of recommendations, highlighting a failure to adhere to the facility's medication review policies.
The facility failed to implement effective infection control measures, as staff did not discard N95 masks after exiting COVID-19 positive rooms and a CNA was not fit tested for N95 masks upon hire. Observations showed an LVN reused an N95 mask across different resident rooms, contrary to the facility's Mitigation Plan and policies. This oversight could contribute to the spread of COVID-19 within the facility.
A facility failed to maintain documentation of a current nursing license for an LVN, whose license had expired. Despite this, the LVN was assigned to care for and administer medications to numerous residents on multiple occasions. The deficiency was confirmed through interviews with the LVN, the DSD, and the DON, who acknowledged the lapse in adhering to state licensure requirements.
The facility failed to document the administration of medications and vital signs for several residents, leading to potential risks of double dosing and inaccurate medication records. Medications were not recorded on MARs and narcotic sheets, and blood pressures were not taken prior to administering BP medications.
The facility failed to ensure that an LVN maintained a valid CPR certification while providing care to residents. Despite reminders, the LVN continued to work without a current CPR card, and the DSD did not follow up to ensure renewal. The DON confirmed that all nursing staff must have a current CPR card to perform their duties.
The facility failed to develop and implement a care plan for a resident with a right leg contracture. Despite the resident's multiple diagnoses and need for maximum assistance, the care plan did not address the contracture, leading to inadequate guidance for staff. The DON confirmed the omission, which was against the facility's policy for comprehensive, person-centered care plans.
Failure to Notify Physician of Resident’s New Fracture and Treatment After Hospital Readmission
Penalty
Summary
The facility failed to immediately notify a resident’s primary care physician of a change in condition and treatment following the resident’s return from a General Acute Care Hospital (GACH). The resident, who had type 2 diabetes mellitus and dementia with severely impaired cognition, was dependent for toileting, lower body dressing, and footwear. According to the electronic medical record progress note dated 12/27/2025 at 22:25, the resident returned from the hospital via ambulance with a right arm splint and sling due to a right elbow fracture. The GACH after-visit summary documented a new diagnosis of a radius fracture and right elbow joint pain, with discharge instructions for a follow-up orthopedic appointment and a nursing communication order for application of a right posterior long arm splint. Record review showed there was no documentation that the attending physician was notified of the resident’s readmission, the new elbow fracture diagnosis, or the presence of the right arm device. During interview, the DON stated that all licensed nurses are expected to notify the physician when residents are readmitted from the hospital or when there is a change of condition, and confirmed there was no such documentation in the resident’s progress notes. The treatment nurse reported that she did not notify the physician about the right arm device because she forgot. The facility’s policy titled “Admission Assessment and Follow up: Role of the Nurse,” revised 01/2025, requires contacting the attending physician to communicate and review findings of the initial assessment and other pertinent information and to obtain admission orders based on these findings.
Failure to Assess, Obtain Orders, and Care Plan for Arm Immobilizer After Hospital Readmission
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to orders, and to complete required assessments and care planning for a resident following readmission from a general acute care hospital (GACH). The resident had diagnoses including peripheral vascular disease, type 2 diabetes mellitus, and a non‑pressure chronic ulcer on the right foot, and had severe cognitive impairment with dependence on staff for toileting hygiene, lower body dressing, and footwear. The resident’s history and physical documented that the resident did not have capacity to understand and make decisions. An SBAR form showed that on one date the resident was found unable to move the right arm and complained of severe pain with movement, and the PCP was notified and ordered transfer to the hospital via 911. Progress notes documented that the resident returned from the GACH later that evening with an arm splint and sling on the right arm due to a right elbow fracture and was experiencing discomfort in the affected arm. Staff interviews indicated that when an LVN started her shift the next day, she observed the resident back from the hospital with a cast on the right arm due to a radial head fracture, but on a later shift the cast was no longer present. The LVN reported being informed by the DON that the cast had been removed because an X‑ray had ruled out a fracture. The Director of Rehabilitation stated that the resident returned with an immobilizer on the right arm but that he did not conduct an assessment upon the resident’s return, explaining that because the fracture was ruled out, he did not consider this a change in condition requiring assessment. During interview and record review with the DON, it was confirmed that the resident returned from the GACH with an immobilizer on the right arm and that facility expectations upon readmission included notifying family and physician, documenting notifications, obtaining pertinent records from the GACH, and conducting comprehensive and skin assessments, as well as initiating and implementing a care plan for any change in condition. However, the record showed no documentation of a comprehensive assessment upon readmission, no physician order for use and monitoring of the right arm device, no resident‑centered care plan addressing the right arm device, and no monitoring of the device’s use. The facility’s policy on comprehensive person‑centered care plans stated that the interdisciplinary team reviews and updates the care plan when a resident is readmitted from a hospital stay, but this was not carried out for this resident.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Inaccurate Joint Mobility Assessment Due to Lack of Hands-On Evaluation
Penalty
Summary
The facility failed to accurately conduct a Joint Mobility Assessment (JMA) for a resident with multiple diagnoses, including dementia, type 2 diabetes, osteoporosis, osteoarthritis, and contracture. The resident was admitted with severe cognitive impairment and required substantial to maximal assistance with most activities of daily living. The JMA, dated 5/27/2025, indicated the resident had minimal to severe loss of lower extremity passive range of motion (PROM) and was at risk for contracture development. The assessment recommended a physical therapy evaluation and RNA services for PROM of both upper extremities. During interviews and record reviews, it was revealed that the physical therapist performed the JMA through observation and interviews with CNAs, without physically touching or moving the resident to assess PROM. The physical therapist confirmed that PROM was not performed during the assessment, and acknowledged that joint integrity could not be determined by observation alone. The Director of Rehab stated that PROM must be performed during a JMA to accurately assess joint condition, and that failing to do so results in an inaccurate assessment. The Director of Nursing also confirmed that inaccurate JMAs could result in residents not receiving necessary care. Facility policy required all services and changes in resident condition to be documented objectively, completely, and accurately in the medical record.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive program but does not provide specific details about individual residents, staff actions, or particular infection control lapses observed during the survey.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Allegation of Staff-to-Resident Abuse
Penalty
Summary
A facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency (SSA) and the Ombudsman within the required two-hour timeframe. The incident involved a resident with multiple diagnoses, including dementia, diabetes, anxiety, osteoarthritis, and chronic kidney disease, who had severely impaired cognition and required significant assistance with daily activities. The resident experienced an unwitnessed fall, resulting in a forehead laceration and bilateral elbow skin tears, and was subsequently transferred to a general acute care hospital for evaluation and treatment. Following the resident's return to the facility, it was discovered during the investigation that a Certified Nurse Assistant (CNA) had overheard the resident say, "you pushed me," in Spanish, directed at the CNA who found her after the fall. This information was initially communicated by the CNA to a Licensed Vocational Nurse (LVN) on the night of the incident, but the LVN misunderstood the statement and did not recognize it as an abuse allegation. The next day, the CNA repeated the statement to the LVN and a Registered Nurse (RN), at which point the allegation was reported to the facility Administrator and Director of Nursing (DON). The facility's policy required immediate reporting of abuse allegations to the SSA, Ombudsman, and other authorities within two hours if the allegation involved abuse or resulted in serious bodily injury. However, due to miscommunication and misunderstanding between staff members, the abuse allegation was not reported until the following day, well beyond the required timeframe. This delay was confirmed through interviews with the involved staff and review of facility documentation.
Failure to Involve Resident in Discharge Planning
Penalty
Summary
The facility failed to follow its policy and procedures for discharge planning for one resident. The resident, who had diagnoses including diabetes mellitus, hypertension, atrial fibrillation, hyperlipidemia, and chronic kidney disease, was assessed as having the capacity to understand and make decisions, with intact cognitive skills for daily decisions. The resident was independent in bed mobility and required varying levels of assistance with other activities of daily living. The care plan for discharge planning included interventions such as providing written and verbal instructions at the patient/family's level of understanding and reviewing and discussing the discharge plan with the resident and family as appropriate. Despite these requirements, a review of the case manager's progress notes revealed that only the resident's family member had been contacted regarding discharge planning, with no documentation indicating that the resident was informed or involved in the discharge plan over the previous three months. The case manager confirmed there was no evidence in the notes to show the resident's involvement. Facility policies reviewed stated that residents have the right to be informed of and participate in their care planning and treatment, and that post-discharge plans should be developed with the assistance of the resident and family. This lack of documentation and involvement constituted a failure to ensure the resident was properly informed and involved in their discharge plan.
Resident Isolated Without Physician's Order
Penalty
Summary
The facility failed to honor the right of a resident to be free from involuntary seclusion by placing a resident in isolation without a physician's order. The resident, who was admitted with diagnoses including dementia, COPD, and dysphagia, was initially placed under droplet and contact isolation precautions upon admission due to a diagnosis of Influenza A. However, after being readmitted from a General Acute Care Hospital, the resident was placed in isolation again despite testing negative for Influenza A and without an active physician's order. Interviews with facility staff, including the Infection Prevention Nurse and a Licensed Vocational Nurse, confirmed that the resident was placed in isolation upon readmission without a physician's order. The staff acknowledged that residents should not be isolated without such orders and recognized the potential negative effects of isolation, such as anxiety and depression. The Director of Nursing also confirmed the absence of an active isolation order upon the resident's readmission. The facility's policy and procedures on isolation and abuse prevention emphasize the use of the least restrictive measures and the necessity of physician orders for isolation. Despite these guidelines, the resident was isolated without proper authorization, which could lead to psychological harm. The Medical Doctor interviewed stated that isolation for influenza should typically last five days, but the resident should not have been isolated upon readmission as there was no active infection warranting such measures.
Failure to Implement Hand Hygiene Practices
Penalty
Summary
The facility failed to implement its infection control policy by not ensuring that staff members performed proper hand hygiene. Observations revealed that a Certified Nursing Assistant (CNA) handled trash and touched high-touch areas such as curtains and bedside tables without applying hand hygiene. Similarly, a Registered Nurse (RN) entered a resident's room, touched a bedside table, and donned gloves without performing hand hygiene before or after the procedure. Additionally, a Housekeeping staff member was observed touching a mop bucket and entering a resident's room without applying hand hygiene. Interviews with the staff confirmed their awareness of the importance of hand hygiene in preventing the spread of infections. The CNA acknowledged the need to apply hand hygiene after handling trash and before touching high-touch areas. The RN admitted to not performing hand hygiene before entering a resident's room and recognized its importance in infection control. The Director of Staffing Development and the Director of Nursing both emphasized the necessity of hand hygiene practices among staff to prevent infection outbreaks, as outlined in the facility's Infection Prevention and Control Program policy.
Failure to Submit Accurate PBJ Data for 3rd Quarter 2024
Penalty
Summary
The facility failed to ensure the accurate and timely submission of the Payroll-Based Journal (PBJ) for the 3rd quarter of 2024, covering the period from April 1 to June 30. This deficiency was identified through a review of the Certification and Survey Provider Enhanced Reports (CASPER) for the PBJ Staffing Data Report, which indicated a failure to submit data for the quarter. During an interview, the Administrator (ADM) and payroll staff (Staff 1) revealed that the previous payroll staff had submitted the PBJ in August 2024, but there were issues with the submission, including a failure to include the rehabilitation department. The facility attempted to rectify this by resubmitting the report in October, but the ADM could not confirm the exact date of the original submission due to a lack of documentation. The facility's policy and procedure for reporting direct care staffing information, dated August 2022, required that staffing data be submitted electronically to CMS no later than 45 days after the end of the reporting quarter, with the deadline for the 3rd quarter being August 14. Despite the ADM's efforts to verify the submission date, the CASPER Reports Submit printout did not include a date, and the ADM was unable to produce evidence of the submission date. This lack of documentation and failure to adhere to the facility's policy resulted in the inaccurate reporting of direct care staffing information, potentially placing the facility at risk of not implementing their policy effectively.
Lack of Emergency Dialysis Kits for Residents on Hemodialysis
Penalty
Summary
The facility failed to ensure that residents receiving hemodialysis had an emergency dialysis kit at their bedside, which is crucial for immediate intervention in case of accidental bleeding. This deficiency was observed in three residents, each with a diagnosis of end-stage renal disease and dependence on renal dialysis. The absence of these kits was confirmed during observations and interviews with the facility's staff, including a registered nurse and the Director of Nursing (DON). Resident 46, admitted with end-stage renal disease, had a care plan that required daily monitoring of the dialysis access site and immediate intervention for any complications. However, during an observation, no emergency kit was found at the bedside. Similarly, Resident 9, also on dialysis, did not have an emergency kit available, as confirmed by a registered nurse. The care plan for Resident 9 included monitoring for signs of infection and bleeding, yet the necessary emergency supplies were missing. Resident 32, with a moderately impaired cognition and on dialysis, was also found without an emergency kit at the bedside. The facility's Director of Nursing acknowledged the importance of having these kits readily available to prevent delays in treatment during emergencies. The report highlights that the facility did not have a policy for dialysis emergency kits, which contributed to the oversight in providing these essential supplies for residents on dialysis.
Failure to Honor DNR Order for a Resident
Penalty
Summary
The facility failed to honor the Physician's Order for Life-Sustaining Treatment (POLST) for a resident, identified as Resident 58, who had a documented Do Not Resuscitate (DNR) order. Despite the POLST indicating that no cardiopulmonary resuscitation (CPR) should be performed if the resident had no pulse and was not breathing, CPR was administered when Resident 58 was found unresponsive. This action was contrary to the resident's documented wishes and the POLST signed by the resident's family member, who was the surrogate decision maker. The deficiency was further highlighted by the lack of a code status order in the resident's electronic health record, which was confirmed by both a registered nurse and the Director of Nursing (DON). The facility's policies on POLST and DNR orders were not followed, as the POLST instructions were not added to the resident's admitting orders for physician review. The facility's policy on dignity, which emphasizes honoring resident goals and preferences, was also not adhered to in this instance.
Failure to Include Resident's Activity Preferences in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident, identified as Resident 16, which resulted in the omission of the resident's preferred activities in their care plan. Resident 16 was admitted with diagnoses including muscle wasting, a sacral pressure ulcer, and dependence on oxygen. The Minimum Data Set (MDS) assessment indicated that reading materials such as books, newspapers, and magazines were important to Resident 16, who had no cognitive impairment but was totally dependent on others for bed mobility and transfers. However, the Activities care plan, revised on 10/10/2024, did not include these interests, focusing instead on inviting the resident to scheduled activities without considering their specific preferences. During an observation and interview, Resident 16 was found reading a magazine in bed and expressed that they had not been able to leave their room due to mobility issues and discomfort from hemorrhoids and a wound on their lower back. The resident mentioned that magazines were offered only once or twice. The Activity Director confirmed that the facility provided various recreational activities but acknowledged that Resident 16's care plan should have been updated to reflect their current interests. The facility's policy on comprehensive person-centered care plans, revised in July 2024, mandates the inclusion of measurable objectives and timeframes to meet residents' needs, which was not adhered to in this case.
Deficiencies in ADL Assistance and Oral Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, Resident 31 and Resident 214, leading to deficiencies in care. Resident 31, who was admitted with paraplegia, Type II diabetes, and end-stage renal disease, required total assistance for toileting and personal hygiene. On the evening of November 11, 2024, Resident 31 requested a diaper change due to a bowel movement, but the assigned CNA did not return to assist, leaving the resident unattended until the next shift. Interviews with staff confirmed that the call light was acknowledged but not acted upon, resulting in a delay of over an hour before the resident received the necessary care. Resident 214, admitted with nontraumatic intracerebral hemorrhage and hemiparesis, was dependent on staff for oral hygiene. Observations revealed that Resident 214 had dry lips and a thick substance on the teeth, indicating a lack of oral care. The resident reported that oral care was last provided by a family member a week prior. The facility's oral hygiene records showed inconsistencies, with several instances marked as non-applicable, suggesting that oral care was not provided as required. Interviews with staff confirmed that oral care was supposed to be provided once per shift, but this was not consistently documented or performed. The Director of Nursing acknowledged the deficiencies in both cases, noting the importance of timely assistance to prevent skin breakdown and maintain dignity. The facility's policies on ADLs and mouth care were reviewed, highlighting the need for staff to report and document care accurately. The discrepancies in documentation and the lack of timely assistance contributed to the deficiencies observed in the care of Residents 31 and 214.
Failure to Conduct Monthly Drug Regimen Review for Resident
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review (DRR) for a resident, identified as Resident 6, who was on psychotropic medications. Resident 6, diagnosed with major depressive disorder and bipolar disorder, was admitted to the facility and was prescribed Venlafaxine and Quetiapine. However, the facility's records showed that the DRR for Resident 6's medications was not conducted for the months of August, September, and October 2024. This oversight was confirmed during a review of the DRR binder and interviews with the Director of Nursing (DON) and the pharmacist. The pharmacist admitted to not sending a list of residents reviewed with no recommendations each month, which led to the absence of DRR documentation for Resident 6. The facility's policy required a monthly medication regimen review for each resident, regardless of whether changes were recommended. The DON acknowledged that the pharmacist was supposed to send the DRR for each resident monthly, and the absence of this review posed a risk of potential medication interactions. The medical director also stated that it was his responsibility to review the medications, but he was unaware of the frequency of the pharmacist's reviews.
Improper Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards of food storage, as observed during a kitchen tour with the Dietary Supervisor (DS). Several food items, including a full pitcher of brown liquid identified as apple juice, were found unlabeled and undated in the walk-in refrigerator. The DS acknowledged the importance of labeling to prevent potential foodborne illness from consuming food past its use-by date. Additionally, three packs of bread in the Dry Storage Room were also found undated, which the DS confirmed should have been labeled with a delivery date to track freshness. During a follow-up visit, further deficiencies were noted with at least 79 cups of juice and milk in the walk-in refrigerator being unlabeled and undated. The DS reiterated the necessity of labeling and dating these items to avoid the risk of foodborne illness. A review of the facility's policy on Food Receiving and Storage, revised in July 2024, indicated that refrigerated foods should be labeled, dated, and monitored for use-by dates, and dry foods should be labeled and dated upon delivery. The facility's failure to comply with these standards placed residents at risk for foodborne illness or contamination.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 14 out of 29 rooms met the required 80 square feet per resident in multiple occupancy rooms. During an observation, the Maintenance Supervisor measured the rooms and found that the square footage per resident was below the required standard in rooms 21, 22, 23, 24, 25, 26, 27, 28, 33, 34, 35, 36, 37, and 38. The measurements were confirmed to match the client accommodation analysis. This deficiency had the potential to result in inadequate space necessary to provide safe nursing care and privacy for residents. Interviews with residents and staff provided mixed feedback regarding the room sizes. One resident mentioned that the room felt tight and had requested a move to a larger room, although they had not followed up on the request. Another resident stated there was no issue with the room size, and there was enough space for care and visitors. A Licensed Vocational Nurse indicated that there were no issues performing tasks in the rooms and that any requests for room changes were addressed promptly. Despite these observations, the facility's policy required bedrooms to measure at least 80 square feet per resident in double rooms, which was not met in the identified rooms.
Lack of Person-Centered Care Plan for Dizziness and Medication Administration
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan for a resident who was experiencing dizziness and was prescribed Meclizine four times a day. The resident, who had a history of dementia, chronic pain syndrome, and Type II diabetes mellitus, was admitted to the facility and required substantial assistance with daily activities. Despite being prescribed Meclizine for dizziness, there was no individualized care plan developed to address the resident's condition or the administration of the medication. The resident's medical records indicated that Meclizine was administered on a scheduled basis for nearly three months without a care plan or monitoring for potential side effects. The facility's Pharmacy Consultant expressed surprise at the prolonged scheduled administration of Meclizine, which is typically prescribed as needed. The Director of Nursing acknowledged the absence of a care plan and monitoring, which should have been initiated following the resident's change in condition. The facility's policies required comprehensive person-centered care plans and monitoring for changes in a resident's condition. However, these were not followed, resulting in a lack of monitoring and appropriate services for the resident. The deficiency was identified through interviews and record reviews, highlighting the facility's failure to develop and implement a care plan for the resident's dizziness and medication administration.
Failure to Conduct Pain Assessment After Change of Condition
Penalty
Summary
The facility failed to provide a pain assessment for a resident diagnosed with chronic pain syndrome after a change in condition, which involved pain on the right side of the head, chest, and hip. The resident, who had a history of dementia and fluctuating cognitive capacity, was admitted with chronic pain syndrome and was receiving scheduled pain medication. Despite the resident's condition worsening, as indicated by the need for transfer to a General Acute Care Hospital for further evaluation, the facility did not complete a required pain assessment. The Director of Nursing confirmed that the licensed staff did not complete a Pain Assessment form following the resident's change of condition, which was a requirement according to the facility's policy. The facility's policy, revised in October 2022, mandates pain assessments upon admission, at quarterly reviews, and whenever there is a significant change of condition or onset of new or worsening pain. The failure to conduct a pain assessment after the resident's change of condition was identified as a deficiency, potentially impacting the resident's care and pain management.
Failure in Medication Regimen Review for Resident
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant (PC) thoroughly completed a monthly Medication Regimen Review (MRR) for a resident, leading to the administration of medication that was not optimal for the resident's medical condition. The resident, who was admitted with diagnoses including dementia, chronic pain syndrome, and Type II diabetes mellitus, was prescribed Meclizine 25 mg four times a day for dizziness. This medication was administered daily from June to August without any recommendations for change from the PC, despite the resident experiencing symptoms such as severe headache, dizziness, and fluctuating blood pressure. The PC admitted to not noticing the continuous prescription of Meclizine 25 mg four times a day during the reviews conducted in June, July, and August. The PC expressed shock upon realizing that the medication was given on a scheduled basis for almost three months and acknowledged the failure to re-evaluate the order based on the resident's symptoms. The Director of Nursing (DON) confirmed that the PC did not make any recommendations regarding the resident's medications during this period, which could have placed the resident at risk for adverse side effects. The facility's policy and procedure on Medication Utilization and Prescribing-Clinical Protocol indicated that the consultant pharmacist should review medication usage patterns and make recommendations for medications that present higher risks. However, the PC did not adhere to these guidelines, as evidenced by the lack of recommendations for the resident's medication regimen. The facility's policy also required the PC to have access to the resident's complete medical records, which should have facilitated a more thorough review of the medication regimen.
Inadequate Infection Control Practices for COVID-19
Penalty
Summary
The facility failed to implement effective infection prevention and control measures to prevent the spread of COVID-19 among residents and staff. Specifically, the facility did not ensure that staff discarded and did not reuse their N95 masks after exiting rooms in the Red Zone, which is designated for residents who have tested positive for COVID-19. An observation revealed that a Licensed Vocational Nurse (LVN) did not change their N95 mask after exiting a COVID-19 positive resident's room and continued to wear the same mask while attending to other residents. The LVN was unaware of the requirement to change N95 masks after exiting droplet/contact isolation rooms, which was confirmed by the Infection Preventionist Nurse who incorrectly stated that N95 masks could be worn all day unless soiled. Additionally, the facility failed to perform fit testing for N95 masks for a Certified Nursing Assistant (CNA) upon hire, which is necessary to ensure the mask provides a proper seal and protection against airborne illnesses. The CNA had been employed for two months and had been assigned to care for both COVID-19 positive and negative residents without having undergone fit testing. The Director of Staff Development confirmed that fit testing was not performed upon hire, and the Director of Nursing acknowledged that this oversight could contribute to the spread of infection. The facility's Mitigation Plan and policies required staff to fully doff all personal protective equipment (PPE) and don new PPE when moving between different sections of the facility, particularly when crossing from the Red Zone to other areas. The plan also specified that face masks should be used only once and discarded in the appropriate receptacle. However, these protocols were not followed, as evidenced by the observations and interviews conducted during the survey, leading to a potential risk of spreading COVID-19 within the facility.
Expired Nursing License Leads to Deficiency
Penalty
Summary
The facility failed to maintain documentation of state licensure for one of its Licensed Vocational Nurses (LVN 2), whose nursing license had expired. A review of LVN 2's employee file revealed that the license expired on a specific date, yet LVN 2 continued to be assigned to care for and administer medications to a significant number of residents on multiple occasions. This oversight was confirmed during an interview with the Director of Staff Development (DSD), who acknowledged that LVN 2 worked at the facility and was responsible for resident care on several specified dates despite the expired license. Interviews with LVN 2 and the Director of Nursing (DON) further confirmed the deficiency. LVN 2 admitted that her nursing license had expired and had not been renewed. The DON stated that all nurses were required to renew their licenses every two years and acknowledged that having staff without a current Vocational Nursing License could potentially result in residents receiving inadequate medical care. The facility's policy on staffing, which was updated recently, indicated that all nursing staff must meet the competency requirements defined by state law, which was not adhered to in this case.
Failure to Document Medication Administration and Vital Signs
Penalty
Summary
The facility failed to ensure that licensed nurses documented the administration of medications on residents' medication administration records (MAR) and controlled drug records (narcotic sheets). Specifically, 26 out of 26 medications were not documented as administered for three residents, and eight out of eight removed narcotic medications were not recorded for four residents. Additionally, blood pressures were not taken or recorded prior to the administration of blood pressure medications for two residents. These deficiencies had the potential to misrepresent the actual medications administered, undercount the actual narcotics taken, and misrepresent the narcotic medication inventory on hand for each shift. Resident 8, who was admitted with chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, and supraventricular tachycardia, had orders for diltiazem to be held for specific blood pressure and heart rate thresholds. However, the MAR indicated that blood pressures and heart rates were not recorded prior to the administration of diltiazem. Resident 9, who had severe cognitive impairment and was admitted with cerebral infarction and hemiplegia, had morphine sulfate not documented as administered or removed from the medication bottle, leading to discrepancies in the narcotic sheet. Resident 2, admitted with type 2 diabetes mellitus, peripheral vascular disease, and hypertensive chronic kidney disease, had multiple medications, including heparin sodium injection and hydralazine, not documented as administered. Blood pressures were also not recorded prior to the administration of hydralazine. Resident 5, who had atherosclerosis, essential hypertension, and polyneuropathy, had several medications, including hydromorphone, not documented as given. Interviews with the residents and licensed vocational nurses (LVNs) revealed that the medications were administered but not documented, leading to potential risks of double dosing and inaccurate medication records.
Expired CPR Certification for LVN
Penalty
Summary
The facility failed to ensure that one of its licensed nurses, LVN 4, maintained a valid CPR certification while providing care to residents. During an observation and record review, it was found that LVN 4's CPR card had expired. Despite being reminded by the Director of Staff Development (DSD) to renew the certification, LVN 4 continued to work in the facility without a valid CPR card. LVN 4 acknowledged the expiration and mentioned that although a CPR class was taken, the renewed card had not yet been received. The DSD admitted to not following up to ensure the renewal was completed, and the Director of Nursing (DON) confirmed that all nursing staff must have a current CPR card to perform their duties. The facility's schedule showed that LVN 4 worked multiple shifts after the CPR card had expired, including double shifts and overnight shifts. The deficiency was identified through interviews with LVN 4, the DSD, and the DON, as well as a review of the facility's schedules and LVN job description. The job description emphasized the necessity for nurses to have the appropriate licensure and certification to perform their tasks. The failure to ensure LVN 4's CPR certification was current had the potential to compromise the quality of care provided to residents, as it is crucial for nurses to stay updated on the latest CPR techniques to respond effectively in emergencies.
Failure to Develop and Implement Care Plan for Resident's Right Leg Contracture
Penalty
Summary
The facility failed to develop and implement a resident-specific care plan for a resident with a right leg contracture. The resident, who was admitted with multiple diagnoses including Type II diabetes mellitus with diabetic chronic kidney disease, unspecified osteoarthritis, and other specified disorders of bone density and structure, had a care plan initiated that did not address the right leg contracture. The care plan only mentioned the resident's limited physical mobility and aimed to prevent complications related to immobility, but it did not include specific interventions for the contracture. The resident required maximum assistance with dressing, toilet use, and personal hygiene, and had an order for restorative nursing assistance to prevent decline in range of motion and strength, but these were not adequately addressed in the care plan. During an observation, it was noted that the resident's right leg was immobilized with a soft cast and pillows, but there was no corresponding care plan to guide this intervention. The Director of Nurses confirmed that no care plan was created for the right leg contracture and acknowledged that this omission meant other disciplines would not know how to properly care for the resident. The facility's policy required a comprehensive, person-centered care plan to be implemented within seven days of the MDS assessment and reviewed and updated as needed, but this was not followed in this case.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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