Garden Grove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Garden Grove, California.
- Location
- 12882 Shackelford Lane, Garden Grove, California 92841
- CMS Provider Number
- 056145
- Inspections on file
- 22
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Garden Grove Post Acute during CMS and state inspections, most recent first.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to compliance with care planning and delivery requirements.
A resident with a history of falls and requiring significant assistance was found lying on a floor mattress, but staff did not recognize this as a fall and failed to assess the resident or notify the physician and family as required by facility policy. The DON confirmed that the incident was not documented or followed up according to post-fall procedures.
Two residents received gastrostomy tube (GT) care that did not match physician orders: one was given enteral feeding at a higher rate than prescribed, and another received water flushes at a lower rate than ordered. Nursing staff and medical record reviews confirmed these discrepancies.
A resident with limited upper extremity range of motion and a history of falls was observed twice with the call light out of reach while in bed, despite facility policy and the resident's care plan requiring the call light to be accessible. Staff confirmed the call light was not within reach and acknowledged the expectation for it to be accessible at all times.
A resident was given Ozempic for diabetes management without a diabetes diagnosis and without care plan monitoring, and was also administered oxycodone for pain at times when pain levels were below the prescribed threshold, including when no pain was present. Facility policy requires medications to be administered as prescribed, but this was not followed.
A LVN left an unlabeled medication in a clear cup unattended on a resident's bedside table, despite the resident being unable to self-administer the medication. Both the LVN and ADON confirmed this was not in line with facility policy for safe medication administration.
A resident did not receive prescribed doses of ketotifen, an antiallergic medication, on two consecutive days because the medication was not re-ordered in time. The MAR reflected missed administrations, and the DON confirmed the lapse during review.
The facility failed to meet food safety and sanitation standards, with improper labeling, dating, and storage of food items, unsanitary kitchen utensils and equipment, and poor hygiene practices by staff. These deficiencies posed a risk of food-borne illnesses to 81 residents.
The facility failed to implement effective infection control practices, including a lack of a comprehensive water management plan and inadequate PPE usage by staff. Specific residents with open wounds and PICC lines were not properly attended to, posing a risk for disease transmission.
The facility failed to document abdominal girth measurements for a resident with a perforated gastric ulcer and did not verify bowel movement status before administering a stool softener to another resident, leading to deficiencies in care.
A facility failed to follow a physician's order for a resident's elbow splint application, leading to a lack of documentation and skin assessment. The splint was not applied as ordered, and there was no record of the times it was applied or removed. Interviews with staff confirmed the absence of documentation and the need for a physician's order for skin assessment.
A resident at high risk for falls was found without required floor mats on both sides of the bed, as per their care plan and physician's order. Despite the resident's severe cognitive impairment and history of falls, staff confirmed the absence of mats, acknowledging the oversight. The DON verified the deficiency, highlighting a lapse in implementing necessary safety measures.
A facility failed to document baseline measurements for a resident's PICC line, potentially delaying the identification of complications. Additionally, an enteral feeding water bag was mislabeled with another resident's name. These deficiencies were confirmed by facility staff and acknowledged by leadership.
The facility failed to follow physician's orders for oxygen therapy for two residents, with one receiving an incorrect oxygen rate and lacking a care plan, and another having improperly maintained equipment. These issues were confirmed by staff and acknowledged by the DON.
A resident with ESRD receiving hemodialysis experienced deficiencies in care at the facility, including lack of post-dialysis assessment, inaccurate fluid restriction documentation, absence of an emergency dialysis kit, and incomplete care plan for transportation. Staff interviews revealed inadequate documentation practices, and the DON acknowledged the failure to follow facility procedures.
The facility failed to provide necessary pharmaceutical services for two residents, leading to discrepancies in medication administration. One resident received artificial tears with different active ingredients than prescribed, while another had inconsistencies between the Controlled Drug Record and MAR for oxycodone. These issues were confirmed by staff and acknowledged by the DON.
A facility failed to follow proper procedures for psychotropic medication management for a resident with dementia. Seroquel was prescribed without a documented diagnosis, informed consent, or least restrictive measures. The care plan was delayed, and side effects were not monitored. Ativan was prescribed without clinical indication. RN 1 confirmed these deficiencies, highlighting lapses in protocol adherence.
The facility failed to update its policy on outside food handling and did not educate staff and visitors on safe practices, posing a risk of foodborne illness. The P&P discouraged bringing potentially hazardous foods and stated they should not be stored or reheated, yet inconsistencies were found in practice. The DSD and DON provided conflicting information on food storage, and no education was provided on safe handling.
A resident was found with Glucosamine/Chondroitin at their bedside without a physician's order and was not qualified to self-administer medications. The facility's policy requires an IDT assessment for self-administration, which indicated the resident was not a candidate due to fluctuating decision-making capacity. The resident self-administered the medication, brought by their daughter, posing potential risks. The DON confirmed that unqualified residents should not have bedside medications.
A facility failed to accurately code the MDS for a resident with ESRD receiving hemodialysis, potentially affecting individualized care plans. The MDS Coordinator confirmed the error, acknowledging the resident's ongoing dialysis treatments. The DON, Administrator, and Nurse Consultant were informed of the findings.
A facility failed to update the care plan for a resident who frequently removed their nasal cannula, which was necessary for oxygen administration. Despite staff awareness and regular checks, the care plan did not address the resident's behavior, potentially affecting the care provided. The issue was acknowledged by the facility's administration.
The facility failed to properly store medications and remove expired items from medication carts. Diclofenac sodium topical gel was stored with oral medications, risking cross-contamination, and two expired skin staple removers were found. LVNs confirmed these issues, and the DON acknowledged the need for better checks by staff.
A resident's enteral feeding water bag was mislabeled with another resident's name, leading to potential risks due to incomplete and inaccurate medical information. The error was confirmed by an LVN and acknowledged by the DON, Nurse Consultant, and Administrator. RN 2 indicated that both night and morning shift nurses should check the labels to prevent such errors.
A resident received the influenza vaccine without informed consent from their responsible party, as required by the facility's policy. The resident was unable to make medical decisions, and the oversight was confirmed by the DSD, Administrator, and DON during a review.
A resident alleged being hit by a staff member, but the facility failed to thoroughly investigate by not interviewing the resident's roommate or other residents who might have been affected. The DON confirmed the investigation was concluded without these necessary interviews, contrary to the facility's policy.
The facility failed to administer Xeloda medication as per physician's orders for a resident and did not follow up timely with the physician when another resident had a hypertensive episode. These lapses in care were confirmed through medical record reviews and staff interviews.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations.
Failure to Assess and Notify After Resident Found on Floor Mattress
Penalty
Summary
The facility failed to provide necessary care and services to prevent a fall incident for one of seven sampled residents. Specifically, when a resident with a history of falls and requiring substantial assistance for mobility and toileting was found lying on a floor mattress, the facility did not follow its own policies for post-fall assessment and notification. The facility's policies require that after any fall, a licensed nurse must immediately assess the resident, notify the physician and family, complete an incident report, and update the care plan. However, in this case, there was no documentation of an assessment, physician or family notification, or follow-up care and monitoring after the resident was found on the floor mattress. Interviews with staff confirmed that the incident was not recognized as a fall by the LVN who was informed, and therefore the required procedures were not initiated. The DON acknowledged that being found on the floor mattress should be considered a fall and that the fall policy should have been followed. The resident's medical record did not contain evidence of assessment or notification, and the DON was unaware of the incident until it was brought up during the survey. This failure to follow established protocols had the potential to negatively impact the resident's well-being.
Failure to Administer Prescribed GT Feeding and Water Flush Rates
Penalty
Summary
The facility failed to provide appropriate care and services related to gastrostomy tube (GT) management for two residents. For one resident, the prescribed enteral feeding rate of Glucerna 1.2 was 50 ml/hour, as ordered by the physician and documented in the care plan and nutritional assessment. However, observations revealed that the resident was receiving the feeding at a rate of 65 ml/hour, which was 15 ml/hour higher than the physician's order. This discrepancy was confirmed by both the nursing staff and a review of the medical records. For another resident, the physician's order specified a GT water flush of 35 ml/hour for 20 hours daily, totaling 700 ml/day. Despite this, the resident was observed receiving a water flush at a rate of 30 ml/hour, which was 5 ml/hour less than ordered. Nursing staff verified the order and acknowledged the lower rate being administered. Both residents were documented as lacking capacity to make medical decisions, and the deviations from prescribed care were confirmed through observation, staff interviews, and medical record review.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident by not ensuring the call light was within the resident's reach. Observations on two separate occasions showed the resident lying in bed with the call light clipped to the right corner of the mattress by the head of the bed, and the cord dangling off the bed, making it inaccessible to the resident. The resident's care plan specifically included an intervention to place the call light within reach due to a history of falls. The facility's policy also required staff to ensure call lights are easily accessible to residents when in bed or seated. Medical record review indicated the resident had clear speech, could sometimes make themselves understood, and had limitations in the range of motion in both upper extremities. The resident was able to use the call light when it was accessible. During an interview, a CNA confirmed the call light was not within reach and repositioned it accordingly. The DON stated that staff are expected to keep call lights within reach at all times.
Failure to Prevent Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications. One resident was administered Ozempic, a medication used to manage type 2 diabetes, despite having no diagnosis of diabetes mellitus (DM) as confirmed by the resident’s history and physical examination and a normal hemoglobin A1c level. The resident’s care plan did not address the use of Ozempic or include monitoring for its side effects. The Assistant Director of Nursing (ADON) confirmed that there was no care plan or monitoring in place for this medication and was unsure if the order had been clarified with the physician. Additionally, the same resident was given oxycodone 10 mg, prescribed for severe pain (pain level 7-10), on multiple occasions when the documented pain level was below the prescribed threshold, including several instances where the pain level was recorded as 0. The ADON verified that the medication should not have been administered when the resident had no pain and acknowledged that the medication should be given only as prescribed by the physician. The facility’s policy requires medications to be administered safely and as prescribed, but these requirements were not met in this case.
Medication Left Unattended at Bedside
Penalty
Summary
A licensed vocational nurse (LVN) left a white tablet inside an unlabeled clear cup unattended on a resident's bedside table. This action was observed during a medication pass, and the medication was not administered to the resident at that time. The resident was unable to self-administer the medication, and the LVN acknowledged that the medication should not have been left unattended and should have been taken back until the resident was ready to receive it. The facility's policy and procedure for medication administration states that medications must be administered in a safe manner, and if a resident is unavailable, the nurse should return later to administer the medication. Both the LVN and the Assistant Director of Nursing (ADON) confirmed that leaving the medication unattended on the bedside table was not in accordance with facility policy.
Failure to Administer Prescribed Medication as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to administer ketotifen, an antiallergic medication prescribed to help prevent asthma attacks, as ordered by a resident's physician. The facility's policy and procedure required medications to be administered as prescribed. Medical record review showed that the resident, who was cognitively intact and had a physician's order for ketotifen 1 mg capsules (two capsules twice daily for chronic urticaria), did not receive the medication on two consecutive days. The medication was not re-ordered in time, resulting in missed doses on the medication administration record (MAR) for those dates. The DON confirmed these findings during an interview and record review.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitation requirements in the kitchen, as evidenced by multiple observations of improper labeling, dating, and storage of food items. Opened food items in the freezer were not properly dated, and foods in the refrigerator were not labeled or dated correctly, with some items past their use-by date not being discarded. Additionally, juice boxes and thickeners were not labeled or dated, and food brought from outside for a resident was not properly labeled and stored. The kitchen utensils and equipment were not maintained in sanitary conditions, with observations of crusted residue on scoopers and spatulas, and debris in bins containing clean cooking utensils. Equipment was also found to be in poor condition, with a can opener having a chipped blade and portion servers with partially melted handles. Furthermore, there was significant ice buildup in bags of English muffins, and a sugar container was not properly covered. The kitchen staff did not adhere to proper hygiene practices, as one staff member with hairy forearms did not cover them during food preparation, and the same staff member failed to wash hands after using a dirty towel to clean surfaces before handling food. Additionally, expired sauces were found in a resident's room, which should have been labeled and stored in the refrigerator. These deficiencies had the potential to expose the medically vulnerable population of 81 residents to food-borne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement effective infection control practices, as evidenced by several deficiencies. The water management plan was not available, and the facility did not have a comprehensive program to address and monitor the growth of Legionella and other waterborne pathogens. The Maintenance Director was unable to provide documentation of a facility risk assessment or a completed water management plan, which should have included testing protocols and control measures. Additionally, the Administrator did not attend the quarterly infection control committee meetings, which are crucial for overseeing and implementing the infection control program. The facility also failed to ensure proper hand hygiene and personal protective equipment (PPE) usage among staff. The Laundry Attendant did not perform hand hygiene after handling soiled linens and before touching clean linens, and there were dirty items stored with clean linens. Staff members did not don appropriate PPE when providing care to residents with specific needs, such as checking blood sugar levels or assisting residents with PICC lines and surgical wounds. These lapses in infection control practices posed a risk for the transmission of disease-causing microorganisms to the residents. Specific residents were affected by these deficiencies. Resident 645, who had an open wound, was not properly attended to with the required PPE by the staff. Resident 745, with a PICC line and abdominal wounds, was not placed on Enhanced Barrier Precautions (EBP) as required, and the signage did not reflect the need for such precautions. Similarly, Resident 696, who was on EBP due to a pressure injury, was fed by a CNA who did not use the necessary gown and gloves. These failures highlight significant gaps in the facility's infection prevention and control program, directly impacting resident safety and care.
Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their care. For Resident 745, who was admitted with a diagnosis of a perforated gastric ulcer, there was a physician's order to measure the resident's abdominal girth every two days. However, the measurements for 3/3 and 3/5 were not documented, and the licensed nurse was unable to provide the measurements or confirm if they were compared to the baseline. This lack of documentation and comparison could potentially delay necessary medical intervention. For Resident 31, the facility failed to adhere to the physician's order regarding the administration of a stool softener. The order specified that the medication should be held if the resident had loose stools. During a medication administration observation, the LVN administered the stool softener without checking the resident's last bowel movement or asking if the resident had loose stools. The LVN acknowledged the oversight, and the DON confirmed that the nurse should have verified the resident's bowel movement status before administering the medication.
Failure to Apply Splint and Document Skin Assessment
Penalty
Summary
The facility failed to follow a physician's order for a resident, identified as Resident 80, regarding the application of an extension splint to the left elbow. The order specified that the splint should be applied for four to six hours a day on specific days of the week. However, during an observation, it was noted that the splint was not applied, and it was found in a plastic bag on the resident's cabinet. Additionally, there was no physician's order or care plan intervention to include a skin assessment when the splint was applied, which is crucial to prevent skin issues. Interviews with the Restorative Nursing Assistant (RNA) and a Registered Nurse (RN) revealed that although the splint was applied, there was no documentation of the exact times it was applied and removed, nor was there any documentation of a skin assessment. The RNA confirmed that she checked the skin after removing the splint but did not document this assessment. The RN acknowledged the lack of documentation and stated that a physician's order for skin assessment should have been obtained. The Director of Nursing (DON) was informed and verified these findings.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to provide the necessary care and services to prevent accidents for a resident identified as being at high risk for falls. The resident, who had severe cognitive impairment and required extensive assistance for activities of daily living, was observed without the required floor mats on both sides of the bed, as per the physician's order and care plan. The absence of these mats was noted during observations on two separate occasions, despite the resident's care plan and physician's order explicitly stating the need for bilateral floor mats to prevent or minimize injuries from falls. Interviews with facility staff, including a CNA, LVN, and RN, confirmed the resident's high fall risk and the requirement for floor mats. However, all staff acknowledged that the mats were not in place, despite the resident's history of falls and a previous incident of a witnessed fall. The Director of Nursing was informed of these findings and verified the deficiency, confirming that the necessary safety measures were not implemented as required by the resident's care plan and physician's order.
Deficiencies in IV and Enteral Feeding Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a PICC line, as baseline measurements of the PICC line external catheter length and arm circumference were not confirmed and documented in the medical record prior to administering IV antibiotics. Additionally, during a dressing change, the facility did not measure and document the PICC line external catheter length as required by the facility's policy and the resident's care plan. This oversight had the potential to delay the identification of catheter-related complications for the resident, who was admitted with a diagnosis of a perforated gastric ulcer and fluctuating capacity to understand and make decisions. The facility also failed to ensure that an enteral feeding water bag was accurately labeled with the correct resident's name. During an observation, it was found that a resident's enteral feeding water bag was incorrectly labeled with another resident's name. This error was verified by a licensed vocational nurse and confirmed by a registered nurse, who stated that enteral feeding bags should be checked by both night and morning shift nurses to prevent such errors. Interviews with the Director of Nursing, Administrator, and Nurse Consultant confirmed the findings of these deficiencies. The facility's policies and procedures were not followed, leading to potential risks in the administration of IV therapy and enteral feeding care. These failures were acknowledged by the facility's leadership during the survey process.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen therapy for two residents, leading to potential negative impacts on their medical conditions. For one resident, the oxygen was administered at a rate of 5 LPM instead of the prescribed 2 LPM, and there was no care plan developed for the use of oxygen. This discrepancy was confirmed by both a Registered Nurse Assistant (RNA) and a Licensed Vocational Nurse (LVN), who were unable to explain the increase in the oxygen rate. Additionally, the resident's care plans lacked documentation for oxygen use, which was verified by a Registered Nurse (RN). For another resident, the facility failed to maintain proper hygiene and equipment management for oxygen therapy. The resident's nasal cannula was observed touching the floor, and the nebulizer tubing was undated and improperly stored in a drawer. These observations were confirmed by an LVN, who acknowledged the issues and stated intentions to rectify them. The facility's Director of Nursing (DON) was informed and verified these findings, indicating a lapse in following the facility's policy for oxygen administration and equipment maintenance.
Deficiencies in Dialysis Care for a Resident
Penalty
Summary
The facility failed to provide necessary dialysis care and services for a resident, identified as Resident 34, who required such services. The deficiencies included a lack of assessment upon the resident's return from dialysis treatment, inaccurate documentation of fluid restriction monitoring, absence of an emergency dialysis kit at the resident's bedside, and an incomplete care plan that did not include transportation information for dialysis as per the facility's policies and procedures. Resident 34, who had end-stage renal disease (ESRD) and received hemodialysis, was not assessed for vital signs, weights, or hemodialysis site condition upon returning from dialysis sessions. The facility's records showed significant discrepancies in pre and post-dialysis weights, which were not clarified or communicated to the physician. Additionally, the resident's care plan lacked details about transportation arrangements to the dialysis center, and the emergency supplies required by the facility's policy were not available at the bedside. Interviews with staff, including an LVN and the DON, revealed that the facility's documentation practices were inadequate. The MAR did not accurately reflect the resident's fluid intake, and there was no documentation of the resident's departure and return times for dialysis. The DON acknowledged that the facility's procedures for dialysis communication and documentation were not followed, which contributed to the deficiencies in care for Resident 34.
Pharmaceutical Services Deficiency in Medication Administration
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services for two residents, leading to discrepancies in medication administration. For one resident, the active ingredients in the artificial tears medication provided did not match the physician's order. The resident was prescribed artificial tears ophthalmic solution 1% with carboxymethylcellulose sodium, but the medication available contained glycerin, hypromellose, and polyethylene glycol 400. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN) during a medication administration observation, and the Director of Nursing (DON) acknowledged the issue, stating that the exact medication should have been ordered from the pharmacy. In another instance, the facility failed to ensure that the Controlled Drug Record matched the Medication Administration Record (MAR) for a resident's oxycodone hydrochloride, a narcotic pain medication. The Antibiotic or Controlled Drug Record indicated that the resident received the medication at a specific time, but this administration was not documented in the MAR. This inconsistency was verified by an LVN, who was unable to explain the discrepancy as the resident had been in a different station previously. The DON confirmed that the nurse should have signed both the controlled drug record and the MAR immediately after administering the medication. These failures in pharmaceutical services had the potential to negatively affect the residents' well-being and posed a risk of diversion of controlled medication. The discrepancies in medication administration and documentation were acknowledged by the facility's administration, including the DON and the Administrator.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper procedures were followed in the administration of psychotropic medications for Resident 56, who had a diagnosis of dementia. The resident was prescribed Seroquel, an antipsychotic medication, without a documented diagnosis prior to its initiation. Additionally, the facility did not obtain informed consent or implement least restrictive measures before starting the medication. The care plan for the use and monitoring of Seroquel was not created until several days after the medication was prescribed, and there was no monitoring for side effects such as postural hypotension. Furthermore, Resident 56 was prescribed Ativan, an antianxiety medication, on an as-needed basis for agitation, but there was no clinical indication or documented behaviors of agitation to justify its use. The facility's policies and procedures required informed consent and a specific diagnosis for the use of psychotropic medications, which were not adhered to in this case. The lack of documentation and failure to follow established protocols placed the resident at risk for receiving unnecessary medications and potential adverse reactions. During an interview, RN 1 confirmed the deficiencies, acknowledging that informed consent was not obtained, and least restrictive measures were not implemented before administering Seroquel. Additionally, RN 1 verified that there was no clinical indication for the use of Seroquel or Ativan, and the care plan for Seroquel was delayed. The facility's failure to monitor for side effects and obtain informed consent for Ativan further highlighted the lapses in following proper procedures for psychotropic medication management.
Failure to Update Policy and Educate on Safe Food Handling
Penalty
Summary
The facility failed to update its policy and procedures (P&P) regarding the handling of outside food brought in by visitors to meet state regulations. The existing P&P, last revised in September 2017, discouraged visitors from bringing potentially hazardous foods such as meats, fish, eggs, custards, and milk products. It stated that such foods should be consumed immediately and not shared with other residents, and that food items brought into the facility could not be reheated or stored. However, interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed inconsistencies in the implementation of this policy. The DSD stated that visitors were encouraged to bring food, which must be consumed immediately or taken home if not consumed, and confirmed that the facility did not store or reheat outside food. In contrast, the DON mentioned that the facility labeled and stored food in the refrigerator for up to 72 hours, which contradicted the written P&P. Additionally, the facility failed to provide education to staff and visitors on safe food handling practices to prevent foodborne illnesses. The DSD confirmed that no education was provided to staff or visitors regarding safe food handling, despite the potential risk of foodborne illness from improperly handled outside food. This lack of education and the discrepancies between the stated policy and actual practices posed a risk to residents consuming food from outside sources. The findings were acknowledged by the DON, Administrator, Nurse Consultant, and Registered Dietitian (RD).
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the safe self-administration of medication for one resident, identified as Resident 745, who was found with a bottle of Glucosamine/Chondroitin at their bedside. This resident did not have a physician's order to keep the medication at the bedside and was not qualified to self-administer medications according to the facility's assessment. The facility's policy requires an interdisciplinary team (IDT) assessment to determine if a resident can safely self-administer medications, and Resident 745's assessment indicated they were not a candidate for self-administration due to fluctuating capacity to understand and make decisions. During an observation, it was noted that Resident 745 had self-administered the medication, which was brought to the facility by their daughter. The RN confirmed that the resident was not a candidate for self-administration and highlighted the potential risks of drug interactions or overconsumption. The Director of Nursing (DON) stated that residents not qualified to self-administer should not have medications at their bedside. The findings were acknowledged by the DON, Administrator, and Nurse Consultant.
Inaccurate MDS Coding for Dialysis Treatment
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident, which could impact the development of individualized care plans. Specifically, the MDS for a resident with End-Stage Renal Disease (ESRD) receiving hemodialysis was not coded to reflect the dialysis treatments. This oversight was identified during a medical record review initiated on March 5, 2025, and confirmed through an interview with the MDS Coordinator on March 6, 2025. The MDS Coordinator acknowledged that the resident had been receiving dialysis for over a year, and the MDS assessment was incorrectly coded. The Director of Nursing (DON), Administrator, and Nurse Consultant were informed of these findings on March 10, 2025.
Failure to Update Care Plan for Oxygen Management
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident 49, regarding the removal of oxygen. During an initial tour, Resident 49 was observed with a nasal cannula on their face, but the nasal prong was not in their nose. The nasal cannula was distributing oxygen at 2 liters per minute (LPM) and was connected to an oxygen concentrator. A medical record review showed that Resident 49 had a physician's order to administer oxygen at 2 LPM continuously to maintain oxygen saturation levels at 92% every shift. However, the care plan did not address the resident's behavior of pulling out the nasal cannula, which was verified by LVN 3 during an observation and interview. Further interviews revealed that the licensed nurses were aware of the resident's behavior and checked the nasal cannula every two hours. RN 2 confirmed the findings and stated that visual checks should be conducted every two hours, and adjustments should be made to prevent the nasal cannula from being dislodged. Despite these practices, the care plan was not updated to reflect the resident's behavior, which could potentially impact the necessary care and services provided to Resident 49. The Administrator and Director of Nursing (DON) were informed and acknowledged the findings.
Improper Storage and Expired Items Found in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and separation of medications, as observed during an inspection of Medication Cart B. The inspection revealed that diclofenac sodium topical gel, an external medication, was stored alongside oral medications such as calcium carbonate tablets, ferrous sulfate tablets, and acidophilus lactobacilli probiotic capsules. LVN 5 confirmed the improper storage and acknowledged that these medications should not be stored together due to the risk of cross-contamination. The Director of Nursing (DON) admitted that the licensed nurse should have checked the medication cart at the beginning of each shift to ensure proper separation of external and internal medications. Additionally, during an inspection of Medication Cart D, two expired skin staple removers were found. LVN 6 verified the expiration of these items and recognized the need to check expiration dates more diligently in the future. The DON acknowledged these findings and stated that the treatment nurse should have checked the treatment cart for expired items before starting treatments. The Administrator and DON were informed of these deficiencies and acknowledged the findings.
Mislabeling of Enteral Feeding Water Bag
Penalty
Summary
The facility failed to ensure that the enteral feeding water bag for one resident was accurately labeled, leading to a potential risk of unmet care needs due to incomplete and inaccurate medical information. During an observation, it was noted that the enteral feeding water bag for Resident 30 was incorrectly labeled with the name of another resident, Resident 46. This error was confirmed by LVN 8 during a concurrent observation and interview. Further interviews with RN 2 revealed that the enteral feeding bags should be checked by licensed nurses from both the night and morning shifts to prevent such errors. The Director of Nursing, Nurse Consultant, and Administrator also verified the finding.
Failure to Obtain Informed Consent for Influenza Vaccine
Penalty
Summary
The facility failed to obtain informed consent for the administration of the influenza vaccine to a resident, identified as Resident 38, during the 2024-2025 influenza season. Resident 38 was administered the influenza vaccine on September 20, 2024, without obtaining written consent from the resident's responsible party, as required by the facility's policy and procedure. The policy, revised in January 2024, mandates that written, informed consent be obtained from the resident or their decision maker prior to vaccine administration. A review of Resident 38's medical records revealed that the resident was unable to make medical decisions, necessitating consent from a responsible party. However, no such consent was documented. The Director of Staff Development (DSD) confirmed the oversight during an interview and acknowledged the failure to secure informed consent before administering the vaccine. The Administrator and Director of Nursing (DON) also acknowledged these findings, confirming the deficiency in the facility's adherence to its vaccination policy.
Failure to Investigate Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who claimed to have been hit in the head by a staff member. The facility's policy and procedure for abuse reporting and prevention required that all reported incidents of abuse be thoroughly investigated by the Abuse Coordinator or designee, including interviews with involved residents and other parties with knowledge of the alleged incident. However, the facility did not document interviews with Resident 1's roommate or other residents who might have been subjected to abuse by the alleged perpetrator. The Director of Nursing (DON) confirmed that the investigation process should include interviews with the alleged victim, involved staff, family, and anyone present at the time of the incident, including the roommate if the incident occurred in the resident's room. Despite this, the facility's investigation file lacked documentation of interviews with other alert residents who received care from the alleged perpetrator. The DON verified that the allegation of abuse was concluded without these interviews being conducted.
Failure to Administer Medication and Follow Up on Change of Condition
Penalty
Summary
The facility failed to ensure the Xeloda (capecitabine) medication was administered as per the physician's orders for Resident 5. Resident 5 was supposed to receive the medication in a specific cycle of two weeks on and one week off. However, the medical records showed inconsistencies in the administration of the medication, with missed doses in October 2023. Despite follow-up appointments with the oncologist, there was no documented evidence of the physician's orders being followed, and the medication was not administered as required. Interviews with the nursing staff and the Director of Nursing (DON) confirmed these findings and revealed a lack of proper follow-up and documentation regarding the medication administration. The facility also failed to follow up with the physician timely when Resident 4 had a change of condition involving an episode of hypertension with a blood pressure reading of 180/100 mmHg. Despite the high blood pressure readings and the resident's unresponsiveness, there was no documented evidence of timely notification to the physician or the Medical Director. The resident's condition was not adequately addressed, and the necessary follow-up actions were not taken. Interviews with the nursing staff and the DON confirmed that the physician was not contacted promptly, and there was no follow-up with the Medical Director as required by the facility's policy. These failures had the potential to negatively affect the residents' health conditions and well-being. The facility's policies and procedures for significant changes in condition and medication administration were not followed, leading to lapses in care for Residents 4 and 5. The lack of proper documentation, follow-up, and adherence to physician's orders contributed to these deficiencies, as confirmed by the medical record reviews and staff interviews.
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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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