Grancell Village Of The Jewish Homes For The Aging
Inspection history, citations, penalties and survey trends for this long-term care facility in Reseda, California.
- Location
- 7150 Tampa Ave, Reseda, California 91335
- CMS Provider Number
- 555137
- Inspections on file
- 37
- Latest survey
- January 16, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Grancell Village Of The Jewish Homes For The Aging during CMS and state inspections, most recent first.
The facility failed to inform cognitively intact residents about the existence and location of the most recent survey results, despite having survey binders posted near dining areas and a nursing station. Multiple residents with conditions such as HTN, osteoarthritis, hypotension, anemia, and muscle weakness, all assessed as capable of daily decision-making, reported during a resident council interview that they were unaware survey results were available or where they were kept. Review of resident council minutes showed no evidence that survey results were discussed, and the AD acknowledged not telling residents about the survey results or their location, while the DON confirmed residents should have been made aware of this information.
Surveyors found that staff failed to inform a cognitively intact resident about the names and purposes of multiple medications at the time of administration, despite facility policy and the resident’s right to make decisions about treatment. In a separate case, another cognitively intact resident had bed side rails in use without a properly completed informed consent form, which lacked the resident or representative signature, the clinical reason for rail use, and nurse verification, contrary to the facility’s bed rail policy requiring informed, voluntary consent before installation.
A resident with sepsis and Parkinson’s disease, who could communicate needs but required substantial assistance with ADLs, was observed seated in a wheelchair with an empty cup and gesturing for more while the call light remained on the bed and out of reach. A CNA acknowledged forgetting to place the call light within reach, despite facility policy and the DON’s expectation that call lights be accessible so residents can communicate needs such as requests for water.
A resident with DM and intact decision-making capacity had an order for daily Novolog insulin. Over multiple days, the resident refused the scheduled insulin doses, as documented on the MAR. However, review of progress notes showed no documentation that the physician was notified of these repeated refusals, despite facility policy requiring notification of the DON and physician when two consecutive doses are refused or withheld. The DON and an LVN acknowledged that the physician should have been informed and that the policy was not followed, resulting in a deficiency for failure to notify the physician of repeated insulin refusals.
Surveyors found that a medication cart computer was left unattended with an open eMAR displaying a resident’s information between a nursing station and dining room. An RN later approached, saw the visible PHI, minimized the screen, and reported the incident to the charge nurse. The LVN responsible admitted she had left the screen open and acknowledged it could expose residents’ personal information, while the DON confirmed this was a HIPAA-related privacy and confidentiality concern. Facility policies on medication administration and protected health information require MARs and electronic screens to be closed or covered and not left open and unattended.
The facility failed to create comprehensive care plans for three residents regarding bed side rail use and one resident for opioid medication management. Despite assessments indicating the need for such plans, they were not developed, posing potential risks to resident safety and care. The Clinical Manager and MDS Nurse acknowledged these deficiencies, highlighting the importance of adhering to facility policies for individualized care planning.
The facility failed to act on a consultant pharmacist's recommendations for two residents. One resident did not receive a timely lipid panel blood draw despite having hyperlipidemia and being on Lipitor. Another resident continued to receive Seroquel without a clear indication or measurable target behavior, as the facility did not clarify the behavior manifestation for its use. These oversights were acknowledged by the facility's staff, highlighting deficiencies in medication management.
A resident with intact cognition and requiring assistance with daily activities was found to have their call light out of reach, potentially delaying needed services. The facility's policy mandates that call lights be within easy reach to ensure residents' needs are met, which was not adhered to in this instance.
A facility failed to transmit the MDS for a resident to CMS within the required timeframe. The resident, admitted with hydronephrosis, acute kidney failure, and depression, was discharged without the completion and submission of the MDS assessment. The MDSN and DON acknowledged the oversight, which had the potential to delay services and payment.
A facility failed to develop a baseline care plan within 48 hours of admission for a resident, specifically addressing pain management. The resident, admitted with chronic obstructive pulmonary disease and gastro-esophageal reflux disease, had physician's orders for pain medications but lacked a care plan detailing goals and interventions for pain management. The Clinical Manager confirmed the omission, which was against the facility's policy requiring a baseline care plan to be completed within 48 hours of admission.
The facility failed to update the care plan for a resident with edema, not reflecting her refusal to elevate her legs and omitting a physician's order for ace wraps. Another resident's family was not informed about the need for non-skid socks, despite the resident's fall prevention care plan. Both cases highlight a lack of adherence to care plan policies, potentially compromising resident care.
A resident's discharge from an LTC facility was mishandled due to failure to develop and review a discharge plan with the resident and family, and incomplete documentation of discharge progress notes. The resident, with a history of falling and muscle weakness, was discharged without proper documentation of the discharge plan meeting, including participants and final plans. Facility staff interviews revealed miscommunication and errors in documentation, contrary to the facility's policies.
A facility failed to implement a Bladder and Bowel Retraining Program for a resident, despite being identified as a good candidate, leading to the development of a Stage 1 pressure ulcer. The resident, admitted with conditions including hypertension and COPD, was incontinent and showed willingness to participate in retraining. The facility's policies required immediate placement on a retraining program, but this was not done, increasing the risk of skin tissue damage.
A facility failed to prevent complications of enteral feeding when an LVN did not check the residual volume in a resident's stomach before administering medication via G-tube. The resident, with severe cognitive impairment and total dependence on staff, had a care plan to minimize infection risk at the G-tube site. Despite an order to check tube placement and residual every shift, the LVN only confirmed tube placement and flushed it with water, neglecting to aspirate stomach contents. The DON acknowledged the oversight, which risked feeding intolerance.
A facility failed to clarify a physician's order for Norco 10/325 mg, leading to inadequate pain management for a resident with chronic pain syndrome. The order lacked a specified pain scale, resulting in inconsistent documentation and administration of the medication. The resident's MAR showed instances where the drug was given without a documented pain assessment, contrary to the facility's pain management policy. The Clinical Manager recognized the need for order clarification to prevent adverse effects.
A resident was prescribed Seroquel for mood disorder manifested by agitation without a clear indication or specific behavior to monitor, leading to a lack of proper documentation and monitoring. The Clinical Manager failed to act on the Consultant Pharmacist's recommendation to review the diagnosis and behavior manifestation, and the Director of Nursing confirmed the absence of specific measurable behaviors for monitoring. This resulted in the resident receiving Seroquel without proper oversight.
The facility failed to follow its Enhanced Barrier Precautions policy when an LVN did not wear a gown while administering medication via G-tube to a resident, increasing the risk of infection. Additionally, a resident's nasal cannula oxygen tubing was observed touching the floor, posing a contamination risk. These lapses in infection control practices were confirmed by facility staff.
A resident was not permitted to return to their LTC facility after hospitalization, despite a bed hold being in place. The facility declined the hospital's referral, citing the resident's need for acute psychiatric management, even though the hospital's physician cleared the resident for discharge. This led to the resident being discharged to a different facility, violating their rights and resulting in displacement.
A resident with intact cognition and multiple diagnoses reported being hit by a nurse, but the LTC facility failed to report the allegation to the SSA within the required two-hour timeframe. The delay was due to the late communication of the incident to the facility's administrator, resulting in a postponed inspection and potential risk to other residents.
Failure to Inform Cognitively Intact Residents of Survey Results and Their Location
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were notified of the existence and location of the most recent standard survey results, as required by 42 CFR 483.10(g)(10)-(11). Ten cognitively intact residents, each with various medical diagnoses such as hypertension, osteoarthritis, hypotension, anemia, and generalized muscle weakness, were identified as not being informed about the survey results. These residents had documented decision-making capacity on their MDS assessments, indicating they were capable of understanding and using such information. Review of resident council meeting minutes for multiple dates showed no documentation that residents were informed about the survey results or where they could be found. During a resident council interview, ten of eleven participating residents stated they were not aware that survey results were available for them to review and did not know where the survey results were located. They also reported that no one had told them about the survey results. Surveyors observed that survey result binders containing the most recent recertification survey were posted in holders near dining room entrances and a nursing station on various floors, indicating that the physical posting requirement had been met. However, during interviews, the Activities Director acknowledged that she had not informed residents during resident council meetings about the existence or location of these survey results, despite recognizing the importance of residents knowing about them. The DON similarly stated that residents should be made aware of the previous year’s survey results and their location, confirming that residents’ rights to examine survey results and receive related information had not been fully implemented in practice.
Plan Of Correction
F-577 Corrective Action for Affected Residents: The Administrator or designee met with Resident 189, Resident 30, Resident 51, Resident 59, Resident 62, Resident 65, Resident 83, Resident 203, Resident 219, and Resident 2, during resident council or individually to inform them of the existence of the most recent survey results, the location of the survey results binder on each floor near the dining room entrance and next to the consumer board in JEK, and their right to review these results at any time. The Administrator or designee provided each resident with written information documenting the location of the survey results on their respective floors. Identifying other Residents having the Potential to be Affected: The Administrator or designee met with residents during resident council meeting on 3/19/26 and informed them of the existence and location of the most recent survey results. The Director of Activities made announcements in all main dining rooms to inform them of the existence of the survey results dated, the location of the survey results binder on their floor, and their right to review the results. Measures put into place or Systemic Changes: The Administrator or designee will notify residents of the existence and location of survey results during the resident council meetings at least quarterly. The Activities Director (AD) or designee added a standing agenda item to resident council meetings to inform residents of the existence and location of survey results, ensuring this information is communicated at least quarterly. The AD or designee will document this notification in the resident council meeting minutes. Plan to Monitor Performance: Beginning 4/6/26, Director of Activities or designee will ask residents during resident council and during randomly to verify they are aware of location and existence of survey findings. The Director of Activities or designee will report audit results, including any identified deficiencies and corrective actions taken, to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Failure to Inform Residents About Medications and Obtain Informed Consent for Bed Rails
Penalty
Summary
The deficiency involves failure to uphold residents' rights to be informed of and participate in their treatment decisions, specifically regarding medication administration and use of bed side rails. For one resident with chronic respiratory failure and age-related osteoporosis, whose MDS documented intact cognitive skills and partial/moderate assistance needs for ADLs, a nurse administered multiple medications, including midodrine, Senokot-S, Trelegy Ellipta, Miralax, Tylenol, and Systane eye drops, without informing the resident of the name and indication of each medication at the time of administration. When questioned, the nurse stated she was not aware that providing this information was required by facility policy. The DON confirmed that residents have the right to be informed about their care, including medications, and that not providing this information restricted the resident from exercising this right. The facility’s administrative manual stated that residents have the right to make decisions about their medical condition and to accept or refuse proposed treatment. The deficiency also includes failure to obtain informed consent for the use of bed side rails for another resident with hypertension and dysphagia, whose MDS also showed intact cognitive skills and partial/moderate assistance needs for ADLs. Review of the resident’s "Informed Consent for Bed Rail Use" form showed it was incomplete, lacking the resident’s or representative’s signature, the reason for side rail use, and the licensed nurse’s signature verifying that consent was obtained. The DON acknowledged that consent had not been obtained and no explanation was provided regarding the reason for side rail use. The facility’s bed rail policy required that, when the IDT determines bed rails are appropriate, the "Informed Consent for Bed Rail Use" form must be used prior to installation, with information presented in an understandable manner and consent given voluntarily and free from coercion.
Plan Of Correction
Joyce Eisenberg - Keefer Medical Center makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. Joyce Eisenberg - Keefer Medical Center is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes Joyce Eisenberg - Keefer Medical Center's written credible allegation of compliance for the deficiencies noted. F-552 Corrective Action for Affected Residents: The Director of Nursing (DON) met with LVN involved to provide 1:1 education regarding requirement. LVN reviewed Resident 59's current medication regimen and ensured that Resident 59 received information regarding the name of each medication, its indication, and the right to refuse medications and resident confirmed she is aware of medications as above. RN Unit Manager completed a comprehensive review of Resident 101's bed rail use and obtained informed consent from Resident 101, including explanation of the reason for bed rail use, risks, benefits, and alternatives. The DON or designee ensured that the Informed Consent for Bed Rail Use form was completed with appropriate signatures including Resident 101 and the licensed nurse verifying that consent was obtained. 3/17/26 Identifying other Residents having the Potential to be Affected: As most residents have medications, DON or designee provided education to licensed nurses on the requirement to provide information regarding the name of each medication, its indication, and the right to refuse medications as applicable. DON educated residents during the 3/19/26 Resident Council meeting regarding their right to be informed on their medications.The Medical Records Manager conducted an audit of other residents currently utilizing bed rails. The RN Unit Managers reviewed the Informed Consent for Bed Rail Use forms to ensure that informed consent was obtained, forms are completed in their entirety including resident or resident representative signature, reason for use, and licensed nurse signature. For residents with incomplete consent forms, the RN Unit Managers or designee obtained proper informed consent including explanation of risks, benefits, and alternatives. Measures put into place or Systemic Changes: The DON or designee in-serviced LVNs and RNs on the requirement to inform residents of medication names and indications prior to administration, the resident's right to be informed of and participate in treatment decisions, and the resident's right to refuse medications. The in-service included review of the facility's Administrative Manual regarding resident rights to make decisions about medical treatment and to accept or refuse proposed treatment.The DON or designee in-serviced LVNs and RNs on the facility's Bed Rails policy and procedure, including the requirement to obtain informed consent prior to bed rail installation, proper completion of the Informed Consent for Bed Rail Use form including resident or resident representative signature, documentation of the reason for bed rail use, explanation of risks, benefits, and alternatives, and licensed nurse signature verifying consent was obtained. Plan to Monitor Performance: RN Unit Manager or designee will begin conducting medication administration observations for a sample of residents with intact cognitive skills for daily decision making. The observations will verify that nursing staff inform residents of medication names and indications prior to administration. These observations will be conducted weekly for four weeks, then monthly for three months. Medical Records department will begin auditing Informed Consent for Bed Rail Use forms for residents utilizing bed rails to ensure forms are completed in their entirety including resident or resident representative signature, reason for bed rail use, and licensed nurse signature. The audits will be conducted weekly. The "Stand Up Meeting Routine Questionnaire" form was updated to include verification of consent for bed rails. Medical Records Manager or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident’s call light was within reach, as required for reasonable accommodation of resident needs and preferences. The resident had been admitted with diagnoses including unspecified severe sepsis and Parkinson’s disease. According to the History and Physical, the resident was able to speak in full sentences, make her own needs known, and make simple medical decisions. The MDS documented that the resident usually made herself understood, usually understood others, and required substantial assistance with upper and lower body dressing, personal hygiene, and putting on and taking off shoes. During an observation in the resident’s room, the resident was seated in a wheelchair with a bedside table in front, positioned between the bed and the entrance door. The resident lifted an empty cup and gestured for more, but the call light, located on the bed, was out of reach. In a concurrent interview, the CNA assigned to the resident stated she had forgotten to place the call light next to the resident and acknowledged that the call light should be within reach so the resident could communicate with staff, including to request water. The DON later stated that all call lights should be within each resident’s reach so staff can attend to their needs timely, and the facility’s “Answering the Call Light” policy indicated staff must ensure the call light is accessible to the resident.
Plan Of Correction
F-558 Corrective Action for Affected Residents: On 3/10/2026, Certified Nursing Assistant (CNA 1) immediately placed Resident 72's call light within reach. Identifying other Residents having the Potential to be Affected: RN Unit Managers conducted facility-wide room checks of current residents to ensure that call-lights were within reach and accessible to residents based on their individual needs and preferences. Out of 62 residents with limited mobility while in their room, 3 were found to not have the call light within reach. Any residents found with call lights out of reach had immediate corrective action taken to place call lights within reach by education to the responsible nurse 3/31/26. Measures put into place or Systemic Changes: The DON and/or Director of Education in-serviced Licensed nurses and Certified Nursing Assistants on the facility policy and procedure titled "Answering the Call Light," with emphasis on ensuring call lights remain within reach and accessible to residents at all times, including when residents are repositioned, moved to wheelchairs, or transitioned between locations. The in-service included education on assessing individual resident needs and preferences for call light placement based on physical limitations, mobility status, and cognitive abilities. Attendance records and lesson plans were maintained. Plan to Monitor Performance: Beginning 4/6/2026, the RN Unit Manager or designee will conduct random room audits of a minimum of 5 rooms per floor per week for four consecutive weeks, to verify that call lights are within reach and accessible to residents based on their individual needs and positioning. If deficiencies are identified during audits, immediate corrective action will be taken and the responsible staff member will receive re-education and supervisory intervention as appropriate. The DON or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Failure to Notify Physician of Repeated Insulin Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when a resident repeatedly refused ordered insulin injections, contrary to federal requirements for notification of significant changes and the facility’s own policy. The resident, who had diabetes mellitus with diabetic polyneuropathy and peripheral vascular disease, was originally admitted in 2023 and re-admitted in 2025. A History and Physical dated 2/27/2026 documented that the resident had decision-making capacity and an HbA1c of 8.9%, above the stated goal of less than 8%. The resident’s MDS indicated intact cognition for daily decision-making. The physician’s order, effective since 3/21/2025, directed administration of Novolog 8 units subcutaneously once daily at 7:30 a.m. for diabetes management, with instructions to hold the dose if blood sugar was less than 100 mg/dL. Review of the MAR for 3/1/2026 to 3/10/2026 showed that the resident refused the scheduled Novolog injections on multiple mornings: 3/1, 3/4, 3/5, 3/6, 3/7, and 3/9. The DON confirmed that the order required daily administration and acknowledged that the resident had a tendency to refuse insulin injections. Review of progress notes for the same period, conducted with the DON and later with an LVN, revealed no documented evidence that the physician was informed of the repeated insulin refusals. Both the DON and LVN stated that licensed nurses should have notified the physician of these refusals, particularly when they occurred on consecutive days. The facility’s “Medication Administration” policy, revised 4/16/2025, specified that the DON and attending physician must be notified when two consecutive doses of medication are refused or withheld. The DON confirmed that this policy was not followed in the resident’s case, resulting in the cited deficiency for failure to notify the physician of repeated insulin refusals.
Plan Of Correction
Corrective Action for Affected Residents: On 3/12/2026, the RN Unit Manager notified Resident 94's physician of the multiple insulin refusals that occurred on 3/1/2026, 3/4/2026, 3/5/2026, 3/6/2026, 3/7/2026, and 3/9/2026. On 3/12/2026, the RN Unit Manager obtained physician orders for Resident 94 regarding the management of insulin refusals and alternative diabetes management strategies. Identifying other Residents having the Potential to be Affected: On 3/25/26, the Medical Records Manager conducted an audit of the Medication Administration Records (MARs) for residents receiving insulin for the period of 3/1/2026 through 3/25/2026 to identify instances where residents refused two or more consecutive doses. No other residents in the facility were identified as refusing insulin. Measures put into place or Systemic Changes: The DON and/or Director of Education in-serviced licensed nurses on the "Medication Administration" policy, with emphasis on the requirement to notify physicians of two consecutive medication refusals, particularly insulin and other critical medications, and the importance of timely documentation of physician notification in the resident's progress notes. Plan to Monitor Performance: Beginning 4/6/2028, the contracted Medical Records Consultant will conduct random audits during scheduled monthly visits of the MARs and corresponding progress notes for residents receiving insulin or other critical medications to verify that licensed nurses are notifying physicians when residents refuse two consecutive doses and documenting such notifications appropriately. The audits will include a sample size of at least ten percent of residents receiving insulin or other critical medications. The DON or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Unattended eMAR Screen Compromises Resident Privacy
Penalty
Summary
Surveyors identified a deficiency related to resident privacy and confidentiality when a medication cart computer screen was left open and unattended, displaying a resident’s electronic Medication Administration Record (eMAR). During an observation on the second floor between the nursing station and main dining room, Team B’s medication cart (Medication Cart 3) was found unattended with the computer screen open to a resident’s eMAR. A registered nurse approached the cart, observed the open screen with resident information visible, minimized the window to remove the eMAR from view, and then left the cart to notify the charge nurse of the incident. In subsequent interviews, the RN who discovered the open screen stated that leaving the window open allowed residents’ information to be seen by others and referenced HIPAA concerns. The LVN responsible for the cart acknowledged that she had left the computer screen open and stated that she should not have done so because it could expose residents’ personal information and leave their privacy unprotected. The DON confirmed that leaving a computer screen open to a resident’s medical record is a HIPAA concern and compromises privacy and confidentiality. Review of facility policies on Medication Administration and Patient Protected Health Information showed that the MAR should be closed or covered when unattended and that employees using electronic devices must not leave them open and unattended, and should close documents and sign out of software programs, with screens not left open and unattended.
Plan Of Correction
F-583 Corrective Action for Affected Residents: On 3/9/2026, the medication cart computer screen was immediately closed by Registered Nurse (RN) 6 to prevent further unauthorized viewing of resident information. Only the surveyor saw the open computer screen. The LVN realized she left it open and returned to close it but the RN had already closed it. Identifying other Residents having the Potential to be Affected: No additional residents were identified as having their personal health information left viewable on unattended computer screens during follow up rounds. Measures put into place or Systemic Changes: RN Unit Manager (RN 6) met with Licensed Vocational Nurse (LVN) 8 to provide supervisory intervention regarding the importance of closing computer screens displaying resident information when stepping away from medication carts to prevent unauthorized disclosure of protected health information. The DON and/or Director of Education in-serviced licensed nursing staff (Registered Nurses and Licensed Vocational Nurses) on the facility's policies and procedures titled "Medication Administration" and "Patient Protected Health Information" with emphasis on: 1) closing or covering the Medication Administration Record when not attended to protect resident confidentiality; 2) closing documents and signing out of software programs when temporarily distracted by another duty; 3) ensuring computer screens are not left open and unattended; and 4) the HIPAA privacy implications of leaving resident information visible on unattended devices. Plan to Monitor Performance: Beginning 4/6/26, the RN Unit Manager or designee will conduct random observations of medication carts during medication passes weekly to ensure computer screens are closed when medication carts are unattended. The audit tool will document the date, time, medication cart number, whether the computer screen was closed when unattended, and any corrective action needed. If non-compliance is identified, the DON or designee will provide immediate re-education and supervisory intervention to the responsible licensed nurse. The DON or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Failure to Develop Comprehensive Care Plans for Bed Rails and Opioid Use
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents regarding the use of bed side rails. Resident 26, who was admitted with pulmonary hypertension and heart failure, did not have a care plan addressing the potential risk of bed side rail entrapment, despite having an intact cognitive ability and requiring assistance with activities of daily living. Similarly, Resident 50, with chronic obstructive pulmonary disease and chronic pain syndrome, and Resident 171, with dysphagia and chronic obstructive pulmonary disease, also lacked care plans for bed side rail use, even though assessments were completed. The Clinical Manager acknowledged that the Interdisciplinary Team should have developed these care plans to ensure resident safety and prevent injuries. Additionally, the facility failed to develop a care plan for Resident 44, who was receiving Hydrocodone-Acetaminophen for pain management. Resident 44, with a history of a displaced fracture of the left femur and type 2 diabetes, had mildly impaired cognitive skills and required significant assistance with daily activities. Despite a physician's order for opioid medication, there was no care plan to address the risks and side effects associated with its use. The MDS Nurse confirmed the absence of a care plan and highlighted the potential for overlooking medication side effects. The facility's policies and procedures, reviewed in October 2024, emphasized the need for individualized comprehensive care plans that include measurable objectives and timetables to meet residents' needs. However, the facility did not adhere to these policies, resulting in the lack of care plans for the use of bed side rails and opioid medication management. The Director of Nursing acknowledged the deficiency, noting the importance of developing care plans to address residents' problems and identified needs.
Failure to Act on Pharmacist Recommendations for Two Residents
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendation for two residents, leading to deficiencies in medication management. For one resident, the facility did not conduct a lipid panel blood draw as recommended by the consultant pharmacist. The resident, who was admitted with hyperlipidemia, had a medication regimen that included Lipitor, a drug used to treat high cholesterol. Despite the pharmacist's recommendation on 10/29/2024 to obtain a fasting lipid panel, the facility did not include this test in the physician's orders until 1/01/2025, resulting in a delay of over two months. This oversight was acknowledged by the Director of Nursing, who noted that the process should have been completed within one to two weeks of receiving the recommendation. For another resident, the facility failed to clarify the behavior manifestation for the use of Seroquel, a psychoactive medication. The resident, diagnosed with Alzheimer's disease and depression, was prescribed Seroquel for mood disorder manifested by agitation. However, the consultant pharmacist noted that the diagnosis and behavior were not appropriately documented, and the behavior of agitation was too subjective. Despite the recommendation to review and clarify the use of Seroquel, the facility did not act upon this advice. The Clinical Manager admitted to forgetting to follow up on the recommendation, resulting in the continued administration of Seroquel without a clear indication or measurable target behavior. The facility's policies and procedures require that psychotropic medications have an appropriate diagnosis and measurable target behaviors for monitoring. However, in the case of the second resident, the physician's order to monitor behavior was discontinued and not reactivated, leading to a lack of monitoring and documentation. The Director of Nursing acknowledged that the oversight in acting upon the consultant pharmacist's recommendation could impact the resident's quality of life, as the effectiveness of the medication could not be measured without specific behaviors to monitor.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 171, which could potentially delay the provision of services and result in unmet needs. Resident 171 was admitted with diagnoses including dysphagia and chronic obstructive pulmonary disease, and required substantial assistance with daily activities such as toileting hygiene, showering, dressing, and moderate assistance with personal hygiene. During an observation, it was noted that the call light cord was hanging on the bed siderail with the call button at the bottom of the bed, out of the resident's reach. Resident 171 expressed a need for assistance and was unaware of the call light's location. A registered nurse confirmed the observation that the call light button was positioned below the bed and stated that it should be within the resident's reach to call for assistance. The Director of Nursing also confirmed that the facility's policy requires call lights to be within easy reach of residents to ensure their needs are met. The facility's policy, last reviewed in October 2024, emphasizes the importance of having call lights accessible to residents to prevent frustration and potential falls or injuries.
Failure to Transmit MDS Timely for a Resident
Penalty
Summary
The facility failed to ensure the timely transmission of the Minimum Data Set (MDS) for a resident, identified as Resident 22, to the Centers for Medicare and Medicaid Services (CMS) system. Resident 22 was admitted with diagnoses including hydronephrosis, acute kidney failure, and depression. The resident had intact cognition and the capacity to understand and make decisions. The MDS assessment for Resident 22, dated 8/25/2024, was not submitted to CMS within the required timeframe. The resident was discharged on 9/7/2024, but the discharge MDS assessment was not completed or submitted as required. During interviews, the Minimum Data Set Nurse (MDSN) and the Director of Nursing (DON) acknowledged the oversight. The MDSN confirmed that the discharge assessment was not completed, and the DON stated that the assessment should have been submitted within 14 days of discharge. The facility's failure to transmit the MDS data timely had the potential to delay services and payment for Resident 22. The facility's policy, as outlined in the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, mandates that all MDS assessments be submitted within 14 days of completion.
Failure to Develop Baseline Care Plan for Pain Management
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, specifically addressing pain management. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease and gastro-esophageal reflux disease, required substantial assistance with daily activities and had intact cognition. Despite having physician's orders for pain management medications such as Meloxicam, Acetaminophen, and Tramadol, the baseline care plan did not include goals and interventions for the resident's pain management. During an interview and record review, the Clinical Manager acknowledged that the baseline care plan, which should have been completed within 48 hours of admission, was missing essential components related to the resident's pain management. The facility's policy mandates the development of a baseline care plan to provide effective and person-centered care, including addressing health and safety concerns immediately upon admission. The absence of a care plan for pain management was identified as a deficiency, potentially leading to ineffective management of the resident's pain.
Failure to Update Care Plans and Engage Family Members
Penalty
Summary
The facility failed to update and revise the care plan for Resident 2, who was diagnosed with conditions including unspecified dementia, edema, and cellulitis. The resident was prescribed Lasix for bilateral lower extremity edema, which required specific interventions such as elevating the legs to manage fluid volume deficit and electrolyte imbalance. However, observations revealed that Resident 2's legs were not elevated as per the care plan, and the resident expressed refusal to have her legs elevated. Despite this refusal, the care plan was not updated to reflect the resident's current condition and preferences, nor did it include the physician's order to apply ace wrap to the resident's legs. This oversight was acknowledged by the MDS Nurse and the Director of Nursing, who confirmed that the care plan had not been revised to incorporate these critical elements. The facility also failed to engage Family Member 2 (FM2) in the care planning process for Resident 34, who had severe cognitive impairment and was dependent on staff for various activities of daily living. Resident 34's care plan included an intervention to wear non-skid socks to prevent falls, but observations showed the resident wearing regular socks brought in by a family member. There was no documentation indicating that FM2 was informed about the necessity of non-skid socks, which was a crucial part of the fall prevention strategy. The Director of Nursing emphasized the importance of involving family members in the care planning process to prevent incidents like falls. The facility's policy and procedure on care plans require that they be reviewed and revised quarterly or as changes in the resident's condition dictate. However, in both cases, the care plans were not updated to reflect the residents' current needs and conditions. This failure to adhere to the facility's policy and procedure potentially compromised the quality of care and supervision provided to the residents, as acknowledged by the Director of Nursing.
Failure in Discharge Planning and Documentation
Penalty
Summary
The facility failed to adhere to its policy and procedure for discharge planning for a resident, identified as Resident 21, who was investigated under a closed record review. The deficiency involved the lack of a developed discharge plan that was reviewed with the resident and/or his family at least 24 hours before discharge. Additionally, there was incomplete documentation of the resident's discharge progress notes, which placed the resident at risk of not receiving necessary care and services related to his discharge goals and needs. Resident 21 was admitted to the facility with a displaced trimalleolar fracture, a history of falling, and muscle weakness. The resident's cognitive skills for daily decision-making were intact, and he required substantial assistance for various activities of daily living. The discharge plan initially indicated that the resident might go home with his wife, but there was a lack of documentation regarding the discharge plan meeting, including the participants and the final discharge plan. The discharge instructions were completed on the day of discharge, contrary to the facility's policy of completing them 24 hours prior. Interviews with facility staff revealed confusion and miscommunication regarding the discharge process. The Medical Record Director mistakenly documented that the resident was discharged to an assisted living facility, while the Social Worker failed to note changes in the discharge plan. The Director of Nursing confirmed that the discharge notes were incomplete, lacking essential information such as the discharge address and mode of transportation. The facility's policies required thorough documentation to ensure effective discharge planning, which was not followed in this case.
Failure to Implement Bladder and Bowel Retraining Program
Penalty
Summary
The facility failed to implement a Bladder and Bowel Retraining Program for a resident, identified as a good candidate for the program, to prevent the development of skin impairment. The resident, admitted with diagnoses including hypertension and chronic obstructive pulmonary disease, was assessed as incontinent of bowel and urine since admission. Despite being oriented and aware, the resident showed willingness to participate in retraining, scoring a four on the Bowel & Bladder Admission assessment, indicating suitability for retraining. The Clinical Manager acknowledged that the resident's incontinence could lead to pressure ulcers and skin breakdown, and that retraining could have prevented the development of a Stage 1 pressure ulcer on the resident's left buttock. The pressure ulcer was identified on a safety event report dated shortly after admission. The facility's policy required immediate placement on a retraining program for residents identified as good candidates, but this was not done, leading to the resident's increased risk of skin tissue damage. Interviews with staff and the resident revealed that the resident could feel the urge to urinate or move her bowels but was not assisted to the bathroom in time, resulting in incontinence. The facility's policies on wound and skin management and bowel and bladder programs emphasized the importance of preventative measures and individualized care plans to maintain skin integrity and prevent complications. However, these policies were not followed, contributing to the deficiency.
Failure to Check Residual Volume Before G-Tube Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a gastrostomy tube (G-tube). The deficiency was identified when a Licensed Vocational Nurse (LVN) did not check the residual volume in the resident's stomach before administering medication through the G-tube. This oversight was observed during a medication administration task, where the LVN confirmed the G-tube placement and flushed it with water but neglected to aspirate the stomach contents to check for residual volume, which is a necessary step to ensure the therapeutic effect of the medication. The resident involved had a history of Parkinson's disease, depression, and severely impaired cognition, making them totally dependent on staff for all activities of daily living. The resident's care plan included a goal to minimize the risk of infection at the G-tube site, and there was an existing order to check tube placement and residual every shift before administering medications and starting feeding. The facility's policy on enteral feeding tube drug administration also required the nurse to follow procedures for proper care and monitoring, including checking residual volume. The Director of Nursing confirmed that the LVN should have followed the procedure, and the failure to do so placed the resident at risk for feeding intolerance.
Inadequate Pain Management Due to Unclear Physician's Order
Penalty
Summary
The facility failed to ensure proper clarification of a physician's order for Hydrocodone-Acetaminophen (Norco 10/325 mg) for a resident, which led to inadequate pain management. The physician's order did not specify the pain scale rating required for administering the medication, resulting in inconsistent documentation and administration of the drug. On several occasions, the medication was given without a documented pain assessment, and the reasons for administration were not aligned with the facility's pain management policy. This oversight was identified during a review of the resident's Medication Administration Record (MAR) and physician's orders. The resident involved had a history of chronic obstructive pulmonary disease and chronic pain syndrome, requiring substantial assistance with daily activities. The facility's Nursing Policy and Procedure on Pain Management emphasized the need for accurate pain assessment using a numerical pain scale. However, the lack of a specified pain scale in the physician's order led to potential risks of adverse drug effects, such as constipation and respiratory depression. The Clinical Manager acknowledged the need for clarification of the physician's order to prevent confusion and ensure effective pain management for the resident.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary use of psychotropic medications, specifically Seroquel, by not monitoring specific, measurable target behaviors related to its use. The resident, who was admitted with diagnoses including Alzheimer's disease, depression, and unspecified mood affective disorder, was prescribed Seroquel for mood disorder manifested by agitation. However, the facility did not have a clear indication or specific behavior to monitor, which is required for the administration of psychotropic medications. The Clinical Manager (CM) acknowledged that the order for Seroquel did not include a clear indication and specific behavior to be monitored, and that agitation is considered a subjective behavior. The CM admitted that the order to monitor the resident's behavior was discontinued and not reactivated, leading to a lack of monitoring and documentation of the resident's behavior. The Consultant Pharmacist had recommended reviewing the diagnosis and behavior manifestation to ensure appropriate use of Seroquel, but the CM failed to act upon this recommendation. The Director of Nursing (DON) confirmed that the physician's order for Seroquel lacked a specific measurable behavior to be monitored, and that the behavior of agitation did not describe the resident's specific behaviors related to the use of Seroquel. The facility's policies and procedures require that all psychotropic medications have an appropriate diagnosis, a specific and clear indication for use, and measurable target behaviors for monitoring. The failure to adhere to these policies resulted in the resident receiving Seroquel without proper monitoring of its effectiveness or potential side effects.
Infection Control Lapses in G-Tube Medication Administration and Oxygen Tubing Management
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which is designed to reduce the spread of multidrug-resistant organisms (MDROs). During a medication administration task, a Licensed Vocational Nurse (LVN) did not don a gown while administering medication via a gastrostomy tube (G-tube) to a resident. This resident, who was totally dependent on staff for all activities of daily living and had severely impaired cognition, was at increased risk of infection due to the presence of a G-tube. The facility's policy required staff to wear gowns and gloves during high-contact care activities, such as administering medication via G-tube, to prevent the spread of MDROs. In another instance, the facility failed to ensure that a resident's nasal cannula oxygen tubing was not touching the floor. The resident, who required supplemental oxygen due to pulmonary hypertension and heart failure, was observed with oxygen tubing that was in contact with the floor. This practice posed a risk of contamination and potential infection, as the floor can harbor bacteria and other microorganisms. The facility's staff acknowledged that the tubing should not touch the floor to prevent contamination and subsequent infection. Both deficiencies highlight lapses in infection control practices within the facility. The failure to adhere to established protocols for gowning during high-contact activities and ensuring that medical equipment does not come into contact with contaminated surfaces increased the risk of infection for the residents involved. These observations were confirmed through interviews with facility staff, including the Infection Prevention Nurse and the Director of Nursing, who reiterated the importance of following the facility's infection control policies.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the resident's rights and resulting in their displacement to an unfamiliar facility. The resident, who had been admitted to the facility with diagnoses including depression and COPD, was transferred to a general acute care hospital due to behavioral disturbances. The facility had a bed hold policy in place, and the resident's bed was held from 12/20/2024 to 1/2/2025, with an extended hold authorized by a family member. Despite the bed hold, the facility declined the hospital's referral to return the resident, citing the resident's need for acute psychiatric management. The hospital's physician cleared the resident for discharge, but the facility maintained that the resident was not stable enough to return. This decision was based on inquiries received from the hospital, which indicated the resident's mood was still labile. The facility planned to accept the resident once they were psychiatrically stable. The facility's actions led to the resident being discharged to a different skilled nursing facility, 19 miles away, which was a locked facility. The facility's administrator stated that there was a miscommunication, and the resident ended up at the other facility. The facility's policy indicated that residents discharged to the hospital should be given priority in readmission, but this was not followed, resulting in the resident's unnecessary prolonged hospitalization and displacement.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to adhere to its policy and procedures for reporting a reasonable suspicion of a crime, specifically an allegation of physical abuse, in accordance with Section 1150B of the Act. The incident involved a resident who claimed to have been hit by a nurse when attempting to go to bed. The facility did not report this allegation to the State Survey Agency (SSA) within the required two-hour timeframe, instead reporting it approximately 4 hours and 53 minutes after the incident was reported to them. This delay in reporting resulted in a postponed onsite inspection by the SSA, which was necessary to ensure the safety of other residents and could have led to unidentified abuse. The resident involved was admitted to the facility with diagnoses including paroxysmal atrial fibrillation, generalized muscle weakness, and the presence of artificial shoulder joints. The resident's cognition was intact, and they required varying levels of assistance with daily activities. The incident was initially reported by the resident to a Licensed Vocational Nurse (LVN), who then informed a Registered Nurse (RN). However, the facility's administrator was not informed until two hours later, which contributed to the delay in reporting to the SSA. The facility's policy, last reviewed in 2023, mandates that any allegations of abuse or serious bodily injury be reported to the SSA within two hours, a requirement that was not met in this case.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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