Grand Park Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2312 West 8th Street, Los Angeles, California 90057
- CMS Provider Number
- 056244
- Inspections on file
- 36
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Grand Park Convalescent Hospital during CMS and state inspections, most recent first.
Surveyors found that two staff members who transferred from dietary roles into Utility Nurse positions did not receive required competency and skills assessments for their new duties upon hire into the role or annually. Their files contained only dietary competency checklists, despite facility policy requiring Utility Nurses to receive orientation on call light response, resident safety and fall prevention, communication protocols, scope of practice, and emergency procedures, with competency to be assessed at hire and yearly. The DSD and DON both acknowledged the importance of these assessments to ensure staff can safely and competently perform Utility Nurse responsibilities.
Two residents with significant risk factors for pressure ulcers were found to have their low air loss mattresses set incorrectly, not matching their actual weights as required by physician orders and manufacturer guidelines. Nursing staff and the DON confirmed the settings were not appropriate, which could reduce the effectiveness of pressure ulcer prevention and treatment.
Two residents with severe cognitive and physical impairments were found without accessible call lights, despite care plans and facility policy requiring call lights to be within reach. In both cases, staff confirmed the call lights were not placed appropriately, leaving the residents unable to call for assistance when needed.
A resident with multiple medical conditions and missing teeth was admitted and assessed as able to participate in care planning and requiring significant ADL assistance. Despite documentation of dental issues and the facility's policy requiring comprehensive care plans, staff did not develop or implement a dental care plan for the resident. Interviews with the RN Supervisor, SSD, and DON confirmed the omission and the importance of including dental needs in the care plan.
A resident with major depressive disorder had a care plan that was not updated after a physician changed the Remeron dosage from 15 mg to 7.5 mg. The care plan continued to reference the outdated dosage, despite facility policy requiring updates after changes in physician orders. Both the MDSN and DON confirmed the care plan should have been revised to reflect the current medication order.
A resident with diabetes and multiple comorbidities received subcutaneous insulin injections in the same anatomical locations on consecutive days, despite facility policy and physician orders requiring site rotation. Nursing staff and the DON confirmed that injection sites should have been rotated, and the facility's EMR system displayed previous sites to assist with compliance, but this was not consistently followed, resulting in a deficiency.
A resident with multiple medical conditions and a history of smoking was not given a smoking risk assessment upon admission or after staff became aware of their smoking activity. Despite being observed smoking with staff assistance and without a protective apron, no updated assessment was completed, contrary to facility policy. This failure potentially placed the resident's safety at risk.
A medication cart was left unlocked and unattended in the hallway by an LVN who entered a resident's room to administer medication, in violation of facility policy requiring medication carts to be locked when not in use.
Nursing staff did not consistently follow EBP protocols during medication administration, with two nurses failing to don gowns as required when caring for two residents under EBP. Additionally, a resident with an indwelling urinary catheter did not have the required EBP identifier posted, despite care plan and policy requirements. These lapses were confirmed by staff interviews and policy reviews.
A room with three beds was found to be only 213.69 sq. ft., not meeting the federal requirement of at least 80 sq. ft. per resident in multiple occupancy rooms. The room was clean and accessible, and no immediate safety or privacy concerns were observed, but the facility's own policy and federal standards were not met.
A resident with dementia and a high fall risk was not provided with an individualized care plan or adequate supervision, leading to a fall and serious injury. The facility's staff failed to implement necessary safety measures, and the care plans lacked specific interventions for dementia care. The resident sustained a displaced right femur, requiring surgery and a blood transfusion.
A resident's medical records were incomplete and inaccurate due to the lack of documentation of their discharge plan. Despite the resident's expressed desire to be discharged to an apartment and the submission of an assisted living waiver application, the discharge plan was not recorded. The facility's policy mandates documentation of services and progress, which was not followed.
A resident with severe cognitive impairment was found with facial injuries of unknown origin, which the facility failed to report to the SSA within the required timeframe. Despite the facility's policies mandating prompt reporting to rule out abuse, the Administrator incorrectly assumed the injuries were reported as an unwitnessed fall, resulting in a delayed investigation.
The facility failed to ensure proper infection control measures for COVID-19. Two residents with cognitive impairments were observed without masks in common areas, contrary to the facility's policy during a COVID-19 outbreak. Additionally, an RN was found wearing an N95 respirator she was not fit-tested for, compromising its effectiveness. These deficiencies in mask usage and adherence to PPE protocols increased the risk of COVID-19 transmission among residents and staff.
A resident with cognitive impairment reported being physically mistreated by a CNA, but the facility failed to report the incident to the State Agency as required by their policies. Despite the facility's policy mandating the reporting of all possible abuse incidents, the Social Service Director and Director of Nursing did not report the incident, believing it did not occur. The Facility Administrator was also not informed, leading to a delay in an onsite inspection by the State Agency.
The facility failed to monitor and document pain levels for three residents during Restorative Nursing Assistant (RNA) services, despite physician orders. Residents with conditions like polyarthritis, osteoarthritis, and severe cognitive impairment were not assessed for pain, and care plans lacked directives for pain monitoring. Staff interviews revealed a misunderstanding of documentation requirements, leading to inadequate pain management.
The facility failed to label and discard food items according to professional standards, as observed by a Dietary Assistant. Several food items, including Aji-Mirin Sweet Cooking Rice seasoning, carrots, Salted Shrimp, ginger, and Dried [NAME], lacked open and use by dates. Additionally, items like Rice vinegar, Dried Seaweed-Sliced, garlic, and tofu were not discarded after their use by dates. Interviews with staff confirmed the facility's policy required labeling and discarding of food to prevent food-borne illnesses, but these practices were not followed.
Two residents with cognitive impairments were fed by staff standing over them, contrary to the facility's policy requiring staff to sit to maintain resident dignity. The DON confirmed the importance of sitting during meal assistance, but staff cited control as a reason for standing.
The facility failed to include advance directives in the medical charts of two residents, potentially compromising their end-of-life treatment decisions. One resident had fluctuating decision-making capacity, while another had mild cognitive impairment but was capable of making decisions. The facility's policy required documentation of advance directives, which was not followed.
The facility failed to report incidents involving two residents to the State Survey Agency within the required timeframe. A resident with cognitive impairments had an injury of unknown origin that was not reported, and another resident experienced a fall with a confirmed fracture that was also not reported. The facility's policies required timely reporting of such incidents, but staff interviews revealed non-compliance, leading to a delay in investigation.
A facility failed to develop a comprehensive care plan for a resident under hospice care, despite the resident's serious medical conditions and hospice orders. The absence of a hospice-specific care plan was confirmed by the RN and DON, highlighting a potential gap in providing necessary and personalized care.
A resident identified as a smoker did not receive a smoking risk assessment upon admission, contrary to facility policy. Despite being supervised while smoking, the lack of assessment meant safety measures were not formally evaluated or implemented, posing a risk of injury or burns.
A resident with end-stage renal disease and depression experienced weight loss due to the facility's failure to implement the RD's recommendation for snacks three times a day. Despite the RD's assessment, there was no order for snacks in the resident's chart or MAR. Interviews with staff revealed a lack of communication and documentation, increasing the risk of further weight loss.
A resident with a feeding tube was found to have tubing that was not changed as required by physician's orders and facility policy, leading to potential infection control issues. The resident, with conditions including Parkinson's Disease and dementia, had tubing dated two days prior still in use, despite a new feeding bottle being started. Both an LVN and the DON confirmed the tubing should have been changed every 24 hours to prevent contamination.
The facility failed to provide adequate staffing, resulting in delayed care for two residents. One resident, requiring assistance due to severe morbid obesity, reported waiting up to an hour for help. Another resident, with severe cognitive impairment, also faced long wait times. Staffing shortages were exacerbated by a no call, no show CNA, leaving eight CNAs to care for 147 residents during a night shift. The facility's reliance on overtime and extra staff calls was not always effective.
The facility's Arbitration Agreement failed to include verbiage allowing residents to choose a convenient venue for arbitration meetings. This deficiency was noted during a review of the agreement form, which did not provide residents the option to select a meeting place. Interviews with the Admissions Coordinator and Business Office Manager confirmed the absence of such verbiage, despite the facility's policy indicating hearings should be at a mutually agreed-upon location.
A deficiency was identified in a room that did not meet the required 80 square feet per resident, with a total of 203.3 square feet for three residents instead of the required 240 square feet. Despite this, residents and staff reported no issues with space or care provision, and privacy curtains were in place.
Missing Initial and Annual Competency Assessments for Utility Nurses
Penalty
Summary
The facility failed to ensure that Utility Nurses had competency and skills assessments completed upon hire and annually, as required by facility policy, for two of six sampled employees working in that role. Interview and record review with the Director of Staff Development (DSD) showed that both Utility Nurse 1 and Utility Nurse 2 were initially hired in the dietary department and later began working as Utility Nurses on 2/25/25 and 8/19/25, respectively. Their personnel files contained competency checklists only for dietary duties and lacked any competency or skills checklists related to their Utility Nurse responsibilities, despite the DSD stating that such competencies should be completed upon hire and yearly to ensure correct resident care procedures. The Director of Nursing (DON) also stated it is important to have competency and skills assessments done upon hire and annually to ensure these staff can safely and competently perform their duties. Review of the facility’s “Utility Nurse” policy, revised on 1/25, indicated that Utility Nurses shall receive orientation on call light response, resident safety and fall prevention, communication protocols, scope of practice, and emergency procedures, and that competency shall be assessed upon hire and annually, which was not done for these two staff members. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Incorrect Low Air Loss Mattress Settings for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs), which are specialized air mattresses designed to prevent and treat pressure ulcers, were set to the correct weight-based settings for two residents. For the first resident, who had a history of peripheral vascular disease, chronic ulcers, dementia, and was dependent on staff for all activities of daily living, the LALM was observed to be set at 80 pounds, while the resident's actual weight was 103 pounds. Both the LVN and the DON confirmed that the mattress was not set correctly, and that incorrect settings would reduce the effectiveness of the mattress in managing skin integrity as ordered by the physician. For the second resident, who had diagnoses including metabolic encephalopathy, severe protein calorie malnutrition, diabetes, and a Stage 3 pressure ulcer, the LALM was set at 150 pounds, despite the resident weighing 103 pounds. A sticker on the mattress indicated the appropriate setting should be between 89-109 pounds. The RN and DON both acknowledged that the mattress was not set according to the resident's weight, which could compromise the intended pressure redistribution for skin management as per the physician's order. In both cases, the operator's manual for the LALM specified that the pressure setting should be adjusted according to the patient's weight, with clear guides provided on the device. The failure to set the LALMs correctly was confirmed through observation, interviews with nursing staff and the DON, and review of medical records and physician orders. This deficiency was identified through direct observation and record review by surveyors.
Call Lights Not Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach and easily accessible for two residents who required significant assistance with activities of daily living and had severely impaired cognition. For one resident with a history of falls, dementia, and limited mobility, the call light was observed on the floor out of reach while the resident was in bed. This was confirmed by a CNA, who acknowledged that the call light should have been placed next to the resident to allow her to call for help when needed. The resident's care plan specifically included an intervention to keep the call light within reach to provide a safe environment. For another resident with muscle weakness, upper mobility impairment, and a history of subarachnoid hemorrhage and encephalopathy, the touch pad call light was observed on the bed, out of reach, while the resident was lying in a geri-chair. The resident was seen attempting to reach the call light but was unable to do so. A CNA confirmed that the call light was not accessible and stated that the resident would not be able to call for assistance in an emergency. The care plan for this resident also required the call light to be within reach and answered promptly. Interviews with nursing staff and the DON confirmed that call lights should always be placed within reach of residents, as outlined in the facility's policy and procedures. The observations and staff interviews demonstrated that the facility did not follow its own policy, resulting in the call lights being inaccessible to residents who were dependent on staff for care and unable to independently summon assistance.
Failure to Develop Comprehensive Dental Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive and resident-centered dental care plan for a resident who was admitted with multiple diagnoses, including encephalopathy, compression fractures, bipolar disorder, panic disorder, and malnutrition. The resident's admission record and Minimum Data Set (MDS) indicated that the resident was able to participate in assessments and goal setting, could be understood, and required substantial to maximal assistance with activities of daily living. The Social Services Evaluation noted the presence of missing teeth and indicated that a referral to dental consultation would be made as needed. However, upon review, it was found that no care plan addressing oral or dental health was created for the resident at the time of admission. Interviews with facility staff, including a Registered Nurse Supervisor, Social Services Director, and Director of Nursing, confirmed that the dental issue should have been included in the resident's care plan. Staff acknowledged the importance of initiating a care plan to set goals and provide proper care and treatment, as well as to facilitate communication between departments. The facility's policy requires that a comprehensive care plan, including measurable objectives and timetables, be developed for each resident within seven days of completing the comprehensive assessment, but this was not done for the resident's dental needs.
Failure to Update Care Plan Following Change in Antidepressant Dosage
Penalty
Summary
The facility failed to conduct a quarterly review and revise the care plan for a resident diagnosed with major depressive disorder (MDD) who was prescribed Remeron. The resident's care plan, last updated to reflect a 15 mg dosage of Remeron, was not revised after the physician changed the order to 7.5 mg. This discrepancy was identified during a review of the resident's records, which showed that the care plan interventions still referenced the outdated 15 mg dosage, despite the medication order having been changed months earlier. The Minimum Data Set Nurse (MDSN) and Director of Nursing (DON) both confirmed that the care plan should have been updated to reflect the new dosage and that the facility's policy requires care plans to be reviewed and revised quarterly or when there is a change in physician orders. The resident, who was admitted with diagnoses including MDD, muscle weakness, and a need for assistance with personal care, continued to be monitored for depressive symptoms. However, the care plan did not accurately reflect the current medication regimen, as it was not updated following the change in Remeron dosage. Both the MDSN and DON acknowledged that this oversight could lead to confusion regarding the correct dosage to be administered, as the care plan was not aligned with the physician's current orders.
Failure to Rotate Insulin Injection Sites as Ordered
Penalty
Summary
The facility failed to ensure proper rotation of insulin injection sites for one resident, as required by physician orders and facility policy. Record reviews showed that the resident, who had a history of type 2 diabetes mellitus, peripheral vascular disease, and bilateral above-knee amputations, received subcutaneous insulin injections in the same anatomical locations on consecutive days. Specifically, injections were administered to the right lower quadrant, left deltoid, and left upper quadrant on multiple consecutive days, contrary to best practices and the facility's own insulin administration policy. Interviews with nursing staff, including an LVN, RN, and the DON, confirmed that insulin injection sites should have been rotated and acknowledged that the electronic medical record system displayed previous injection sites to help prevent repeated use of the same site. Despite this, staff administered insulin in the same location on consecutive days. The staff interviewed were aware of the need for site rotation and the potential for tissue damage if not followed, but the practice was not consistently implemented for this resident. The facility's policy and procedure for insulin administration, dated January 2025, specified that injection sites should be rotated within the same general area to ensure safe administration. The failure to rotate injection sites as documented in the resident's Location of Administration Report was in direct violation of this policy and the physician's orders, resulting in a deficiency related to the administration of care according to orders and established guidelines.
Failure to Complete Smoking Risk Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking risk assessment for a resident who was admitted with multiple diagnoses, including encephalopathy, type 2 diabetes, hypertension, and heart failure, and who required assistance with personal care. Upon admission, the resident's care plan identified a risk for injury due to smoking and included an intervention to re-evaluate smoking privileges per facility policy. However, the initial nursing risk assessment indicated that a smoking safety evaluation was not completed because the resident was believed not to smoke, and no further smoking safety evaluations were conducted after admission. Subsequent documentation showed that the resident had a past interest in smoking, and direct observation revealed the resident smoking on the facility's patio with assistance from activity staff, but without a protective smoking apron. Interviews with nursing staff and the DON confirmed that a smoking risk assessment should have been performed when it became known that the resident smoked, in accordance with facility policy, which requires such assessments on admission, quarterly, and as needed. The lack of an updated smoking risk assessment potentially placed the resident's safety at risk.
Unattended Unlocked Medication Cart by LVN
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to lock and secure a medication cart while it was left unattended in the hallway. The LVN was observed preparing medication at the doorway of a resident's room and subsequently entered the room, leaving the medication cart unlocked. Upon exiting the room, the LVN acknowledged that the cart had not been locked. Review of the facility's policy and procedures confirmed that medication carts are required to be locked when not in use and not left unattended while unlocked.
Failure to Adhere to Enhanced Barrier Precautions and Proper Resident Identification
Penalty
Summary
The facility failed to ensure that nursing staff adhered to its enhanced barrier precautions (EBP) policy during medication administration for two residents. Specifically, during medication passes, one nurse performed hand hygiene but did not don a gown before providing care to a resident with an EBP sign posted, while another nurse donned gloves but failed to wear a gown before measuring vital signs and administering medication to another resident under EBP. Both nurses acknowledged the requirement to use gloves and gowns as indicated by the EBP signage, with one nurse stating she forgot to put on the gown. Facility policies reviewed indicated that staff are required to follow established infection control procedures and receive education on proper techniques. Additionally, the facility did not provide a proper identifier for a resident on EBP due to an indwelling urinary catheter. The resident's care plan required appropriate infection control precaution signs to be placed next to the door entrance with the room number, but during observation, no such identifier was present. Both the nurse and the Infection Preventionist confirmed the absence of the EBP indicator, and the Director of Nursing acknowledged that signage should be placed above the resident's bed or outside the door as per the care plan intervention. Facility policy stated that the Infection Preventionist or designee is responsible for determining and implementing appropriate notification for EBP.
Resident Room Fails to Meet Minimum Space Requirements
Penalty
Summary
The facility failed to ensure that one of its resident rooms met the required minimum space of 80 square feet per resident for multiple occupancy rooms, as mandated by federal regulations. Specifically, room [ROOM NUMBER] was measured by the maintenance supervisor and found to be 213.69 square feet, yet it contained three beds, falling short of the required 240 square feet for three residents. This was confirmed through observation, staff interviews, and review of the Client Accommodations Analysis and a Room Variance Waiver Letter, both of which documented the room's insufficient size. Despite the room being clean, free from clutter, and no immediate safety or privacy concerns being observed during multiple visits, the facility's own policy also requires compliance with the square footage standards, which was not met in this instance.
Failure to Provide Adequate Dementia Care and Fall Prevention
Penalty
Summary
The facility failed to provide appropriate care and services to a resident diagnosed with dementia, who was also at high risk for falls. The resident, who had a history of falls and was diagnosed with dementia, syncope, psychosis, and gait abnormalities, was not provided with an individualized care plan through an Interdisciplinary Team (IDT) approach. The care plan lacked specific interventions to maximize the resident's safety and did not include supervision for bed mobility as required by the Activities of Daily Living (ADL) Self-Care Performance Deficit care plan. On multiple occasions, the resident was noted to have an unsteady gait and balance problems, yet the care plans did not adequately address these issues. Despite being identified as a high fall risk, the resident's care plan did not include measurable goals or interventions to address the diagnosis of dementia. The facility's staff, including the Registered Nurse (RN) and Certified Nursing Assistant (CNA), failed to provide the necessary supervision and safety measures, resulting in the resident falling and sustaining a serious injury. The resident was found on the floor in her room and later diagnosed with a displaced right femur, requiring surgery and a blood transfusion. Interviews with facility staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed that the care plans lacked clear language and individualized interventions for dementia care. The facility's policies on dementia care and fall risk management were not effectively implemented, contributing to the resident's fall and subsequent injury.
Incomplete Documentation of Resident's Discharge Plan
Penalty
Summary
The facility failed to ensure that the medical records for a resident were complete and accurate, specifically regarding the resident's discharge plan. The resident, who was admitted with diagnoses including osteoarthritis and gait abnormalities, was cognitively intact and expressed a desire to be discharged to live in an apartment, having been homeless prior to admission. The Minimum Data Set indicated the resident's goal was to discharge to the community, but the discharge plan was not documented in the medical record. Interviews revealed that the social services department was searching for placement for the resident, and an application for an assisted living waiver was submitted but on hold. However, the Social Service Designee admitted to not documenting discussions about the discharge plan with the resident's next of kin. The Director of Nursing emphasized the importance of documenting the discharge plan to demonstrate the facility's efforts. The facility's policy requires documentation of services provided and progress toward care plan goals, which was not adhered to in this case.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy and procedures by not reporting an injury of unknown origin to the Survey State Agency (SSA) within 24 hours for a resident. The resident was found on the floor with discoloration to the left side of the face and a scratch on the nose. Despite the presence of these injuries, the facility did not report them to the SSA, resulting in a delayed investigation. The resident, who had severe cognitive impairment and required significant assistance with daily activities, was later observed to have extensive bruising and swelling on the left side of the face. The injuries were considered of unknown origin as no staff witnessed the incident, and the resident was unable to explain how they occurred. Interviews with facility staff, including a CNA, social worker, and the Director of Nursing, confirmed that the injuries should have been reported as per the facility's policy. The facility's policies required that injuries of unknown origin be reported to the SSA to rule out abuse. However, the Administrator mistakenly believed the injuries were reported as an unwitnessed fall, despite no staff observing the fall. The facility's policies clearly outlined the need for prompt reporting of such incidents, but these procedures were not followed, leading to the deficiency.
Inadequate Infection Control Measures for COVID-19
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in preventing the transmission of COVID-19. Two residents, both with cognitive impairments and requiring substantial assistance for activities of daily living, were observed not wearing masks while interacting with others in common areas. Resident 1, with severe cognitive impairments, was seen walking around the unit without a mask and was unaware of the requirement to wear one. Similarly, Resident 3, with moderate cognitive impairment, was observed sitting in a wheelchair near the nurses' station without a mask, in close proximity to other residents. Additionally, a registered nurse (RN 1) was found not adhering to the facility's policy regarding the use of N95 respirators. The nurse was observed wearing a respirator that she had not been fit-tested for, which compromised the effectiveness of the protective equipment. The nurse admitted to wearing a different respirator than the one she was fitted for, acknowledging the importance of a proper fit to prevent the spread of COVID-19. The facility's policies and procedures require all staff to wear fit-tested N95 respirators in areas with residents in COVID-19 isolation or under investigation. Furthermore, during a COVID-19 outbreak, all residents are required to wear masks when leaving their rooms. The infection prevention nurse confirmed these requirements, emphasizing the necessity of proper mask usage to prevent transmission. The facility's failure to ensure compliance with these protocols placed both residents and staff at risk of infection.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting suspected abuse in accordance with state and federal law for a resident. The resident, who had chronic respiratory failure, congestive heart failure, and dysphagia, was cognitively impaired and dependent on staff for activities of daily living. The resident reported that a Certified Nursing Assistant (CNA) had physically mistreated her, which was documented in the progress notes. Despite this report, the Social Service Director (SSD) and the Director of Nursing (DON) decided not to report the incident to the State Agency (SA) because they believed the incident did not occur after their investigation. The facility's policy, titled 'Abuse Prevention Program,' requires the identification, assessment, investigation, and reporting of all possible incidents of abuse within the required timeframes. However, the SSD and DON did not adhere to this policy, as they did not report the incident to the SA, police, or ombudsman. The Facility Administrator was not informed of the incident, which further indicates a breakdown in communication and adherence to the facility's policies. This failure resulted in a delay of an onsite inspection by the SA and had the potential to result in unidentified abuse within the facility.
Failure to Monitor Pain During Restorative Nursing Services
Penalty
Summary
The facility failed to adequately monitor and document the pain levels of three residents before, during, and after Restorative Nursing Assistant (RNA) services, as required by physician orders. Resident 52, who has diagnoses including polyarthritis and neuralgia, was not assessed for pain during RNA services despite a physician's order to do so. The resident's care plan did not include instructions to monitor pain, and there was no documentation of pain assessment from June 1 to June 18, 2024. Similarly, Resident 92, with conditions such as osteoarthritis and fibromyalgia, was not monitored for pain during RNA services, as indicated by the absence of documentation for the same period. Although the resident reported experiencing pain and receiving medication, the care plan lacked directives for pain monitoring. The resident's fluctuating cognitive capacity further complicated the situation, as the facility did not consistently assess and document pain levels. Resident 129, who has severe cognitive impairment and requires significant assistance, also did not have pain levels documented during RNA services. Despite a physician's order to monitor pain, the care plan did not reflect this requirement, and no documentation was found for the specified period. Interviews with staff revealed a misunderstanding of documentation requirements, with the RNA only recording pain when it was present, contrary to the facility's policy and procedure guidelines.
Failure to Label and Discard Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not labeling several food items with open and use by dates. During an observation, a Dietary Assistant noted that a plastic container of Aji-Mirin Sweet Cooking Rice seasoning, a bag of carrots, a plastic container of Salted Shrimp, a plastic bag of ginger, and a plastic bag of Dried [NAME] were not labeled with open or use by dates. Additionally, several items, including a bottle of Rice vinegar, a bag of Dried Seaweed-Sliced, a container of garlic, and packs of tofu, were found with open and use by dates but were not discarded after their use by dates had passed. Interviews with the Dietary Supervisor, Dietary [NAME], and the Director of Nursing revealed that the facility's policy required all food to be labeled with open and use by dates and discarded after the use by date to prevent food-borne illnesses. The staff acknowledged the importance of these practices to ensure resident safety. The facility's undated policy on food storage indicated that all food should be covered, labeled, and dated, and checked to ensure consumption by their safe use by date. However, these practices were not followed, leading to the potential risk of food-borne illnesses.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents during meal assistance. Resident 87, who has Alzheimer's disease, bipolar disorder, and essential hypertension, was observed being fed by an Activity Assistant who stood over the resident instead of sitting at eye level. This practice was against the facility's policy, which requires staff to sit while assisting residents with meals to promote dignity. The Director of Nursing confirmed that staff are required to feed residents with attention to dignity by sitting down. Similarly, Resident 93, who has dementia and requires substantial assistance for eating, was fed by a Certified Nursing Assistant who also stood over the resident. The CNA stated that standing provided better control over the resident. However, this was contrary to the facility's policy and the expectations set by the Director of Nursing, who emphasized the importance of sitting while feeding residents to maintain their dignity. Both instances were observed and confirmed by a Licensed Vocational Nurse, highlighting a consistent failure to adhere to the facility's policy on meal assistance.
Failure to Document Advance Directives in Resident Charts
Penalty
Summary
The facility failed to ensure that a copy of the advance directive was included in the medical charts of two residents, which could potentially lead to the facility not honoring the residents' medical decisions regarding end-of-life treatment. Resident 92 was admitted with diagnoses including abnormalities in gait and mobility, osteoarthritis, and fibromyalgia. Despite having an advance directive and fluctuating capacity to make decisions, the document was not present in the resident's medical chart. Both the Director of Social Services and the Director of Nursing acknowledged the importance of having the advance directive in the chart to ensure the resident's wishes are respected. Resident 140 was admitted with diagnoses including hypotension and a need for assistance with personal care. The resident had mild cognitive impairment but was capable of making decisions. However, the Advance Directive Acknowledgment form was not completed upon admission, which could result in the resident not being informed about their rights to accept or refuse medical treatments. The Social Services Director admitted responsibility for completing the form and acknowledged the oversight. The facility's policy required that upon admission, residents be provided with information about their rights to accept or refuse treatment and to formulate an advance directive. The policy also stated that information about the existence of an advance directive should be prominently displayed in the medical record. The failure to adhere to this policy for Residents 92 and 140 indicates a lapse in ensuring that residents' medical decisions are documented and respected.
Failure to Report Incidents Timely
Penalty
Summary
The facility failed to report incidents involving two residents to the State Survey Agency within the required timeframe. For Resident 13, the facility did not report an injury of unknown origin, which included a bump on the forehead, discoloration on the hand, and an abrasion on the knee. Despite the resident's cognitive impairments and inability to recall the incident, the Director of Nursing (DON) did not report the incident based on advice from a consultant, which was later acknowledged as a mistake. For Resident 195, the facility failed to report a fall with injury. The resident, who had moderately impaired cognition and required assistance with personal care, reported a fall during a self-transfer from the toilet to a wheelchair, resulting in hip pain. Although initial assessments and x-rays did not reveal a fracture, a subsequent x-ray confirmed a left ischial ring fracture. Despite the resident's report of a fall and the confirmed fracture, the incident was not reported to the Department of Public Health or the ombudsman. The facility's policies required that incidents of unknown origin and falls with major injuries be reported within two hours. However, these incidents were not reported, leading to a delay in investigation by the California Department of Public Health. Interviews with staff, including the DON and Registered Nurses, revealed a lack of adherence to reporting protocols, which contributed to the deficiencies identified in the report.
Failure to Develop Comprehensive Hospice Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was readmitted with serious medical conditions, including malignant neoplasm of the stomach, severe protein-calorie malnutrition, and sepsis. The resident was under hospice care, as indicated by the physician's order, but the care plan did not include hospice-specific interventions. This oversight was confirmed during interviews with the RN and the DON, who acknowledged the absence of a hospice care plan and the potential for the resident to not receive necessary and personalized care. The facility's policy requires a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs. The care plan should describe the services to be furnished to attain or maintain the resident's well-being and include the resident's stated goals and desired outcomes. However, the care plan for this resident did not reflect these requirements, particularly in relation to hospice care, which was a critical aspect of the resident's treatment plan.
Failure to Conduct Smoking Risk Assessment for Resident
Penalty
Summary
The facility failed to ensure safety measures were assessed and implemented for a resident who was a smoker. Despite the resident's admission records indicating they did not smoke, a subsequent social services evaluation identified the resident as a smoker who required supervision. However, the facility did not initiate a smoking risk assessment, which was a necessary step to evaluate and implement appropriate safety measures. This oversight was acknowledged by the Registered Nurse responsible for Quality Assurance and the Director of Nursing, who both confirmed that the assessment should have been conducted to prevent potential risks of injury or burns. The resident, who had intact cognition and required varying levels of assistance with daily activities, was observed smoking under supervision without a completed risk assessment. The facility's policy required an evaluation of smoking status upon admission and periodic re-evaluations, but this protocol was not followed. The failure to conduct a smoking risk assessment left the resident vulnerable to potential harm, as the necessary safety precautions were not formally assessed or implemented.
Failure to Implement Nutritional Recommendations for Resident
Penalty
Summary
The facility failed to provide adequate nutrition to a resident, identified as Resident 133, consistent with the weight loss assessment and the Registered Dietitian's (RD) recommendations. Resident 133, who was admitted with end-stage renal disease, dependence on renal dialysis, and depression, experienced a gradual weight loss of 3.8% over 30 days, which was concerning due to the resident's slightly underweight BMI. The RD recommended providing snacks three times a day to address this issue. However, there was no order for these snacks in the resident's chart, and the Medication Administration Record (MAR) did not reflect this intervention. Interviews with facility staff, including a Certified Nursing Assistant (CNA), Quality Assurance Nurse (QAN), Licensed Vocational Nurse (LVN), Dietary Supervisor (DS), and the Director of Nursing (DON), revealed a lack of communication and documentation regarding the RD's recommendations. The QAN and LVN confirmed the absence of an order for snacks, and the DS was unaware that the diet communication needed to be in the resident's order or MAR. The DON acknowledged that the missing order could increase the risk of further weight loss for the resident. The facility's policy required monitoring of nutritional status and response to interventions, which was not effectively implemented in this case.
Failure to Change Tube Feeding Set as Required
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for a resident with a feeding tube. Resident 124, who was admitted with conditions including Parkinson's Disease, aftercare following digestive system surgery, gastrostomy, dysphagia, and dementia, was observed with tube feeding tubing that had not been changed as per the physician's order and facility policy. The physician's order specified that the tube feeding syringe and tubing set should be changed every night shift, but during an observation, it was found that the tubing dated 6/15/2024 was still in use on 6/17/2024, despite a new tube feeding bottle being started on 6/16/2024. Licensed Vocational Nurse (LVN) 5 confirmed the discrepancy and acknowledged the potential for infection control issues due to the reuse of the tube feeding tubing. The Director of Nursing (DON) also stated that the tubing should be changed every 24 hours along with the tube feeding bottle to prevent infection control issues. The facility's policy on enteral feedings and the Jevity 1.5 tube feeding bottle label both indicated that feeding sets are for single patient use and should be changed at least every 24 hours, or as specified by the manufacturer, to avoid contamination.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by the experiences of two residents. On a specific date, the facility had eight CNAs working the night shift to care for 147 residents, resulting in each CNA being responsible for 17-19 residents. This situation arose when one CNA was a no call, no show, and her absence was not covered, leading to increased workloads for the remaining staff. Resident 99, who required assistance with personal care due to severe morbid obesity and other health conditions, reported having to wait for care, sometimes for an hour, which was frustrating and impacted their ability to use the bathroom in a timely manner. Similarly, Resident 28, who had severe cognitive impairment and was dependent on staff for various daily activities, also experienced delays in receiving care. A family member of Resident 28 noted that wait times during the night could be excessively long. Interviews with staff, including a CNA and the Director of Staff Development, highlighted the challenges faced due to staffing shortages, particularly during the night shift. The Director of Nursing acknowledged the issue but stated that the facility did not use registry staff and relied on offering overtime or calling in extra staff, which was not always successful.
Arbitration Agreement Lacks Venue Selection for Residents
Penalty
Summary
The facility failed to include specific verbiage in their Arbitration Agreement that allowed residents the freedom to choose a convenient venue for arbitration meetings. This deficiency was identified through a review of the facility's undated Arbitration Agreement form, which lacked provisions for residents to select a meeting place. During interviews, both the Admissions Coordinator and the Business Office Manager acknowledged the absence of such verbiage and agreed that it would be beneficial for residents to have a say in the meeting location. The facility's policy and procedure document, dated July 2023, indicated that hearings would be conducted at a mutually agreed-upon time and place, but this was not reflected in the actual agreement form.
Deficiency in Room Space Requirements
Penalty
Summary
The facility failed to meet the space requirements of 80 square feet per resident in room [ROOM NUMBER], which was identified as a deficiency. The room in question was observed to have a total of 203.3 square feet for three residents, falling short of the required 240 square feet for a three-bed capacity room. Despite the deficiency, observations during the survey period indicated that nursing staff were able to provide adequate care, and privacy curtains were in place for residents. Interviews with residents and staff revealed that there were no complaints regarding space or the ability to provide care. Residents expressed satisfaction with the room's space, and staff, including a CNA and an LVN, confirmed that there was enough room to provide care. A Room Waiver letter from the Administrator suggested that the space issue would not adversely affect the health and safety of the residents, but the deficiency was noted due to the room not meeting the specified square footage requirements.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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