Harbor Villa Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 861 S. Harbor Blvd, Anaheim, California 92805
- CMS Provider Number
- 055742
- Inspections on file
- 32
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Harbor Villa Care Center during CMS and state inspections, most recent first.
The facility failed to control resident access to razors and other sharp objects, resulting in one resident with depressive disorder inflicting multiple lacerations to the wrist using a razor and another resident with schizoaffective disorder and anxiety keeping two razors and two scissors in an unlocked bag in a closet. Staff confirmed that sharp items were not supposed to be stored in resident rooms, yet razors supplied by staff were found there. An RN also showed that additional razors were kept in an unlocked cart at a nurse station and in an unlocked drawer in an unlocked supply closet near common areas, making them easily accessible to residents.
Three residents were affected when the facility did not provide necessary care to prevent accidents, including a resident who left unsupervised and fell, and two residents who did not receive required post-fall neuro checks as outlined in their care plans. Staff confirmed that education on safety and completion of assessments were not documented as required.
The facility did not report or investigate an alleged physical altercation between two residents, despite staff being aware of the incident and facility policy requiring immediate reporting of abuse allegations. The DON confirmed the event should have been reported to authorities and thoroughly investigated.
A facility did not thoroughly investigate an alleged physical altercation between two residents, despite both being cognitively intact and staff being aware of the incident. Staff interviews confirmed the event was reported, but the DON could not provide evidence of an investigation, violating facility policy on abuse investigation and reporting.
Two residents were involved in an incident where one, who was confused, accidentally grazed another's cheek while being moved by staff. The facility did not initiate or update care plans for either resident to address the incident, despite both being cognitively intact and able to make decisions. The DON confirmed that care plan problems related to the event were missed and only addressed after the issue was identified during review.
A resident was discharged without the required physician documentation indicating the basis for discharge, as mandated by facility policy. Medical record review and staff interviews confirmed that the attending physician did not document the clinical justification for discharge prior to issuing the LCD, despite ongoing therapy needs noted in the resident's records.
A facility failed to ensure a resident was free from physical restraints without medical necessity. A soft mitten restraint was applied to a resident's left hand without a physician's order, necessary assessments, or informed consent. The resident, with a history of hemiplegia and cognitive impairment, was observed wearing the restraint without proper documentation or monitoring. Staff confirmed the lack of compliance with facility policies regarding restraint use.
The facility failed to provide necessary care for two residents, including not assessing or obtaining orders for supplemental oxygen, not following up on medication delivery, and not maintaining a humidifier. Staff interviews revealed communication lapses and policy non-compliance.
A facility failed to notify a physician when a resident's right leg showed signs of a change in condition, including being purplish and cold, which indicated a lack of circulation. Despite a care plan for non-healing cellulitis and a physician's order for treatment, the LVN did not follow up on notifying the physician due to being busy and unfamiliar with documentation procedures. The RN and interim DON confirmed the lack of documentation and notification, acknowledging the oversight.
A resident with multiple impairments and incontinence did not receive appropriate pressure ulcer care as the facility failed to follow physician's orders for wound treatment and did not develop a care plan for Stage 3 pressure injuries. The resident's elbow wounds were treated with Medihoney instead of the prescribed Santyl ointment without a physician's order, and no care plan was initiated for pressure injuries on the lower back and sacrum. The interim DON and Administrator acknowledged these deficiencies.
The facility failed to ensure residents were free from unnecessary psychotropic medications, lacking non-pharmacological interventions and proper monitoring. A resident was prescribed multiple psychotropic medications without evidence of non-pharmacological interventions or monitoring for side effects. Another resident was prescribed Xanax and Remeron without reassessment or informed consent, and PRN orders for two residents were not limited to 14 days. Additionally, informed consent for a resident was improperly obtained. The DON acknowledged these deficiencies.
The facility failed to maintain effective infection control practices, lacking monthly surveillance logs and accurate QA reports. The Infection Preventionist did not track residents according to Loeb's criteria and omitted those with infection symptoms not on antibiotics. Staff failed to perform hand hygiene during care, and Enhanced Barrier Precautions were not properly implemented. The IP admitted to insufficient training, contributing to the facility's inability to control infection transmission.
The facility failed to ensure safe self-administration of medications for three residents. A resident self-administered dorzolamide eyedrops without an assessment or physician's order. Another resident had a gabapentin capsule left by a nurse for later self-administration, also without proper assessment or order. A third resident applied Vicks VapoRub ointment without a physician's order for self-administration. These oversights risked inaccurate medication administration and potential adverse reactions.
The facility failed to ensure call lights were within reach for several residents, potentially delaying care and impacting well-being. Observations and interviews revealed that residents often could not access their call lights, requiring assistance from roommates or yelling for help. Staff confirmed these findings, indicating a systemic issue with call light accessibility.
The facility did not address concerns from Resident Council meetings regarding medication timing, snack availability, and CNA interactions. Issues were not communicated effectively to relevant departments, and documentation was inadequate, leading to unresolved resident concerns.
The facility failed to provide individualized activity programs for residents, impacting their engagement and satisfaction. A resident was unable to watch TV in her preferred language, while another resident's activity participation records were blank, indicating a lack of engagement. Additionally, Bingo games were disrupted due to staff needing to supervise smoking residents, leading to dissatisfaction among residents.
A facility failed to provide a resident with the prescribed thin liquid consistency diet, as the care plan was not updated to reflect the physician's order change from nectar to thin liquid. The resident, with severe cognitive impairment and a risk of aspiration, was observed with thin liquid at the bedside, contrary to the updated order. The DON and Administrator confirmed these findings.
The facility failed to provide necessary respiratory care for four residents, including improper application of a nasal cannula, lack of physician's order for oxygen, and inadequate storage of respiratory equipment. Observations revealed that oxygen cannulas and nebulizer masks were not stored in clean set-up bags, and required signage was missing. These deficiencies were confirmed by facility staff during interviews and observations.
A facility failed to accurately monitor a dialysis resident's fluid intake and output, leading to potential life-threatening conditions. The resident's medical records showed discrepancies between daily fluid intake and output and the Weekly Intake and Output Evaluation. Nursing staff estimated fluid output based on incontinent briefs, and dietary intake was assumed from food consumption percentages, not accurately measured. This practice did not align with physician's orders for fluid restriction, resulting in inaccurate monitoring of the resident's fluid status.
The facility failed to ensure that the Infection Preventionist (IP) and nursing staff had the necessary competencies for infection control. The IP lacked training, leading to errors in identifying infection types and documenting meetings. Additionally, CNAs and LVNs were not adequately trained in Enhanced Barrier Precautions (EBP), increasing the risk of improper infection control practices.
A facility failed to monitor a resident for side effects of Norco, an opioid medication, as required by their pain management policy. The resident, capable of making medical decisions, had an order for Norco for pain management, but no documentation was found regarding monitoring for adverse effects. A nurse confirmed the lack of documentation, and the DON acknowledged the issue.
A facility's medication error rate was found to be 23.33%, exceeding the acceptable limit of 5%. Errors included failure to assess vital signs before medication administration, not administering medications with food as required, and not administering prescribed medications despite signing them as given. These errors involved three LVNs and affected three residents, with the DON and Administrator acknowledging the findings.
A resident did not receive prescribed medications for depression, manic disorder, and enlarged prostate due to a failure in medication administration. The medications were not administered by an LVN, despite being signed off on the MAR, and the pharmacy had not refilled the prescriptions after the initial supply ran out. The DON and Administrator confirmed these findings.
The facility failed to ensure proper medication storage and labeling, with expired and improperly stored medications found during inspections. Medications were left unattended in residents' rooms, and some medications lacked accurate labeling or physician orders. These deficiencies were acknowledged by the DON and staff.
The facility failed to follow food safety and sanitation guidelines, with wet coffee pots stored improperly, unsanitary kitchen equipment, and a lack of backflow prevention in the food preparation sink. The CDM and Maintenance Director confirmed these deficiencies.
A facility failed to ensure proper documentation and scheduling of hospice services for a resident. The hospice visit calendar was missing from the resident's medical record, and there was no accurate documentation of hospice staff visits. Interviews with staff confirmed the lack of verification of hospice visits and adherence to the plan of care, posing a risk for delayed hospice care.
The facility failed to implement its Antibiotic Stewardship Program effectively, as the IP could not provide documentation that physicians were notified about residents prescribed antibiotics without meeting Loeb's Criteria. This oversight was acknowledged by the DON, highlighting a lapse in the program's implementation, which could lead to inaccurate infection identification and inappropriate treatment.
A facility failed to provide a clean and homelike environment for a resident, as chipped paint was observed on the wall by the resident's bed. The Maintenance Director was unaware of the issue, while a CNA admitted to noticing the chipped paint for a week but forgot to report it. The Administrator and DON were informed and acknowledged the findings.
A facility failed to notify a resident's representative of the bed hold policy upon the resident's transfer to a hospital. The facility's policy requires written notification of bed hold rights, but there was no documentation for this in the resident's medical record. Staff interviews confirmed the oversight, and the DON acknowledged the deficiency.
A resident's PASARR Level 1 assessment was inaccurately coded, failing to reflect prescribed psychotropic medications and mental health diagnoses. The resident had orders for Zyprexa and lorazepam for mental health conditions, yet the assessment indicated no such medications. The MDS Coordinator and DON confirmed the error, necessitating a re-screening.
A facility failed to develop a care plan for a resident with an indwelling urinary drainage catheter, despite a physician's order for its use due to urinary retention and obstructive uropathy. An LVN confirmed the absence of a care plan, which should have been initiated to prevent complications. The DON acknowledged the deficiency.
A facility failed to administer methylphenidate as ordered for a resident with depression. The medication was not signed on the Controlled Drug Record and was unavailable in the emergency kit. An LVN confirmed these findings, and the DON acknowledged the issue.
A facility failed to ensure follow-up on a resident's monthly Medication Regimen Review (MRR) for unnecessary medications. Although the MRR was conducted, the resident's records lacked evidence of recommendations or completion status. Interviews with RN 2 and the DON confirmed the MRR was done, but no follow-up documentation was available.
The facility failed to ensure food palatability, as observed with mushy, overcooked broccoli served to residents. A resident expressed dissatisfaction with the taste of the food, and a test tray inspection confirmed the broccoli was softer than guidelines allowed. The DON was informed of these findings.
The facility failed to ensure complete and accurate medical records for two residents. A resident's POLST was unsigned by the legal decisionmaker, and another resident's vital signs were inaccurately documented posthumously. These deficiencies were confirmed by an LVN and acknowledged by the DON.
The facility failed to maintain the frozen storage area in the residents' refrigerator at Station B, which had significant ice buildup. This was confirmed by an RN during an observation and interview. The refrigerator, lacking a separate door for the freezer, stored food for a resident, and the RN acknowledged the need for defrosting. The DON was informed and acknowledged the issue, which could affect the proper temperature maintenance of stored food.
A resident was physically abused by a CNA during a care session, resulting in facial redness and embarrassment. The incident was witnessed by another CNA, who reported that the resident became combative during a wheelchair transfer, leading to the slap. The facility's policy on resident rights, which prohibits abuse, was violated.
A resident with moderately impaired cognitive skills eloped from the facility and was taken to a hospital for evaluation. Despite being cleared to return, the facility denied readmission, citing the need for a lock-down unit due to the resident's elopement history. The facility failed to conduct an IDT meeting or obtain a physician's documentation to support the discharge decision, violating its own policies.
A resident with moderately impaired cognitive skills eloped twice from the facility undetected due to inadequate supervision and failure to reassess elopement risk. Despite having a Wanderguard, the system did not alert staff, and the resident's elopement risk assessment was not updated as recommended by the IDT. Interviews revealed a lack of consistent monitoring and supervision, contributing to the resident's ability to leave the facility.
Failure to Secure Razors and Sharp Objects Accessible to Residents
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not adequately control resident access to sharp objects. One resident with a documented diagnosis of depressive disorder expressed suicidal ideation and was later found during nursing rounds with multiple self-inflicted lacerations on the left wrist and a razor in hand, stating he wanted to harm himself. This resident was transferred to an acute hospital for further evaluation and treatment of the self-inflicted injuries. The report does not indicate how this resident obtained the razor, and the Administrator acknowledged the facility did not know how the resident got it. Another resident, diagnosed with schizoaffective disorder and anxiety and documented as having decision-making capacity, was observed with a beard and stated he was independent with shaving. During an observation and interview in this resident’s room, the resident retrieved a personal bag from the closet that contained two razors and two pairs of scissors, which the resident stated had been supplied by facility staff. An LVN confirmed that sharp items were not supposed to be stored in residents’ rooms. Additionally, an RN demonstrated that razors for resident use were stored in an unlocked, transparent drawer cart at a nurse station and in an unlocked drawer inside an unlocked supply closet near common areas, all easily accessible to residents. The RN acknowledged that these razors were not secured and were easily accessible to residents.
Failure to Prevent Accidents and Complete Required Assessments
Penalty
Summary
The facility failed to provide necessary care and services to prevent accidents for three residents. One resident left the facility unsupervised after dinner without informing staff and was pulled by another resident on an electric chair. While passing over a gate frame, the resident's chair tilted, causing her to fall and land on her right shoulder. Although there were no head or skin injuries and vital signs were normal, the resident was transferred to an acute care hospital. The care plan for this resident included interventions such as educating her on the importance of informing staff before leaving the facility and explaining the risks of not doing so. However, there was no documented evidence that this education or explanation of risks was provided. Additionally, the resident's smoking assessment was not completed upon readmission, as verified by staff review. Two other residents experienced falls and were placed on care plans that required post-fall neurological checks for 72 hours. One resident was found sitting on the floor with no injuries, and the other was found lying on the floor after attempting to reach for a diaper, also with no injuries. Despite care plan interventions specifying neuro checks, medical record reviews for both residents failed to show any documented evidence that these assessments were completed following their falls. Staff interviews confirmed that neuro checks should have been performed and documented, but no such documentation was found. The Director of Nursing and other nursing staff verified the lack of documentation for both the education regarding leaving the facility and the required post-fall neuro checks. The facility's policies and procedures require comprehensive care planning, accurate assessments, and documentation of all relevant care and interventions, but these were not followed in the cases reviewed. These failures had the potential to negatively affect the health and well-being of the residents involved.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: For Resident 1, who was directly affected, corrective actions were taken immediately. On 8/1/25, the resident was re-educated by the DON and SS on the facility's out-on-pass policy, including the requirement to notify staff before leaving the premises. The charge nurse will monitor the signing in and out book. The resident was also informed of the potential dangers and/or risks associated with going out on pass, including the possibility of accident or injury. Specific safety concerns were addressed, such as nearby streets with vehicle traffic, and environmental hazards like uneven pavement, gravel, curbs, driveways, sidewalk cracks, steps, and stairs. This education was provided verbally and acknowledged in writing by the resident. A smoking assessment for Resident 1 was accurately completed by the LN per facility procedure, and all documentation was placed in the medical record on August 1, 2025. Residents 2 and 3 did not experience any harm as a result of the missed post-fall neuro checks. Both residents have since been discharged from the facility in accordance with their individual discharge plans. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On August 1, 2025, the Medical Records audited residents who have an order for going out on pass. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on providing/documenting unsupervised leave risk education, including the monitoring of the sign-in and out book for completeness and accuracy. On August 1, 2025, the Medical Records identified and audited the residents who smoke. All smoking assessments were audited for completeness and accuracy. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on smoking assessment completion at admission, re-admission, and quarterly. On August 1, 2025, the Medical Records audited residents with similar risk factors and confirmed timely neuro checks for the other fall case. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on following care plans and completing neuro checks after falls. What measures will be put in place or what systemic changes will the facility make to ensure that the deficient practice does not recur: To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, regarding their responsibility to initiate and document all resident education about the risks of leaving the facility without staff notification and monitoring the sign-in and out book. The RN Supervisor or designee reviews the resident signing in and out book daily for completeness and accuracy. To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, to complete smoking assessments for all identified smokers at admission, re-admission, and quarterly. Medical Records verifies weekly that all residents identified as smokers have a current smoking assessment for completeness and accuracy. The DON and Medical Records director are responsible for ensuring these processes are maintained. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On August 1, 2025, the Medical Records audited residents who have an order for going out on pass. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on providing/documenting unsupervised leave risk education, including the monitoring of the sign-in and out book for completeness and accuracy. On August 1, 2025, the Medical Records identified and audited the residents who smoke. All smoking assessments were audited for completeness and accuracy. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on smoking assessment completion at admission, re-admission, and quarterly. On August 1, 2025, the Medical Records audited residents with similar risk factors and confirmed timely neuro checks for the other fall case. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on following care plans and completing neuro checks after falls. What measures will be put in place or what systemic changes will the facility make to ensure that the deficient practice does not recur: To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, to initiate post-fall neuro checks in accordance with the facility's policy. The RN supervisor or designee now reviews all changes of condition daily to ensure neuro checks are initiated and documented. The DON and Medical Records Director are responsible for ensuring these processes are maintained. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. To ensure sustained compliance, the Medical Records conducts daily audits of the residents with an out-on-pass orders. The RN Supervisor or designee will monitor the completeness and accuracy of the signing-in and out book. Any omissions are reported immediately to the DON for corrective action and follow-up re-education. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews the out-of-the-facility education and monitoring of the sign-in and out book for completeness and accuracy. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. To ensure sustained compliance, the Medical Records completes a weekly review of smoking safety assessments for all identified smokers, ensuring they are complete, accurate, current, and incorporated into the care plan. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews the smoking assessments for completeness, accuracy, currency, and incorporation into the care plan. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. To ensure sustained compliance, the Medical Records conducts daily audits of all new falls to verify neuro checks and resident education are documented. Any omissions are reported immediately to the DON for corrective actions and follow-up re-education. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews care plan compliance quarterly to confirm interventions for falls. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. Compliance will be submitted to the QA committee monthly (Aug-Sep-Oct) or until substantial compliance is maintained. The Administrator will ensure compliance.
Failure to Report and Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to follow its policy and federal regulations regarding the reporting and investigation of alleged abuse when an incident occurred involving two residents. One resident alleged that another resident hit him on the right cheek, and in response, he hit back. The incident was witnessed by staff, and the involved residents were both found to be cognitively intact and able to make decisions. Documentation in the medical record described the event as an accidental graze to the cheek, with no injury noted, and the responsible party and physician were notified. However, staff interviews revealed that the incident was described as an altercation and considered by the charge nurse to be abuse, which should have triggered immediate reporting and a thorough investigation as per facility policy and federal requirements. Despite these requirements, the facility did not report the alleged abuse to the appropriate authorities, including the State Survey Agency and law enforcement, nor did it conduct a thorough investigation as required. The Director of Nursing confirmed that the incident should have been reported and investigated according to policy. This failure to report and investigate the alleged resident-to-resident physical altercation had the potential to leave the involved residents and others at risk of unaddressed abuse.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the same deficient practice: On 6/12/25, after Administrator and DON were notified of the alleged abuse incident, immediate review of the incident was conducted. Upon review of 5/28/25 incident residents 1 and 2 were separated, monitored, and provided protective measures. Both resident 1 and 2 were assessed by the charge nurse, with no injuries identified. The physician, and responsible parties were notified of the incident. Resident 1 remains in the facility without any physical or psychological distress. On 6/12/25, the Administrator, DON, RN Supervisor, and charge nurse completed rounds and reviewed facility charts and current residents to determine if any other residents had been affected by the same deficient practice. No other residents were identified to have been affected. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken: A comprehensive audit of current residents' records was conducted by the Medical Records Director (MRD), DON, and Administrator on 6/12/25 to assess for any unreported or delayed reports of alleged abuse. No additional incidents of unreported allegations were identified. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, the DON initiated facility-wide in-service training for staff on the facility's Abuse Prevention Policy and Reporting Procedures, in accordance with federal and state regulations. The training emphasized the following: - All allegations or suspicions of abuse must be reported immediately to the Administrator (Abuse Coordinator), DON, and appropriate state agencies. - Immediate protection of the resident involved is mandatory while the investigation is ongoing. - Documentation of the incident, notification of responsible parties, and reporting to regulatory agencies must be completed promptly. - Staff understanding of the difference between suspicion of abuse and confirmed abuse, reinforcing the obligation to report suspected abuse without delay. - The Abuse Policy has been updated to include a mandatory reporting checklist to assist staff in ensuring compliance. - The Abuse Coordinator (Administrator) will review all incident reports weekly for compliance with reporting protocols. How the facility will monitor its performance to ensure solutions are sustained: The Medical Records Director will conduct weekly audits of incident reports for 3 months starting the month of June to September 2025 to verify timely reporting and documentation of suspected abuse. Results of the audits and any identified deficiencies will be presented to the monthly QA Committee for review and further action. Quarterly QA meetings will continue to review trends, audit findings, and provide recommendations for ongoing compliance for a minimum of two quarters or until compliance is fully sustained. The Administrator (Abuse Coordinator) and DON will provide ongoing oversight to ensure that all reporting requirements remain in full compliance with regulations.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate an alleged resident-to-resident physical altercation involving two residents. One resident alleged that another resident hit him on the right cheek, and in response, he hit back. Medical record reviews indicated that both residents were competent and cognitively intact at the time of the incident. Documentation from a change in condition note described the event as an accidental graze by one resident's hand, but staff interviews revealed conflicting accounts, with one CNA stating that the incident was reported as a hit and a retaliatory action. Despite these reports, there was no evidence that the facility conducted a thorough investigation into the incident. Interviews with staff present during the incident, including CNAs and LVNs, confirmed that the event was known and reported to nursing leadership. However, the Director of Nursing (DON) was unable to provide documentation or evidence of an investigation, such as interviews with involved staff or a formal review of the incident. The facility's policy required all allegations of abuse to be thoroughly investigated and reported, but this process was not followed in this case, resulting in a deficiency for failure to investigate and document the alleged abuse.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the same deficient practice: On 6/25/25 upon notification of the alleged violation, the facility immediately initiated an investigation following the facility's Abuse Policy and Investigation Protocol. The involved resident (Resident 1) was assessed with no injuries noted, and protective measures were implemented during the immediate period of the alleged incident. The responsible parties (resident 1 is self-responsible, and responsible party for resident 2) were notified. The alleged perpetrator (resident 2) was discharged to a different facility on 6/17/25. On 6/25/26 and 6/26/25, the Administrator, DON, Medical Records Director, and Social Services reviewed current residents to ensure no other unresolved allegations were pending investigation. No other residents were identified as affected. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken: A review of the incident/accident logs, grievance logs, and nursing notes was conducted on 6/25/25 by the Administrator (Abuse Coordinator), DON, Medical Records Director, and Social Services to ensure that any previous allegations had been fully investigated, resolved, and documented appropriately. No additional concerns requiring investigation were identified. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, the DON conducted in-service training to staff on the facility's Abuse Prevention, Reporting, and Investigation policies, emphasizing: - All allegations of abuse must be reported immediately. - Prompt initiation of investigations upon receiving allegations. - Documentation of each step of the investigation process. - Implementation of protective measures during investigations. - Timely reporting of findings and corrective actions taken. Abuse Binders were placed in each nursing station with an investigation checklist to guide staff with proper documentation and timely follow-up. The Administrator (Abuse Coordinator) will review all incident reports weekly to confirm that any allegations are promptly investigated and resolved according to policy. How the facility will monitor its performance to ensure solutions are sustained: The Administrator (Abuse Coordinator), DON, and Medical Records Director will audit all investigation files weekly for the months of June to September 2025 to ensure allegations are investigated promptly and thoroughly, with documentation completed accurately. Results will be reviewed during monthly QA meetings, and trends or gaps will be addressed immediately. Quarterly reviews will continue thereafter to ensure continued compliance with regulations. The Administrator and Medical Records Director will oversee ongoing compliance, ensuring all allegations are investigated and resolved promptly. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, the DON conducted in-service training to staff on the facility's Abuse Prevention, Reporting, and Investigation policies, emphasizing: - All allegations of abuse must be reported immediately. - Prompt initiation of investigations upon receiving allegations. - Documentation of each step of the investigation process. - Implementation of protective measures during investigations. - Timely reporting of findings and corrective actions taken. Abuse Binders were placed in each nursing station with an investigation checklist to guide staff with proper documentation and timely follow-up. The Administrator (Abuse Coordinator) will review all incident reports weekly to confirm that any allegations are promptly investigated and resolved according to policy. How the facility will monitor its performance to ensure solutions are sustained: The Administrator (Abuse Coordinator), DON, and Medical Records Director will audit all investigation files weekly for the months of June to September 2025 to ensure allegations are investigated promptly and thoroughly, with documentation completed accurately. Results will be reviewed during monthly QA meetings, and trends or gaps will be addressed immediately. Quarterly reviews will continue thereafter to ensure continued compliance with regulations. The Administrator and Medical Records Director will oversee ongoing compliance, ensuring all allegations are investigated and resolved promptly.
Failure to Develop Comprehensive Care Plans After Resident Altercation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents following an incident in which one resident, who was confused, accidentally grazed another resident's right cheek while being moved by staff. The care plans did not reflect the individual care needs of either resident in relation to this incident, as required by federal regulations. Specifically, there was no care plan initiated on the day of the incident to address the event for either resident. Medical record reviews showed that both residents were competent and able to make decisions at the time of the incident. One resident had a BIMS score indicating cognitive intactness, and both had recent admissions or readmissions to the facility. Despite the incident being documented in the change in condition notes, the care plans for both residents did not include any problems or interventions related to the altercation. During an interview and concurrent medical record review with the DON, it was confirmed that the care plan problems related to the incident were missed for both residents. The DON acknowledged that the care plan for one resident was only completed after the surveyor's inquiry, which was not timely in relation to the date of the incident.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the same deficient practice: On 6/13/25, the IDT (Interdisciplinary Team), including the Administrator, DON, MDS Coordinator, Social Services, and Dietary Manager, reviewed and updated the care plan of the identified resident to ensure it was comprehensive, addressing all assessed needs, goals, and interventions, including psychosocial, medical, and functional needs. The resident and responsible party were included in the care plan discussion, and documentation was completed in the medical record. On 6/13/25, the DON and MDS Coordinator reviewed other residents' active care plans for gaps or incomplete documentation. No other residents were found to have been affected by incomplete or non-comprehensive care plans. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken: A facility-wide audit of all current residents' care plans was initiated on 6/13/2025 by the Medical Records Director, MDS Coordinator, and reviewed by the DON to ensure all plans reflected residents' current status, needs, goals, and preferences. Any identified discrepancies were corrected immediately, with the care plan updated, and responsible parties notified as appropriate. No additional concerns were identified. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, an in-service training was conducted by the DON for licensed nurses and IDT members on the requirements for developing and implementing a comprehensive care plan per federal and state regulations. Training emphasized: - Care plans must address identified needs from resident assessments. - Care plans must include measurable goals, specific interventions, and timelines. - Involvement of residents and/or responsible parties in care-plan development. - Timely updates to care plans when changes in condition occur. The MDS Coordinator will conduct care plan audits to ensure completeness, resident-specific interventions, and timely updates. The IDT will conduct care plan reviews in weekly clinical meetings and quarterly care plan meetings with resident/family participation. How the facility will monitor its performance to ensure solutions are sustained: The DON and MDS Coordinator will conduct random audits of 5 resident care plans weekly for June to September 2025 to ensure compliance with comprehensive care plan requirements. Findings will be presented at the monthly QA meetings for review, trend monitoring, and corrective action planning if needed. Audits will continue quarterly thereafter to ensure ongoing compliance. The Administrator and DON will provide oversight to ensure care plans remain current, complete, and compliant with regulations.
Failure to Document Physician Basis for Resident Discharge
Penalty
Summary
The facility failed to ensure that the discharge process was properly followed for a resident, as required by its own policies and procedures. Specifically, the closed medical record for the resident did not contain documentation from the attending physician indicating the basis for the resident's discharge. The facility's policy states that the attending physician must document the reason for transfer or discharge in the clinical record, particularly if the discharge is due to the resident's welfare or improvement in health. However, a review of the resident's medical record revealed that, prior to providing the resident with the Letter of Continued Determination (LCD), there was no physician documentation supporting the discharge decision. Further review of the resident's history showed that the resident was admitted, had a physician's order for discharge, and was later transferred to an acute care hospital. The History & Physical examination indicated ongoing need for in-patient therapy, and there was no indication that the resident was ready for discharge based on physician documentation. Interviews with the Social Services Director and the Administrator confirmed the absence of required physician documentation correlating with the discharge planning and progress notes.
Failure to Obtain Orders and Consent for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless needed for medical treatment. Specifically, the facility did not obtain a physician's order for the application of a soft mitten restraint on a resident's left hand. Additionally, the facility did not conduct the necessary assessments prior to applying the restraint, nor did it obtain informed consent from the resident or their representative. The resident involved had a medical history of hemiplegia and hemiparesis following a cerebral infarction, affecting the right dominant side, and aphasia. The resident was assessed as having severely impaired cognitive skills for daily decision-making and was not competent to enter into contracts. Despite these conditions, the facility did not have a care plan in place to address the use of restraints, nor did it monitor the resident for the use of the restraint as required by the facility's policies and procedures. Observations on two separate occasions confirmed that the resident was wearing a soft mitten restraint without the necessary documentation or oversight. Interviews with facility staff, including the Director of Staff Development (DSD), confirmed the lack of a physician's order, assessments, informed consent, monitoring, and care plan for the restraint. The DSD acknowledged that the mitten was considered a restraint and should have been documented accordingly. The facility's failure to adhere to its policies and procedures regarding restraint use had the potential to negatively affect the resident's physical mobility and psychosocial well-being.
Deficiencies in Oxygen and Medication Management
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. For the first resident, the facility did not assess the need for supplemental oxygen or obtain a physician's order for its use, as required by the facility's policies and procedures. The resident experienced a change in condition with abnormal lung sounds and a drop in oxygen saturation, yet there was no documented evidence of monitoring or a physician's order for the increased oxygen administered. Additionally, the facility did not follow up with pharmacy services to ensure the timely delivery of breathing treatment medications, resulting in missed doses. The second resident's care was compromised by the facility's failure to maintain the humidifier on the oxygen concentrator. The humidifier was found to be unlabeled, undated, and empty, which could lead to discomfort due to dry air. The facility's policy required daily checks and refills of humidifiers, but this was not adhered to, as observed during the survey. Interviews with facility staff, including LVNs and the DON, revealed a lack of communication and follow-up regarding medication delivery and changes in residents' conditions. The staff acknowledged the deficiencies, including the absence of physician notification and pharmacy follow-up for the first resident's medication, and the failure to maintain the second resident's humidifier as per policy.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained the highest practicable physical well-being. Specifically, the facility did not notify the physician in a timely manner when the resident experienced a change in condition regarding the right leg. The facility's policy requires prompt notification of the physician and resident representative when there is a change in the resident's condition. However, this protocol was not followed, as evidenced by the lack of documentation and communication regarding the resident's leg condition. The resident, who was competent and had intact cognitive function, had a care plan addressing non-healing bilateral lower extremity cellulitis and risk for skin breakdown. Despite a physician's order for daily application of mupirocin ointment, the resident's right leg was observed to be purplish, cold, and with blisters, indicating a lack of circulation. The LVN who noticed these changes did not follow up on notifying the physician due to being busy and not knowing how to document the change. The RN and interim DON confirmed the absence of documentation and notification, acknowledging the oversight in communication and documentation of the resident's condition change.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to treat and prevent pressure injuries for a resident, identified as Resident 2. The resident, who was not competent and had impairments in both upper and lower extremities, was dependent on staff for bed mobility and toileting and was always incontinent. The facility did not follow the physician's orders for wound treatment, as observed when LVN 5 applied Medihoney instead of the prescribed Santyl ointment to the resident's elbow wounds. This discrepancy was acknowledged by LVN 5, who stated that Medihoney was used based on a wound consultant's recommendation when Santyl was unavailable, but without obtaining a physician's order for this substitution. Additionally, the facility failed to develop a care plan to address the resident's Stage 3 pressure injuries on the right lower back, sacrum, and lumbosacral spine. Although a care plan was initiated to address the resident's risk for skin breakdown due to incontinence and fragile skin, it did not include specific interventions for the existing Stage 3 pressure injuries. This omission was confirmed by LVN 5 during an interview, who verified that no care plan was initiated for these specific pressure injuries. The interim DON and the Administrator were informed of these findings and acknowledged the deficiencies. The interim DON stated that nurses are expected to follow physician's orders and clarify them as needed, and that each pressure injury should have a treatment order and a written plan of care. However, the facility's failure to adhere to these protocols resulted in the resident not receiving the appropriate care and services to promote healing of the pressure ulcers.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that five residents were free from unnecessary psychotropic medications, as evidenced by the lack of non-pharmacological interventions and proper monitoring. Resident 745 was prescribed multiple psychotropic medications, including quetiapine, Ativan, duloxetine, and divalproex sodium, without evidence of non-pharmacological interventions. Additionally, there was no monitoring for side effects or behavior for Ativan use, and the resident was not reassessed for the as-needed use of quetiapine beyond 14 days. Resident 84 was prescribed Xanax and Remeron without proper reassessment or informed consent. The facility did not limit the PRN order for Xanax to 14 days, and there was no informed consent obtained prior to its administration. Furthermore, there was no evidence of non-pharmacological interventions for the use of Remeron. The Director of Nursing (DON) acknowledged these deficiencies during an interview. Residents 5 and 19 were also affected by the facility's failure to limit PRN orders for psychotropic medications to 14 days. Both residents were prescribed lorazepam without documented reasons for extending the medication beyond the 14-day limit. Additionally, Resident 64's informed consent for psychotropic medications was improperly obtained, as the consent was signed by the resident who was deemed not competent. The DON and other staff members verified these findings, indicating a systemic issue with the facility's management of psychotropic medications.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement effective infection control practices, as evidenced by the absence of monthly Infection Prevention and Control Surveillance logs for several months in 2024. The Infection Preventionist (IP) confirmed the lack of documentation for July, September, and December 2024, attributing the September lapse to the departure of the previous IP. Additionally, the surveillance logs from August to November 2024 did not include whether residents met Loeb's criteria for true infection, instead using McGeers criteria, which was not in line with the facility's stated practices. The facility's Infection Prevention and Control Quality Assurance (QA) Reports for October and November 2024 were found to be inaccurate, with discrepancies between the QA Reports and the Infection Surveillance Monthly Reports. The IP, who prepared these reports, was unable to explain the inconsistencies. Furthermore, the IP did not maintain a surveillance log to track residents who met or did not meet Loeb's criteria, and only included residents prescribed antibiotics in the infection surveillance report, omitting those with signs and symptoms of infection who were not prescribed antibiotics. Additional deficiencies were observed in staff practices, including failure to perform hand hygiene after glove removal during medication administration and wound care, and improper handling of a Foley catheter bag. Enhanced Barrier Precautions (EBP) were not implemented correctly, as evidenced by the absence of EBP signage and PPE carts for residents requiring such precautions. The IP admitted to insufficient training and lack of knowledge about the EBP protocols, further contributing to the facility's failure to control the transmission of infections effectively.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that three residents were safe to self-administer medications found at their bedside. Resident 394 was observed with dorzolamide eyedrops at her bedside, which she administered herself without an assessment or a physician's order authorizing self-administration. Despite having the capacity to make decisions, Resident 394's medical records did not reflect any orders for self-administration of the medication, and she had previously indicated she did not want to self-administer her medications. Resident 74 was found with a gabapentin capsule in a medication cup on her nightstand, which she stated was left by the charge nurse for her to take later. Although Resident 74 was competent and able to make decisions, there was no assessment or physician's order for her to self-administer the gabapentin. The nurse confirmed that Resident 74 had not been assessed for safe self-administration, and no such order existed in her medical records. Resident 24 had Vicks VapoRub ointment on her bedside table, which she applied herself. Her medical records did not contain a physician's order for the ointment or for self-administration. The nurse verified the absence of such an order and acknowledged the need to notify the physician. These oversights in assessments and documentation posed a risk of inaccurate medication administration and potential adverse reactions.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach and accessible for several residents, which could lead to delays in care and negatively impact residents' psychosocial well-being. Observations and interviews revealed that multiple residents, including those requiring substantial assistance with bed mobility, were unable to reach their call lights. For instance, Resident 9 was observed yelling for help as the call light was clipped out of reach, and Resident 38 reported frequently needing to ask her roommate to press the call light for her. These issues were confirmed by staff members during interviews. Additionally, during a Resident Council meeting, several residents reported similar issues with call light accessibility, indicating a pattern of neglect in ensuring call lights were within reach. Resident 5 mentioned having to yell for help, while Resident 35 noted that CNAs often forgot to place the call light within reach after providing care. Resident 48 was observed with the call light hanging on a wheelchair, away from the bed, despite being able to use his upper extremities. These findings highlight a systemic issue in the facility's adherence to its policy on call light accessibility.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address concerns raised by residents during Resident Council meetings on three separate occasions. On 7/11/24, a resident reported not receiving pain medication on time, but there was no documentation showing that the nursing department addressed this issue. On 9/12/24, residents expressed dissatisfaction with medications not being ordered on time and a lack of snacks, yet the response from the nursing department was illegible, and there was no documentation indicating that the dietary department addressed the snack concern. On 10/10/24, residents reported that CNAs sometimes spoke to them in a childish tone, but this concern was not documented as being addressed by the nursing department. Interviews with facility staff, including the Activities Director, DON, DSD, and CDM, revealed that these concerns were not communicated effectively to the relevant departments. The DON and DSD were unaware of the issues raised in the meetings, and the CDM was not informed about the dietary concerns. The Activities Staff relied on the Resident Council Departmental Response Form to document and communicate these concerns, but without proper documentation and follow-up, the facility failed to take appropriate administrative actions to resolve the issues raised by the residents.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of certain residents. Resident 9 was observed watching a television program in a language she did not understand, as her preferred language was not available. Despite being awake and in bed, Resident 9 did not have access to a television in her preferred language, which was confirmed by CNA 7. This lack of access to preferred language programming was not addressed, leaving Resident 9 without appropriate activities that met her interests. Resident 22, who had limited English proficiency, was also affected by the facility's failure to provide activities in her preferred language. Although her care plan indicated a need for 1:1 enrichment programming and activities that accommodated her communication abilities, Resident 22 was observed watching her roommate's television in a language she did not understand. The Activities Director and Staff confirmed that Resident 22's activity participation records for January 2025 were blank, indicating a lack of engagement in activities that met her preferences. Additionally, the facility's activities department was responsible for supervising residents who smoked, which interfered with scheduled activities such as Bingo games. Residents 5 and 35 expressed concerns that their Bingo games were cut short to accommodate smoking supervision. The Activities Staff confirmed that the Bingo game was often interrupted or started late due to the need to supervise smoking residents, particularly on weekends. This disruption in scheduled activities did not align with the residents' preferences and contributed to dissatisfaction among the residents.
Failure to Update Liquid Consistency Order
Penalty
Summary
The facility failed to provide a resident with the prescribed liquid consistency diet as per the physician's order. During an initial tour, a cup of thin clear liquid was observed on the resident's bedside table, despite the resident's meal ticket indicating a thin liquid consistency order. A CNA confirmed the presence of the thin liquid and removed it, while also pointing out a pitcher labeled as nectar thickened liquid. The Speech Therapist later confirmed that the resident's liquid consistency order had been changed from nectar to thin liquid consistency. Further investigation revealed that the resident's care plan had not been updated to reflect the change in liquid consistency order from nectar to thin liquid, as per the physician's order dated 1/2/25. The Director of Nursing (DON) and the Administrator verified these findings. The resident, who had a severe cognitive impairment with a BIMS score of six, was at risk of aspiration due to a decline in swallowing, as noted in the care plan dated 11/21/24.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide necessary respiratory care for four residents, leading to deficiencies in their care. Resident 44's nasal cannula was not properly applied, as the nasal prongs were not inserted into the resident's nose, despite the oxygen being administered at two liters per minute. This was confirmed by LVN 1 during an observation, who then corrected the placement of the nasal cannula. Resident 44's medical records indicated a diagnosis of hypoxemia, necessitating continuous oxygen administration. Resident 97's oxygen cannula was found on the floor and not stored in a clean set-up bag, and there was no physician's order for oxygen administration. Additionally, a No Smoking/Oxygen in Use sign was not posted outside the resident's room, contrary to the facility's policy. These findings were verified by LVN 5 during an observation and interview. The absence of proper signage and storage practices for oxygen equipment was also noted for other residents using oxygen. For Resident 99, a nebulizer mask and canister were improperly stored inside a reusable shopping bag, rather than a clean set-up bag. This was confirmed by LVN 5 during an observation. Similarly, Resident 20's nebulizer mask and canister were found on a nightstand without proper storage, as verified by RN 1. The Central Supply Staff indicated that respiratory equipment should be changed weekly and as needed, and that licensed nurses have access to the necessary supplies to maintain proper storage and signage.
Inaccurate Monitoring of Dialysis Resident's Fluid Intake and Output
Penalty
Summary
The facility failed to accurately monitor the fluid intake and output for a resident receiving hemodialysis care, which could lead to life-threatening conditions related to fluid imbalance. The facility's policy required accurate documentation of intake and output when ordered by a physician or implemented by nursing staff. However, the medical records for the resident showed discrepancies in the documentation of fluid intake and output. The resident's medical records indicated an average daily fluid intake of 500 to 640 ml, with outputs recorded as three times daily. However, the Weekly Intake and Output Evaluation showed inconsistent data, with a 24-hour average intake of 1100 ml and varying outputs, which did not match the daily records. The nursing staff estimated the resident's fluid output based on the condition of incontinent briefs, and dietary intake was assumed based on the percentage of food consumed, rather than being accurately measured. The facility's documentation practices did not align with the physician's orders for fluid restriction, leading to inaccurate monitoring of the resident's fluid status. The discrepancies were verified by RN 2, who acknowledged that the intake and output were assumed rather than accurately monitored, highlighting a significant deficiency in the facility's care for the resident requiring dialysis.
Inadequate Training and Competency in Infection Control
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) and other nursing staff had the necessary competencies to provide safe and efficient care to residents. The IP was unable to identify the six moments of Enhanced Barrier Precautions (EBP) and failed to document meeting minutes for the Infection Control Committee. Additionally, the IP incorrectly identified Healthcare-Associated Infections (HAI) and Community-Acquired Infections (CAI), and misunderstood the definition of infection onset date. These deficiencies were compounded by the IP providing inaccurate information to a physician regarding a resident's antibiotic use. The facility's policies and procedures required the IP to lead infection prevention efforts and ensure staff competency. However, the IP reported insufficient training, having only received four days of training for the role. This lack of training contributed to the IP's inability to perform essential duties, such as correctly identifying infection types and documenting critical infection control meetings. The IP's lack of knowledge and training posed a risk to resident safety and infection control within the facility. Furthermore, the facility failed to provide adequate training on EBP to Certified Nursing Assistants (CNA) and Licensed Vocational Nurses (LVN). CNA 8 and LVN 6 were unable to correctly identify when to use EBP and had not received recent in-service training on the subject. This lack of training and competency among staff members increased the potential for improper infection control practices, further endangering resident safety.
Failure to Monitor Opioid Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring of a resident's drug regimen, specifically concerning the use of Norco, an opioid medication. The facility's policy and procedure (P&P) for pain management, dated October 2022, required staff and physicians to monitor for adverse effects of pain medications, including opioids. However, a review of the medical records for a resident, who had the capacity to make medical decisions, revealed no documentation of monitoring for side effects related to Norco, as per the facility's P&P. The resident had an order for Norco to be taken orally every four hours as needed for moderate to severe pain. During an interview, a registered nurse confirmed the absence of documentation for side effect monitoring. The Director of Nursing was informed and acknowledged these findings.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 23.33%. During a medication administration observation, three licensed nurses (LVNs) were found to have made errors. LVN 1, while administering medications to Resident 32, did not assess the resident's apical pulse and lung sounds before administering budesonide inhalation, and left residual Lasix in the medicine cup. This was contrary to the physician's orders which required monitoring of blood pressure, apical pulse, and lung sounds pre and post administration. LVN 2, during a medication administration for Resident 29, failed to administer Augmentin and ferrous sulfate with food, as required by the physician's orders and the medication's bubble pack instructions. This oversight was acknowledged by LVN 2, who noted the need for clarification of the order with the physician. LVN 3, while administering medications to Resident 745, did not administer tamsulosin, duloxetine, and quetiapine fumarate, despite these medications being signed as given on the Medication Administration Record (MAR). The resident was noted to be not competent and unable to enter into a contract, including an admission agreement. The Director of Nursing (DON) and Administrator verified and acknowledged these findings.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that Resident 745 was free from significant medication errors, as observed during a survey. The resident, who had been prescribed duloxetine for depression, quetiapine fumarate for manic disorder, and tamsulosin for symptoms of an enlarged prostate, did not receive these medications as required. On the day of the survey, LVN 3 did not administer the prescribed medications to Resident 745, despite having signed the Medication Administration Record (MAR) as if they had been given. Further investigation revealed that the medications were initially filled for a 14-day supply on December 19, 2024, with a refill request made on December 26, 2024, which was not fulfilled. The pharmacy's records indicated that the last doses were administered on January 2 and 3, 2025, and no further medications were available. The facility's Director of Nursing (DON) and Administrator confirmed these findings, acknowledging the lapse in medication administration for Resident 745.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, as evidenced by several observations of expired and improperly stored medications. During an inspection of Medication Cart C, expired Hydrogel impregnated gauze and Curad oil emulsion dressings were found, along with open and single-use wound dressings that were not discarded after use. Similar issues were noted with Medication Cart A, where a bottle of Active liquid Protein Concentrated nutrition was found sealed but expired, and another bottle was found open. Additionally, a Covid self-test with an extended expiration date was found in Medication Room A, and an unlabeled Amjevita auto injection was found in Medication Room B. The facility also failed to ensure medications were not left unattended in residents' rooms. A bag containing wound dressings and ointments was found on a resident's nightstand, and the resident was unaware of its presence. Similarly, medication cups containing white pasty cream were left on the nightstands of two other residents, with no licensed staff present. These residents were either unaware of the medication or confirmed it was for their use, but the nursing staff should not have left the medications unattended. Furthermore, the facility did not maintain accurate labeling and secure storage of medications for another resident, as a white cream was found on the bedside stand without a corresponding physician's order. A Vitamin A&D packet was also left on a resident's bedside table, despite physician orders for its application. These failures in medication management and storage had the potential to negatively impact residents' well-being and lead to medication errors, as acknowledged by the Director of Nursing and other staff members.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by several observations during a survey. Two coffee pots were found stored wet, contrary to the USDA Food Code 2022, which requires equipment and utensils to be air-dried before storage to prevent microorganism growth. Additionally, the kitchen equipment and utensils were not maintained in a sanitary condition. A white freezer was observed with brownish-black discoloration on its Styrofoam lining, and four small red bowls with dried food crumbs were stored in a clean dish storage area. The facility's Certified Dietary Manager (CDM) confirmed these observations and acknowledged the need for proper cleaning. Further deficiencies were noted in the maintenance of the ice machine and the food preparation sink. The ice machine's inside lining was peeling and had a sticky brown discoloration, which the Maintenance Director confirmed was not a cleanable surface. Additionally, the food preparation sink lacked a backflow prevention system, as required by the USDA Food Code 2022, to prevent contamination from the sewage system. The Maintenance Director was unable to demonstrate the presence of a backflow prevention system, confirming the deficiency.
Deficiency in Hospice Care Documentation and Scheduling
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services was provided with the necessary care and services. Specifically, the facility did not maintain an accurate hospice visit calendar in the resident's medical record, nor did it ensure that hospice staff visits were documented accurately. The hospice provider's plan of care required a skilled nurse to visit weekly, a hospice aide to visit twice weekly, and a social worker to visit monthly. However, the facility's records did not include a calendar for January 2025, and the December 2024 hospice calendar lacked proper documentation of visits, including the designation of the visiting staff. Interviews with facility staff, including an LVN and the DON, confirmed these deficiencies. The LVN was unable to verify the hospice staff's visit schedule or confirm if the plan of care was followed. The DON acknowledged the lack of documentation and verification of hospice visits. These failures posed a risk for delayed communication and provision of hospice care between the hospice provider and the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program effectively, as evidenced by the inability of the Infection Preventionist (IP) to provide documentation that physicians were notified about residents who were prescribed antibiotics without meeting Loeb's Criteria. This oversight was identified during an interview and concurrent record review with the IP, where it was revealed that there was no documentation to show that the physicians were informed about the inappropriate antibiotic prescriptions. The Director of Nursing (DON) acknowledged these findings and confirmed that the IP should have notified the physicians about the residents who were prescribed antibiotics without meeting the necessary criteria. The report highlights that antibiotics are frequently prescribed in nursing homes, with a significant portion being prescribed incorrectly. The facility's policy, revised in December 2016, mandates that antibiotics should be prescribed and administered under the guidance of the antibiotic stewardship program. However, the failure to notify physicians about residents who did not meet Loeb's Criteria for antibiotic use indicates a lapse in the program's implementation. This deficiency has the potential to lead to inaccurate identification of true infections and may prevent residents from receiving appropriate treatment and care.
Facility Fails to Maintain Homelike Environment Due to Chipped Paint
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for a resident, as evidenced by chipped paint on the wall by the resident's head of bed. During an initial tour, the chipped paint was observed, and the Maintenance Director, upon touching the chipped paint, stated that they had not seen it before and acknowledged the findings. A Certified Nursing Assistant (CNA) confirmed that the chipped paint had been present for a week but admitted to forgetting to report it, as their focus was on the resident. The Administrator and Director of Nursing (DON) were informed and acknowledged the findings.
Failure to Notify Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident's representative of their right to a bed hold policy upon the resident's transfer to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, which require that residents and their representatives be informed in writing of the bed hold policies both in advance of any transfer and at the time of transfer. In the case of Resident 44, who was not competent to enter into a contract, there was no documented evidence that the resident's representative was notified of the bed hold provision when the resident was transferred to the hospital. Interviews with facility staff, including an LVN and the Admissions Coordinator, confirmed the absence of documentation regarding the bed hold notification for Resident 44. The LVN acknowledged that the responsible party should have been informed of the bed hold to ensure awareness of the resident's ability to return to the facility within seven days. The Admissions Coordinator also verified the lack of bed hold notification documentation in the resident's medical record. The Director of Nursing was informed of these findings and acknowledged the deficiency.
Inaccurate PASARR Level 1 Assessment for a Resident
Penalty
Summary
The facility failed to ensure the PASARR Level 1 assessment was accurately coded for a resident, which is a federal requirement to prevent inappropriate placement in nursing homes. The resident in question was admitted to the facility with a PASARR Level 1 Screening Form indicating no prescribed psychotropic medications for mental illness. However, a review of the resident's Order Summary Report revealed that the resident had physician's orders for Zyprexa, an antipsychotic medication, and lorazepam, an anti-anxiety medication, both prescribed for mental health conditions. Further review of the resident's Admission Record showed diagnoses of major depressive disorder, bipolar disorder, and anxiety, confirming the need for psychotropic medication. Interviews with the MDS Coordinator and the DON verified these findings and acknowledged the error in completing the PASARR Level 1 assessment. The MDS Coordinator confirmed that the assessment was not completed accurately, which necessitated a re-screening and appropriate referral.
Failure to Develop Care Plan for Catheter Use
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 75, who was admitted with a diagnosis of urinary retention and obstructive uropathy. The resident's medical records included a physician's order for the use of an indwelling urinary drainage catheter every shift. However, a review of the resident's plan of care revealed that there was no care plan developed to address the use of this catheter. During an interview, a Licensed Vocational Nurse (LVN) confirmed the absence of a care plan and acknowledged that it should have been initiated to prevent complications related to the catheter. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency.
Failure to Administer Methylphenidate as Ordered
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided to meet the needs of a resident, specifically regarding the administration of methylphenidate. The resident, who was competent and able to make decisions, had an order for methylphenidate to be administered twice daily for depression. However, the medication was not signed as given on the Controlled Drug Record for a specific date and time, and the emergency kit did not contain the medication. During an observation and interview with an LVN, it was confirmed that the methylphenidate was not signed on the Controlled Drug Record and was not available in the emergency kit. The Director of Nursing was informed and acknowledged these findings. This failure to administer the medication as ordered by the physician had the potential to negatively affect the resident's health and well-being.
Failure to Follow Up on Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant followed up on the monthly Medication Regimen Review (MRR) for a resident reviewed for unnecessary medications. The Executive Summary of the Consultant Pharmacist's MRR indicated that the resident's medication regimen was reviewed during a specified period. However, the resident's medical records did not show whether the MRR for December 2024 included any recommendations or if it was completed without recommendations. During interviews and document reviews, both RN 2 and the Director of Nursing (DON) confirmed that the MRR was conducted but were unable to provide evidence of any follow-up on recommendations. The DON acknowledged the lack of documented evidence regarding the completion of the MRR with or without recommendations.
Deficiency in Food Palatability
Penalty
Summary
The facility failed to ensure that the food served to residents was palatable, specifically with the preparation of broccoli. Observations and interviews revealed that the broccoli served was mushy and overcooked, contrary to the facility's guidelines which stated it should be tender but not mushy. This was confirmed during a test tray inspection involving the Certified Dietary Manager (CDM), a Registered Nurse Assistant (RNA), and a Licensed Vocational Nurse (LVN), who all acknowledged the broccoli was softer than it should have been. Resident 5, who was competent and able to make decisions, expressed dissatisfaction with the taste of the food, indicating a broader issue with the palatability of meals served at the facility. The Director of Nursing (DON) was informed of these findings.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for two residents, leading to potential unmet needs due to incomplete and inaccurate medical information. For Resident 24, the POLST (Physician Orders for Life-Sustaining Treatment) was not signed by the legal decisionmaker, which was verified during an interview with an LVN. The LVN acknowledged that the absence of a signature meant the POLST's validity was uncertain, and the licensed nurse or social worker should have contacted the family to ensure its validity. The Director of Nursing (DON) was informed and acknowledged these findings. For Resident 92, the facility failed to maintain accurate documentation of vital signs. The Record of Death indicated that Resident 92 passed away, yet the Weights and Vital Signs Summary showed vital signs recorded after the resident's death. An LVN confirmed that these vital signs were documented in the electronic health record posthumously, attributing the error to carelessness by the licensed staff. The DON verified the discrepancy and stated that the staff should have deactivated the resident's account to prevent unnecessary documentation.
Ice Buildup in Residents' Refrigerator Freezer
Penalty
Summary
The facility failed to ensure the frozen storage area inside the residents' refrigerator located in Station B was free of ice buildup. During an observation and interview on January 7, 2025, at 0846 hours, RN 1 confirmed the presence of ice buildup in the frozen storage area of the refrigerator, which was the only one available for storing residents' food in Station B. The frozen storage area did not have a separate door, and food for a resident was stored in the refrigerator. RN 1 acknowledged that the refrigerator needed to be defrosted. On January 9, 2025, at 1445 hours, the Director of Nursing (DON) was informed of the findings and acknowledged the issue. The ice buildup in the freezer area had the potential to prevent the food from maintaining the proper temperature, posing a risk to food safety.
Resident Abuse by CNA During Care
Penalty
Summary
The facility failed to protect a resident's rights to be free from physical abuse by a staff member. The incident involved a certified nursing assistant (CNA 2) who was observed by another CNA (CNA 1) slapping a resident on the face, resulting in redness. The resident, who was able to communicate effectively and understand others, reported feeling embarrassed by the incident. The facility's policy and procedure on resident rights, revised in February 2021, mandates that all residents be treated with kindness, respect, and dignity, and be free from abuse, which was not adhered to in this case. The incident occurred during a care session when CNA 2 was transferring the resident to a wheelchair, and the resident became combative. CNA 1, who was assisting with the care, witnessed CNA 2 slap the resident and subsequently reported the incident. The medical record review indicated that the resident was assessed and noted with skin discoloration following the incident. This failure to protect the resident from physical abuse had the potential to cause serious injury and psychological harm.
Improper Discharge After Resident Elopement
Penalty
Summary
The facility failed to properly discharge a resident, referred to as Resident 1, after an elopement incident. Resident 1, who had moderately impaired cognitive skills, was found after eloping from the facility and was transported to an acute hospital for evaluation. Despite being medically cleared to return, the facility denied readmission, citing the need for a lock-down unit due to Resident 1's history of elopement. This decision was made without conducting an Interdisciplinary Team (IDT) meeting or obtaining a physician's documentation to support the discharge decision. The facility's policy and procedure for transfer or discharge documentation require that the basis for such actions be documented, especially if the resident's needs cannot be met at the facility. However, in this case, there was no documentation of an IDT meeting or a physician's note explaining the facility's inability to meet Resident 1's needs. The Director of Nursing (DON) acknowledged that the facility could not prevent Resident 1 from leaving unsupervised but failed to document this inadequacy formally. Interviews with the DON and review of Resident 1's medical records revealed that the facility did not follow its protocol for facility-initiated discharges. The DON confirmed that Resident 1 was cleared for transfer back to the facility but was instructed to inform the hospital that Resident 1 required a locked facility. The lack of documentation and failure to conduct an IDT meeting or obtain a physician's note contributed to the deficiency in the discharge process.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and necessary services to prevent the elopement of a resident, identified as Resident 1, who was at risk for elopement. Resident 1, who had moderately impaired cognitive skills, was able to leave the facility undetected on two separate occasions. The facility's policies and procedures for wandering and elopement, as well as the use of Wanderguard systems, were not effectively implemented, leading to these incidents. Despite having a Wanderguard bracelet applied, the system failed to alert staff when Resident 1 exited the facility. The facility did not reassess Resident 1 for elopement risk following the initial elopement episode, as recommended by the Interdisciplinary Team (IDT). The IDT had recommended updating the elopement risk assessment and reeducating the resident to stay within the facility premises unless supervised. However, the elopement risk assessment was not updated, and there was no documentation of monitoring for exiting behaviors, which were defined as attempts or verbalizations of intent to leave. Interviews with facility staff, including the Director of Nursing (DON), revealed that there was a lack of consistent monitoring and supervision of Resident 1. On the day of the second elopement, staff members did not hear any door alarms, and there was no staff reliever to watch Resident 1 when the assigned nurse went on break. The DON acknowledged that Resident 1 was at risk for elopement and verified that the necessary assessments and monitoring were not conducted as required.
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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