Healthbridge Children's Hospital - Orange D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Orange, California.
- Location
- 393 S Tustin St, Orange, California 92866
- CMS Provider Number
- 555753
- Inspections on file
- 15
- Latest survey
- February 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Healthbridge Children's Hospital - Orange D/p Snf during CMS and state inspections, most recent first.
A facility failed to report a sexual abuse allegation involving a resident to the appropriate State and Federal agencies in a timely manner. The resident's family member reported the incident to the CEO, who later confirmed awareness but did not retain documentation of the report or investigation. The CEO claimed the allegation was unsubstantiated, but no evidence of the investigation was kept, risking the allegation going unreported and uninvestigated.
A facility failed to follow its abuse P&P in investigating a sexual abuse allegation involving a resident. The resident's family reported the abuse, but the facility did not document a body assessment or conduct a comprehensive investigation, including interviews with family members or visitors. The CEO acknowledged the allegation but lacked documentation of staff interviews and did not retain the investigation report.
The facility failed to implement individualized care plans for three residents, leading to potential risks. A resident's family member was not educated on infection control measures, another resident was transferred with a mechanical lift by only one staff member instead of two, and a third resident's care plan did not address anticoagulant and antibiotic use. Staff interviews confirmed these deficiencies.
The facility failed to update care plans for two residents, one involving an abuse allegation and another regarding the use of bilateral AFOs. A resident's care plan was not revised to reflect an abuse allegation reported to the Administrator, while another resident's care plan lacked documentation for the use of AFOs as per a physician's order. These omissions were confirmed through interviews and medical record reviews.
A facility failed to ensure proper care for a resident with a GT feeding. The resident's head of bed was not positioned at the recommended 30 to 45 degrees, increasing the risk of aspiration. Additionally, the facility did not properly label the feeding formula, lacking a system to indicate when the formula was added. Staff confirmed these deficiencies, which were observed on multiple occasions.
The facility failed to date respiratory equipment for two residents, leading to potential infection risks. One resident's cool aerosol therapy bag was not changed weekly as required, and another resident's suction canister was not dated upon installation. Both residents had significant respiratory conditions, including chronic respiratory failure and tracheostomy status.
A facility failed to monitor a resident's behavior and side effects for alprazolam and sertraline, both prescribed for OMS. Staff interviews revealed that there was no specific behavior monitoring for sertraline, and alprazolam monitoring was inaccurate. The lack of specific physician orders for behavior monitoring was acknowledged by the staff.
The facility failed to properly store and label medications for two residents and had expired supplies in three medication carts. A resident had a tube of wound dressing on the bedside table, and another had ointment and wound dressing, both of which should have been secured. Additionally, expired supplies were found in three medication carts, including protective wipes, a pressure manometer, and feeding tube extension sets. Staff confirmed these findings and acknowledged the need for immediate removal of expired items.
The facility failed to submit accurate staffing data to CMS, resulting in a One-Star Staffing Rating. While RN and LVN hours met requirements, CNA hours were below the minimum on several days. The CEO submitted the PBJ in the wrong format, leading to its rejection, and was unable to resubmit due to lack of contact information and documentation.
The facility failed to maintain safe operating conditions for resident care equipment. A mechanical lift stopped working mid-transfer due to a dead battery, requiring manual intervention to return a resident to bed. Additionally, ice buildup was observed in the refrigerator used for storing enteral feedings, posing potential risks for equipment hazards.
A resident with severe brain injury and difficulty swallowing was not assisted with meals in a timely manner, as observed on multiple occasions. Despite physician orders for CNA assistance with feeding, the resident's breakfast and lunch trays were left covered and untouched for extended periods, potentially affecting meal enjoyment.
A resident's room in the facility was found to have a supply cabinet drawer that was difficult to open and had thin wood material protruding, along with chipped blue paint on the wall near the call light system. These issues were confirmed by an LVN and a family member, who expressed concern about the broken state of the cabinet. The CEO acknowledged the findings.
A facility failed to send a Notice of Transfer/Discharge to the LTC Ombudsman for a resident transferred to an acute care facility. The resident, unable to make decisions, was transferred without the required notification. The Case Manager confirmed the oversight, attributing it to the resident's short stay, and acknowledged the error.
A facility failed to report an abuse allegation involving a resident to the CDPH L&C Program, as required by their policy and procedure. The incident involved a resident allegedly abused by an unknown provider, reported by the resident's family to a hospital social worker. Despite documentation by the SS/CM, the facility did not notify the CDPH L&C Program, and the CEO and SS/CM could not provide evidence of notification during an interview.
A facility failed to investigate an alleged abuse incident involving a resident, as required by its policy. Despite a complaint received by the CDPH, the facility's CEO could not provide documentation of an internal investigation. The facility's SS/CM claimed the allegation was vetted multiple times with no evidence found, but the required thorough investigation was not documented.
The facility failed to establish and maintain an infection prevention and control program, specifically lacking a proper water management plan to prevent the growth and spread of Legionella and other pathogens. Interviews revealed that the Director of Maintenance and a CNA were not following comprehensive water management protocols, increasing the risk of infection spread.
The facility failed to complete bed entrapment assessments for six residents, missing critical measurements for Zones 5, 6, and 7. Observations and interviews confirmed the use of side rails, and the Maintenance Director admitted to incomplete assessments. The CEO verified the findings.
The facility failed to ensure a resident was free from physical restraints without proper assessment and consent. The resident was subjected to a hand mitten and abdominal binder without the necessary documentation, assessment, or informed consent, contrary to the facility's policies. Staff interviews and medical record reviews confirmed these deficiencies.
The facility failed to develop comprehensive care plans for four residents, including the use of a lap tray, tobramycin medication, side rails, and restraints, despite physician's orders. Interviews and medical record reviews confirmed these omissions, posing a risk to individualized care.
The facility failed to prevent accidents and ensure safety measures for four residents. One resident did not receive immediate vital signs or neurological assessment after a fall, and the care plan was delayed. Another resident was not monitored in a stroller as required, and two residents did not have the necessary padded side rails for safety and seizure precautions.
The facility failed to document the external catheter measurements and develop a care plan for a resident with a CVAD, potentially delaying the identification of catheter-related complications. This was confirmed through observations, interviews, and medical record reviews.
The facility failed to label and date the mechanical ventilation tubing setup bag for a resident with a tracheostomy tube, as required by its policies and procedures. The respiratory therapist confirmed the setup bag should be changed weekly and labeled, but this was not done.
The facility failed to ensure the least restrictive alternatives were attempted before using side rails for a resident. The resident was observed with bilateral full padded side rails elevated, and the medical record did not show any evidence of less restrictive measures being tried. Interviews with staff confirmed the omission.
The facility failed to act on the Pharmacy Consultant's recommendations for two residents. One resident did not have blood pressure monitoring added to their Diuril medication order, and another resident's Culturelle medication order was not evaluated for chronic use as recommended. The CEO confirmed these recommendations were not addressed.
A facility failed to ensure a resident was free from unnecessary psychotropic medications by not monitoring episodes of crying inconsolably for Risperdal use, not documenting non-pharmacological interventions, and having inaccurate side effects monitoring for both Risperdal and diazepam.
The facility failed to properly store, label, and dispose of medications. Discontinued medications were found in the medication refrigerator, and oral medications were stored with externally used medications in a medication cart. Staff verified these findings, indicating a failure to follow the facility's policies.
The facility failed to meet sanitary requirements in the kitchen, including the presence of expired and moldy food items, improperly stored frozen food, and wet and damaged cutting boards. These deficiencies were verified by the CDM and pose a risk of foodborne illness to residents.
The facility failed to implement an accurate antibiotic stewardship program by excluding residents on long-term antibiotic therapy from the surveillance listing. Two residents on long-term antibiotics were not tracked, and the Infection Preventionist confirmed that the Quality Assurance and Performance Improvement report was based on this incomplete listing. The duration of antibiotic therapy was not reviewed, and the pharmacist did not review the antibiotic usage data, leading to potential inappropriate antibiotic use.
The facility failed to complete a comprehensive discharge assessment for a resident who was transferred to another facility. The CEO confirmed that the MDS for discharge was not completed.
The facility failed to update a resident's care plan to include the use of padded side rails for seizure/safety precautions, despite a physician's order. This oversight was confirmed through observation, interviews, and medical record reviews.
Failure to Report Sexual Abuse Allegation Timely
Penalty
Summary
The facility failed to implement its abuse policy and procedures (P&P) for reporting a reasonable suspicion of a crime, specifically regarding a sexual abuse allegation involving a resident. The facility did not report the allegation to the local State and Federal agencies in a timely manner, as required by section 1150 B of the Social Security Act. The incident involved a nonsampled resident, referred to as Resident 12, who was reportedly afraid of a Certified Nursing Assistant (CNA 2). The resident's family member reported the abuse allegation to the facility's CEO in April 2024, but the CEO claimed to have only been informed of the allegation in May 2024 by the local police department. During an interview, the CEO confirmed awareness of the allegation but failed to provide documented evidence of reporting the incident to the local State agency. The CEO stated that a report was hand-delivered to the agency, but no copies of the documents were retained. Additionally, the CEO mentioned that an investigation was conducted, and the allegation was found to be unsubstantiated, yet no documentation of the investigation was maintained. This lack of documentation and timely reporting posed a risk of the abuse allegation going unreported and uninvestigated.
Failure to Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure (P&P) related to the investigation of a sexual abuse allegation involving a nonsampled resident, referred to as Resident 12. The facility's P&P required documentation of all allegations, injury assessments by a licensed nurse, and interviews with family members, visitors, other residents, and staff from different shifts. However, the facility did not adhere to these procedures. Family Member 1 reported that Resident 12 was sexually abused by CNA 2, and expressed concerns about the facility's attempt to discharge Resident 12 prematurely. Family Member 1 observed Resident 12's distress when hearing CNA 2's voice and reported the abuse to the CEO in April 2024. Despite this, the medical record for Resident 12 lacked documentation of a body assessment related to the alleged abuse. The CEO confirmed awareness of the sexual abuse allegation, which was also reported by the local police department in May 2024. However, the CEO's investigation was incomplete, as it only involved interviews with night shift staff and lacked documented evidence of staff statements or a list of interviewed staff. Additionally, the CEO did not interview Resident 12's family members or visitors regarding the allegation. The CEO deemed the allegation unsubstantiated but failed to retain a copy of the investigation. Consequently, the facility did not provide documented evidence to demonstrate a thorough investigation of the sexual abuse allegation.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents, leading to potential risks. For Resident 4, the facility did not create a care plan to educate the resident's family member on the use of gown and gloves during high-contact interactions, despite the resident being on enhanced-based precautions for infection prevention. This oversight was observed when the family member entered the room without proper protective equipment and performed suctioning on the resident. Staff interviews confirmed the lack of documentation and education provided to the family member. Resident 12's care plan included the requirement for two staff members to assist with transfers using a mechanical lift, as per the facility's policy. However, an observation revealed that only one staff member conducted the transfer, contrary to the care plan and policy, posing a risk of injury or fall. Additionally, Resident 19's care plan did not address the use of anticoagulant and antibiotic medications, despite physician orders for these treatments. Staff interviews confirmed the absence of care plan problems for monitoring these medications, acknowledging it as a mistake.
Failure to Revise Care Plans for Abuse Allegation and AFO Use
Penalty
Summary
The facility failed to revise the care plans for two residents, which posed a risk of not providing appropriate care. For Resident 12, the care plan was not updated to reflect an abuse allegation reported by the resident to a family member, who then informed the Administrator in April 2024. Despite the Administrator's awareness of the allegation, the care plan did not address this issue, as confirmed during an interview with the Administrator and a review of the resident's medical records. For Resident 17, the care plan was not revised to include the use of bilateral ankle-foot orthoses (AFOs) as ordered by a physician. The order, dated November 15, 2024, specified the use of AFOs for two hours on and two hours off from 0800 to 2200 hours, along with instructions for maintaining ankle alignment, performing passive range of motion exercises, and monitoring skin integrity. During an interview and medical record review, RN 1 acknowledged the absence of documentation in the care plan regarding the AFOs and confirmed the need for revision.
Failure to Ensure Proper GT Feeding Protocols
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (GT) feeding received appropriate treatment and services to prevent complications. Specifically, the head of the bed (HOB) for the resident was not positioned at the recommended 30 to 45 degrees during GT feeding, which is necessary to reduce the risk of aspiration. Multiple staff members, including a respiratory therapist, registered nurse, licensed vocational nurse, and certified nursing assistant, confirmed that the HOB should be at least 30 degrees. However, observations revealed that the HOB was only at 20 degrees, which was verified by staff as incorrect. This improper positioning was observed on multiple occasions, and staff acknowledged the error and adjusted the HOB accordingly. Additionally, the facility did not properly label the tube feeding formula. The facility's policy required that the enteral feeding formula label include the initials, date, and time the formula was hung or administered. However, observations showed that the feeding formula and water flush bags were labeled only with the date and time when the bags were changed, not when the formula was added. Staff confirmed that there was no system in place to label the GT feeding bags with the date and time of formula addition, which could lead to confusion and potential complications for the resident.
Failure to Date Respiratory Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents, leading to potential increased risk of infection. For one resident, the facility did not ensure that the cool aerosol therapy plastic bag was dated according to the facility's policy and procedure (P&P). The bag was observed to be dated 2/6/25, and it should have been changed on 2/13/25, as per the weekly change requirement. This resident had a medical history of chronic respiratory failure, tracheostomy status, and multiple congenital heart malformations. For another resident, the facility failed to date the suction canister when it was installed and connected to the suction machine. The canister was observed with 60-70 ml of whitish secretions and was not dated, which was verified by the LVN. This resident had a medical history of acute and chronic respiratory failure with hypoxia, tracheostomy status, and dependence on ventilator status. The CEO was made aware of these findings and acknowledged the deficiencies.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the facility did not monitor the episodes of OMS as a behavior manifestation and side effect for the medications alprazolam and sertraline, both prescribed for the same indication. This lack of monitoring could lead to inaccurate assessments of behavior and side effects, potentially affecting the physician's ability to determine the effectiveness of the medications for the resident. During interviews and medical record reviews, it was revealed that there was no specific behavior monitoring for the use of sertraline, and the behavior monitoring for alprazolam was not accurately documented. Both RN 4 and LVN 6 acknowledged that the physician's orders did not specify which behaviors to monitor for these medications, and there was no side effect monitoring in place. This oversight in monitoring and documentation was verified by the staff involved.
Improper Storage and Expired Supplies in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals for two residents and three medication carts. Resident 4 had a tube of Triad hydrophilic wound dressing on the bedside table, which was brought in upon admission and should have been stored in the medication treatment cart. Similarly, Resident 273 had a tube of mupirocin ointment and a tube of Venelex wound dressing on the bedside table, which were also brought in upon admission and should have been secured in the medication treatment cart. Both instances were verified by the respective nursing staff, who acknowledged that the medications should have been stored securely. Additionally, three medication carts contained expired supplies. Medication Cart 2 had eight packets of SurePrep protective wipes past their expiration date. Medication Cart 4 contained an expired AG Cuffill pressure manometer. Medication Cart 6 had expired GT feeding tube extension sets with Enfit connectors and 42 packets of SurePrep protective wipes. The nursing and respiratory staff confirmed the presence of expired supplies and acknowledged that they should be removed immediately, as expired supplies could be less effective.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS, which resulted in a One-Star Staffing Rating. The review of the CMS CASPER reports indicated that the facility did not submit data for the quarter from July 1, 2024, to September 20, 2024. The Pediatric Monthly Subacute Staffing Report revealed that while RN and LVN hours met the requirements, CNA hours were below the minimum on several days across multiple months, totaling significant hours below the required minimum. Despite the negative variances in CNA hours, excess nursing hours were reported, suggesting that nursing staff assisted with resident care. During an interview and document review with the CEO, it was revealed that the PBJ was submitted electronically in October 2024 but not in the required XML format, leading to its rejection. The CEO did not initially notice the rejection and was unable to resubmit the PBJ due to a lack of available options and contact information for CMS. The CEO also failed to provide documentation of the rejection notice, as she was unable to print it from the CMS PBJ website.
Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain resident care equipment in safe operating condition, as evidenced by two specific incidents. In the first incident, a mechanical lift used to transfer a resident from bed to wheelchair stopped working mid-transfer due to a dead battery. This occurred when the resident was approximately one and a half feet above the wheelchair, necessitating manual intervention by the CNA to return the resident to bed. The facility's policy required the lift to be charged daily for a minimum of eight hours, and the Maintenance Director confirmed that staff were expected to replace the lift's battery with a charged one after each use. In the second incident, ice buildup was observed in the refrigerator designated for enteral feedings, which were stored alongside food items brought from outside the facility. This was confirmed during an observation and interview with an RN, who verified the presence of ice buildup along the back side of the refrigerator. These deficiencies posed risks for equipment hazards or unsafe practices that could affect the residents' well-being.
Failure to Assist Resident with Timely Meal Consumption
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 12, was assisted with her meals in a timely manner, which could potentially affect the enjoyment of her meals at an appetizing temperature. On the morning of February 19, 2025, Resident 12's breakfast tray was delivered at 0800 hours but was observed still covered and untouched at 0940 hours, with the overbed table positioned about one foot away from the foot of her bed. At 1000 hours, a CNA was observed feeding Resident 12 oatmeal. Later, at 1146 hours, the CNA placed Resident 12's lunch tray on the overbed table and left the room without assisting her. By 1205 hours, the lunch tray remained covered and untouched. Resident 12's medical records indicate she was admitted to the facility with severe brain injury, multiple back and rib fractures, chronic lung disease, and difficulty swallowing. A physician's order dated February 18, 2025, specified that Resident 12 was to be on a soft and bite-sized texture diet and required assistance from CNAs for feeding. Despite these orders, the CNA failed to assist Resident 12 promptly with her meals, as verified during an interview with the CNA, who could not explain the delay in providing assistance.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for a resident residing in Room A. Observations revealed that the supply cabinet drawer in the room was difficult to open, with thin wood material protruding from the face of the drawer, and the drawer rails were not aligned. Additionally, the wall near the call light system had chipped blue paint. These issues were confirmed during an observation and interview with an LVN, who was unaware of how long these conditions had existed. A family member of the resident also noted the broken condition of the supply cabinet drawer, expressing concern that it might fall if pulled open, and mentioned the peeling paint on the wall. The family member chose not to use the cabinet due to its broken state. The CEO of the facility acknowledged these findings and indicated that a job order had been sent to the maintenance department for repair.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a copy of the Notice of Transfer/Discharge was sent to the LTC Ombudsman for a resident who was transferred to an acute care facility for a higher level of care. The resident, who lacked the capacity to understand and make decisions, was admitted to the facility and later transferred without the required notification being sent to the Ombudsman. This oversight was confirmed during an interview with the Case Manager, who acknowledged that the notice was not sent due to the short duration of the resident's stay at the facility. The Case Manager admitted that this procedure was incorrect and recognized the necessity of sending the notice regardless of the resident's length of stay.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure (P&P) for reporting a reasonable suspicion of a crime, specifically an allegation of abuse, in accordance with section 1150B of the Act. This deficiency was identified when the facility did not report an abuse allegation involving a resident to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program. The facility's P&P, revised in January 2024, mandates that all alleged violations and substantiated incidents be reported to the state department of health and other relevant agencies within two hours by telephone and within twenty-four hours in writing. However, the facility did not comply with this requirement in the case of the abuse allegation concerning the resident. The incident involved a resident who was allegedly physically abused by an unknown provider, as reported by the resident's family member to a social worker at an acute care hospital. This information was documented in the resident's progress notes on September 13, 2024, by the Social Services/Case Manager (SS/CM). Despite this documentation, the facility did not notify the CDPH L&C Program of the alleged abuse. During an interview conducted on October 17, 2024, the Chief Executive Officer (CEO) and the SS/CM were unable to provide evidence that the required notification had been made, highlighting the facility's failure to report the abuse allegation as per their established P&P.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was allegedly abused by an unknown staff member. The facility's policy and procedure (P&P) on abuse, revised in January 2024, mandates a timely and thorough investigation of any incident or allegation of abuse, neglect, mistreatment, or misappropriation of a resident's property. This includes reviewing the resident's medical record, interviewing the person(s) reporting the incident, any witnesses, and staff members who had contact with the resident, and reviewing all events leading up to the alleged incident. However, the facility did not adhere to these procedures. The deficiency was identified when the California Department of Public Health Licensing and Certification Program received a complaint on October 16, 2024, alleging that a resident was physically abused by an unknown provider on September 11, 2024. A review of the resident's progress notes revealed that a social worker from an acute care hospital informed the facility of the abuse allegation reported by the resident's family member. The facility's social services/case manager (SS/CM) claimed that the allegation had been thoroughly vetted by the facility and CalOptima three times with no evidence found. However, during an interview on October 22, 2024, the CEO was unable to provide documentation of an internal investigation, despite stating that a meeting was held with the night shift staff regarding the alleged abuse.
Inadequate Water Management Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. Specifically, the facility did not ensure that their water management program was properly established and implemented. The program lacked an assessment of the facility water systems to identify where Legionella and other opportunistic pathogens could grow and spread. Additionally, there were no measures in place to prevent the growth of these pathogens, nor was there a monitoring system to ensure the effectiveness of any control measures. This deficiency was confirmed during an interview and document review with the Infection Control Preventionist, who was unable to provide the necessary documentation, including a flow diagram of the building's water system and identification of areas where water may stagnate. Further interviews revealed that the Director of Maintenance was only checking water temperatures for resident comfort and to prevent scalding, not as part of a comprehensive water management plan. A CNA also confirmed that the water was used for all residents for showering and handwashing, indicating a potential risk for the spread of infection due to the lack of proper water management protocols. The facility's failure to implement a thorough water management plan increased the risk of spreading infections among residents.
Incomplete Bed Entrapment Assessments
Penalty
Summary
The facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for six of 12 final sampled residents. This deficiency was observed through a combination of observation, interview, medical record review, and facility document review. The residents involved were found to have incomplete bed entrapment assessments, specifically missing measurements for Zones 5, 6, and 7, which are critical areas for potential entrapment according to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. For instance, Resident 9 was observed multiple times with bilateral full padded side rails elevated. The medical record review showed a physician's order for padded side rails due to seizure and safety precautions. However, the Bed System Measurement Device Test Results Worksheet for Resident 9 did not include assessments for Zones 6 and 7. Similar deficiencies were found for Residents 1, 7, 10, 17, and 22, where the bed entrapment assessments were incomplete, missing measurements for critical zones that could pose a risk of entrapment. Interviews with the facility staff, including Licensed Vocational Nurses (LVNs), Certified Nursing Assistants (CNAs), and the Maintenance Director, confirmed the use of side rails for the residents and the responsibility of the Maintenance Director for conducting the bed inspections. The Maintenance Director admitted to using a Bionix safety measuring device but verified that the assessments for Zones 5, 6, and 7 were incomplete. The CEO of the facility was also informed and verified the findings, acknowledging the incomplete bed entrapment assessments for the residents involved.
Failure to Ensure Proper Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that Resident 21 was free from the use of physical restraints without proper assessment and consent. Specifically, the facility did not conduct an assessment or implement the least restrictive measures before applying a mitten to Resident 21's hand and an abdominal binder. Additionally, the facility did not obtain informed consent from the responsible party for the use of these restraints. These actions were contrary to the facility's policy and procedures, which require a written order from a physician, an initial assessment of the resident's mental, behavioral, and physical status, and informed consent before applying restraints. The medical record review for Resident 21 showed no documentation of the required assessment, consent, or monitoring for the use of the hand mitten and abdominal binder. Observations and interviews with facility staff confirmed the use of the mittens and abdominal binder on Resident 21 without the necessary documentation and assessments. The resident's medical record indicated that the mittens were used on a specific date, but there was no evidence of when the mittens were released or any skin assessment for circulation during their use. Interviews with the LVN, RN, and CEO verified the lack of consent, assessment, and monitoring for the restraints applied to Resident 21. The facility's failure to follow its own policies and procedures posed a risk to the resident's independence and psychosocial well-being.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-focused care plans for four of twelve sampled residents, leading to deficiencies in individualized care. Resident 1 was observed using a lap tray attached to their wheelchair for positioning, but the care plan did not address this use despite a physician's order. Similarly, Resident 8 was prescribed tobramycin inhalation nebulization solution, but the care plan failed to include this medication. Resident 10 was observed with all four side rails elevated in bed, yet the care plan did not document the use of side rails for protection, even though there was a physician's order for one side rail to secure ventilator tubing. Resident 21 was observed with an abdominal binder and mittens to prevent pulling out a GT, but the care plan did not address these restraints despite physician's orders for their use. Interviews and concurrent medical record reviews with registered nurses confirmed the lack of care plans for these specific needs. The CEO was also informed and verified the findings. These omissions in the care plans posed a risk of not providing appropriate, consistent, and individualized care for the residents, as the care plans did not reflect the necessary interventions and supports required for their conditions.
Failure to Prevent Accidents and Ensure Safety Measures
Penalty
Summary
The facility failed to provide the necessary care and services to prevent accidents for four residents. Resident 11 experienced a fall incident, but the facility did not take vital signs or complete a neurological assessment immediately after the fall. The care plan problem was only initiated nine days later, and there was no documentation of addressing the causative factors of the fall or consulting the pharmacist and physical therapist as per the care plan. Additionally, there was no IDT review conducted as per the facility's policy and procedures on falls. Resident 4 was observed in a stroller that was not strapped to the crib as per the physician's order. There was no documentation showing that Resident 4 was monitored while in the stroller, and the facility failed to develop a care plan problem related to the use of the stroller. The CEO confirmed that if the stroller was not strapped to the crib, a staff member should be with the resident, and Resident 4 should be watched the most. Resident 7 was observed in bed with four side rails elevated but without the required padded side rails as per the physician's order and care plan. The facility did not document when the resident's family member removed the paddings or any education provided to the family member. Similarly, Resident 22 was observed with side rails elevated but without the required padded side rails for seizure precautions. The facility failed to ensure the side rail paddings were properly placed as per the physician's order and care plan intervention.
Failure to Document CVAD Care and Develop Care Plan
Penalty
Summary
The facility failed to ensure the proper administration and documentation of care for a Central Venous Access Device (CVAD) for one resident. Specifically, the facility did not complete and document the external catheter measurements in the medical record for the resident, nor did it develop a care plan for the use of the CVAD. These omissions were identified through observation, interviews, and medical record reviews, which revealed that the necessary measurements and assessments were not documented, and there was no specific care plan addressing the CVAD. The resident in question had a PICC line tunneled on the right upper chest, with dressing changes scheduled weekly and as needed. However, the medical record lacked documentation of the external catheter measurements and a care plan for the CVAD. The RN and CEO both verified these findings during interviews, confirming that the required documentation and care planning were not in place, potentially delaying the identification of catheter-related complications for the resident.
Failure to Label and Date Respiratory Equipment
Penalty
Summary
The facility failed to ensure the mechanical ventilation tubing setup bag for one resident was labeled in accordance with the facility's policies and procedures (P&P). This was observed on multiple occasions, where the setup bag was found unlabeled and undated. The facility's P&P required that all respiratory disposable treatment equipment be dated when changed, and the setup bag for mechanical ventilation tubing should be labeled with the resident's initials and room number. The respiratory therapist (RT) confirmed that the setup bag should be changed weekly and labeled accordingly, but this was not done for the resident in question. The resident involved had a tracheostomy tube and was connected to a mechanical ventilator. The medical record review showed that the resident had specific physician's orders for mechanical ventilation and the administration of dornase alfa inhalation solution. Despite these orders, the facility did not adhere to its own P&P regarding the labeling and dating of respiratory equipment. The RT Director also confirmed that the close suction system should be changed three times a week and that the respiratory setup bags should be labeled and dated, which was not done in this case.
Failure to Attempt Least Restrictive Alternatives Before Using Side Rails
Penalty
Summary
The facility failed to ensure the least restrictive alternatives were attempted prior to the use of side rails for one of the sampled residents. Resident 9 was observed on multiple occasions lying in bed with bilateral full padded side rails elevated. The medical record review for Resident 9 showed a physician's order to apply the padded side rails every shift for seizure and safety precautions. However, the Side Rail Use Assessment Form dated 1/18/22, which should document the least restrictive measures attempted, was left blank. Further review of the medical record did not show any evidence that less restrictive alternatives were attempted before the use of side rails. During interviews and concurrent medical record reviews with LVN 3 and RN 2, it was verified that Resident 9's medical record did not show the least restrictive alternatives were attempted prior to the use of side rails. Both LVN 3 and RN 2 confirmed that the side rail assessment form was the only form used to document the least restrictive measures, and it was left blank for Resident 9. This failure had the potential to put the resident at risk for entrapment and serious injury.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations from the drug regimen review were acted upon for two residents. For Resident 11, the Pharmacy Consultant recommended adding blood pressure monitoring to the Diuril medication order in the MAR. However, this recommendation was not implemented, and the resident's blood pressure was not monitored and documented prior to administering the medication from 3/1 to 3/14/24. The medical record showed no evidence that the Pharmacy Consultant's recommendations were addressed. For Resident 4, the Pharmacy Consultant recommended discussing with the primary care physician the need for the continuation of the Culturelle medication and to add the word 'for chronic use' to the medication order if it was for chronic use. This recommendation was also not acted upon, and there was no documented evidence that the Culturelle medication was discussed with the primary care physician or that the medication order was updated. During an interview, the CEO confirmed that the Pharmacy Consultant's recommendations for both residents were not addressed.
Failure to Monitor Psychotropic Medication Use and Side Effects
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the facility did not monitor episodes of crying inconsolably as one of the behavior manifestations for Risperdal medication for the resident. Additionally, the facility did not ensure that the monthly behavior summary and side effects monitoring were accurate related to the use of Risperdal. Furthermore, the facility did not document the implementation of non-pharmacological interventions prior to the use of Risperdal medication and failed to ensure there was a monthly summary of side effects monitoring related to the use of diazepam medication. The medical record review showed that the resident was administered diazepam and Risperdal medications without proper documentation of non-pharmacological interventions and accurate side effects monitoring. The resident's Medication Administration Records (MAR) and Treatment Administration Records (TAR) for January, February, and March 2024 revealed inconsistencies and inaccuracies in documenting behavior manifestations and side effects. For instance, there was no monitoring for episodes of crying inconsolably related to Risperdal use, and the monthly summaries for side effects monitoring were either missing or inaccurate. An interview with a registered nurse confirmed these findings, indicating that the resident should have been monitored for emotional lability and crying inconsolably instead of emotional lability and toning for Risperdal use. The nurse also acknowledged that the monthly behavior summary for toning should have been documented under emotional lability. These failures had the potential to result in inaccurate behavior and side effects monitoring, thereby preventing the physician from having the necessary information to determine the effectiveness of the medication for the resident.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure the proper storage, labeling, and disposal of medications, leading to potential safety risks. In Medication Room A, a Ziplock bag containing several foil packets of Tobramycin for a resident was found inside the medication refrigerator, despite a physician's order to discontinue the medication months earlier. Both RN 5 and RT 2 verified the findings and acknowledged that discontinued medications should be removed and given to the RT Director. This oversight indicates a failure to follow the facility's policy on medication storage and disposal. Additionally, an inspection of Medication Cart A revealed that medications administered orally were not stored separately from externally used medications. Various medications, including nasal sprays, eye drops, and suppositories, were found stored together with oral medications like antispasmodics, anticholinergics, and analgesics. LVN 4 and the CEO confirmed these findings, with the CEO noting that dividers should be used to ensure proper separation. These lapses in medication management could lead to unsafe medication administration and cross-contamination.
Sanitary Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by several observations during an inspection. Expired and moldy food items were found in the refrigerator, including a container of mozzarella cheese and strawberries with visible mold. Additionally, a bag of beef patties with freezer burns and an improperly stored bag of sausage patties were observed. These findings were verified by the Certified Dietary Manager (CDM) during the inspection. The facility's failure to discard expired and moldy food items and properly store frozen food items poses a risk of foodborne illness to residents receiving food prepared in the kitchen. Further inspection revealed that the facility did not adhere to proper air-drying procedures for kitchen equipment. Four cutting boards were found wet and stored on shelves, ready for use, which the CDM confirmed. Additionally, two cutting boards were heavily marred with knife marks, making them difficult to clean and sanitize effectively. The facility's policy and procedure on sanitation require all utensils and equipment to be kept clean and in good repair, free from breaks and cracks. The failure to air-dry cutting boards and replace damaged ones compromises the sanitary condition of the kitchen and the safety of the food prepared there.
Failure to Implement Accurate Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an accurate antibiotic stewardship program, as evidenced by the exclusion of residents on long-term antibiotic therapy from the surveillance listing. Specifically, two residents were not included in the surveillance line listing despite being on long-term antibiotic therapy. Resident 1 had orders for gentamicin sulfate and Tobramycin for infection prophylaxis, and Resident 8 had an order for Tobramycin inhalation nebulization solution for pneumonia prophylaxis. These residents were not tracked in the facility's surveillance line listing for antibiotic use, which only included residents on short-term antibiotic therapy. The Infection Preventionist (IP) confirmed that the residents on long-term antibiotic therapy were not included in the surveillance line listing and that the Quality Assurance and Performance Improvement (QAPI) report on antibiotic stewardship was based on this incomplete listing. The IP also verified that the duration of antibiotic therapy was not reviewed, and the pharmacist did not review the antibiotic usage data, including the duration or days of therapy. Consequently, the facility's antibiotic stewardship program did not accurately reflect the number of residents prescribed antibiotics, leading to potential inappropriate antibiotic use and failure to meet the program's objectives.
Failure to Complete Comprehensive Discharge Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment for discharge for one nonsampled resident. Resident 14 was admitted to the facility and later discharged to another facility. Upon review of the medical records and an interview with the CEO, it was confirmed that the Minimum Data Set (MDS) for discharge was not completed for Resident 14. This oversight was verified by the CEO during the interview and concurrent medical record review.
Failure to Update Care Plan for Padded Side Rails
Penalty
Summary
The facility failed to ensure the comprehensive plan of care for Resident 21 was revised to reflect the resident's current care needs and interventions. Specifically, the care plan was not updated to address the use of padded side rails, which were ordered by the physician for seizure/safety precautions. This oversight was identified through observation, interview, and medical record review, revealing that the care plan problem for the resident's seizure disorder did not include the necessary intervention of padded side rails, despite a physician's order dated 11/25/23 for their use every shift. During an interview and concurrent medical record review, RN 1 confirmed the use of padded side rails for Resident 21's safety and acknowledged that the care plan should have been updated to reflect this intervention. The CEO also verified these findings. The facility's policy and procedure for care planning, dated 5/2023, mandates that care plans be individualized and regularly reviewed and revised to reflect the reassessment of the resident's needs, which was not adhered to in this case.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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