Healthcare Center Of Orange County
Inspection history, citations, penalties and survey trends for this long-term care facility in Buena Park, California.
- Location
- 9021 Knott Ave, Buena Park, California 90620
- CMS Provider Number
- 055674
- Inspections on file
- 26
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Healthcare Center Of Orange County during CMS and state inspections, most recent first.
A resident with documented lack of decision-making capacity was discharged to an acute care hospital after experiencing vomiting and distress when GT feeding was resumed and 911 was called. After this discharge, an SSA later called the resident’s family to schedule a care plan meeting based on the MDS calendar and documented this call in the progress notes, despite the resident no longer being in the facility. The DON and SSA confirmed that this entry was made after discharge, resulting in an inaccurate medical record.
A resident with a history of brain injury, who was nonverbal and bedbound, experienced an unwitnessed fall resulting in a subdural hematoma after staff failed to investigate a family grievance about the resident's position near the bed edge and did not update the care plan or accurately assess fall risk. Staff were aware of the resident's behavior of dangling legs off the bed, but this was not documented or addressed prior to the incident.
A resident with a history of brain injury and on anticoagulant therapy experienced an unwitnessed fall resulting in a head injury. An LVN delayed contacting 911, first attempting to arrange transport through regular ambulance services despite physician orders for hospital evaluation. The resident was eventually transferred and diagnosed with a small subdural hematoma. Facility leadership confirmed that 911 should have been contacted immediately in such circumstances.
Two residents did not receive scheduled medications as prescribed, and staff failed to accurately document medication administration on the MAR. In one case, medications were recorded as given after a resident had been transferred to a hospital, and in both cases, blank spaces indicated missed doses. The DON and LVN confirmed these documentation and administration failures during interviews.
A resident experienced a fall and was subsequently assessed as high risk for falls, but the care plan was not updated to reflect this increased risk. Review of records and staff interviews confirmed that the care plan continued to indicate only a moderate fall risk, contrary to facility policy requiring updates when a resident's condition changes.
Two residents had incomplete and inaccurate medical records, including fall risk assessments with missing information and incorrect documentation of medication classes taken. Staff interviews confirmed these documentation issues, which did not meet the facility's policy for complete and accurate records.
Three cognitively intact residents experienced ongoing issues with non-functioning TV channels, their preferred activity, despite repeated complaints to staff and documentation in facility records. The facility failed to address these concerns in individualized care plans or provide effective follow-up, resulting in unmet activity needs as required by policy.
The facility did not maintain enough portable oxygen tanks for all residents with continuous supplemental oxygen orders, leaving several without access in an emergency. Additionally, a resident's BiPAP machine and stand were found unclean and cluttered with trash and an unlabeled urinal, with no documentation of required cleaning, as confirmed by staff and the DON.
The facility did not include in its assessment the number of portable oxygen tanks needed to evacuate all residents with continuous oxygen orders during an emergency. At the time of review, 55 residents required continuous oxygen, but only 46 full portable tanks were available, leaving the facility unable to provide for all affected residents during an evacuation.
Residents repeatedly reported during council meetings that call lights were not answered in a timely manner, with some waiting up to 20-30 minutes for assistance. Despite facility policy requiring documentation and follow-up on such concerns, there was no evidence that the nursing department addressed or resolved the issue. The Activities Director and DON confirmed the lack of documented response and ongoing nature of the problem.
A resident was observed eating lunch in her room when a pest was found floating in her milk. The resident reported feeling nauseated and refused to drink the milk due to the contamination. An LVN confirmed the presence of the insect and removed the milk, while the Central Supply Supervisor acknowledged the issue after being informed.
Three residents received psychotropic medications without documented non-pharmacological interventions as required by facility policy and physician orders. One resident also did not have accurate orthostatic blood pressure monitoring as ordered. Nursing staff and the DON confirmed that non-pharmacological interventions were not routinely provided or documented prior to medication administration.
A resident with complex medical needs, including wound care and an indwelling urinary foley catheter, was discharged home without documented discharge instructions for medication management, wound care, or catheter care. The discharge instruction form was left blank, and there was no evidence that the resident's representative received the necessary information, as confirmed by staff interviews and record review.
A resident with updated diagnoses of depression, schizoaffective disorder, bipolar disorder, and anxiety disorder was not properly assessed through the PASARR program, as the facility failed to complete a new PASARR after the resident's medical record and MDS assessment reflected these mental health conditions and related medications.
A resident with Clostridium difficile colitis and an order for contact isolation precautions did not receive the required infection control measures. Staff followed an incorrect Enhanced Barrier Precautions sign, and a CNA entered the room without proper PPE, indicating a failure to implement the care plan as ordered.
Multiple residents with impaired ROM and mobility did not receive restorative nursing assistant (RNA) services as ordered by physicians, including PROM/AAROM exercises, orthotic device application, and ambulation assistance. Documentation showed missed sessions without clinical justification, and staff interviews confirmed that RNAs were often reassigned to CNA duties, resulting in the failure to provide required restorative care.
A resident experienced a significant weight loss over a short period, but staff did not reassess the weight, notify the physician, or document follow-up as required by facility policy. The care plan noted nutritional risks but did not specify thresholds for significant weight change, and the DON confirmed the lack of monitoring and documentation after the event.
Three residents with gastrostomy tubes did not have appropriate physician-ordered diets, and two residents were observed receiving enteral feedings with the head of bed elevated less than 30 degrees, contrary to orders and policy. Additionally, a resident with dysphagia received medications ordered and documented as oral, despite being unable to take anything by mouth. Nursing staff and leadership confirmed these deficiencies during interviews and record reviews.
A resident's peripheral IV (PIV) site was found unlabeled and not discontinued after IV antibiotics were stopped, contrary to facility policy requiring labeling and removal if not in use. Nursing staff and the DON confirmed there were no current IV orders and acknowledged the PIV should have been removed after therapy ended.
A resident receiving enoxaparin for DVT prophylaxis did not have injection sites rotated as ordered by the physician and required by facility policy. Nursing staff confirmed that multiple injections were given in the same abdominal area over several days, and acknowledged that the sites should have been rotated to comply with orders and standard practice.
A pharmacist did not identify or report a missing dose in a physician's order for docusate sodium during the monthly drug regimen review. A resident received one 100 mg tablet twice daily via GT based on available stock, without dose clarification from the physician. The MAR and order both lacked a specified dose, and the issue was not detected by the pharmacist as required by facility policy.
Surveyors observed that two nurses failed to properly verify and administer medications to two residents, resulting in a medication error rate of 14.29%. One nurse administered a medication without a specified dose, while another did not ensure full dosages were given, as evidenced by residue left in medication cups after administration via GT. The facility's policies requiring dose verification and complete administration were not followed, and the DON acknowledged these deficiencies.
Surveyors identified multiple deficiencies in medication storage and security, including a resident found with an unlabeled medicine cup containing Betadine at bedside, expired medications present in two medication carts, and an LPN leaving a medication cart unlocked while unattended. The DON and staff confirmed these findings, indicating noncompliance with facility policies and pharmacy service requirements.
Surveyors found that food safety and sanitation guidelines were not followed, including the use of a can opener with a stripped blade, frying pans and a strainer with visible residue, an opened box of gloves stored on clean plates, and food residue in a resident-accessible microwave. These deficiencies were confirmed by the Dietary Service Supervisor, Kitchen Dishwasher, LVN, and DON, and affected 39 residents who consumed food prepared in the kitchen.
Surveyors observed overflowing dumpster bins with lids unable to close, scattered trash on the ground, and seven sharps containers left on top of biohazard bins instead of being properly disposed. Additional non-trash items were found improperly stored near the generator. The Central Supply Supervisor and DON confirmed these sanitation lapses.
Two residents experienced deficiencies in medical record documentation: one had an outdated NPO order that was not discontinued after a new diet order was implemented, and another had repeated blood pressure readings documented from an arm with a hemodialysis AV shunt, contrary to facility policy. These issues were confirmed by nursing staff and the DON.
Multiple failures in infection prevention and control were identified, including improper implementation of contact isolation for a resident with C. difficile, lack of dedicated equipment, missing signage for enhanced barrier precautions, improper handling of soiled linens, and inadequate hand hygiene by staff. The facility also lacked a comprehensive water management program as required by policy and regulation.
A resident who had previously received only the PPSV23 vaccine was not offered a dose of PCV 20, PCV 21, or PCV 15 as recommended by current CDC guidelines. Facility policy required assessment and offering of pneumococcal vaccines, but the resident's records and immunization registry showed no evidence of the required vaccine being offered or administered. The IP relied on outdated guidance and did not ensure the resident's vaccination status was current.
Surveyors found that the medication refrigerator used for storing residents' medications had thick ice buildup and was not being defrosted frequently enough, as confirmed by an RN and the DON. Additionally, required nightly quality control checks for a glucometer on a medication cart were not documented on two occasions, despite staff stating these checks should be performed and recorded.
Three residents using bilateral side rails were found to have bed system gaps exceeding FDA-recommended limits, with measurements in multiple entrapment zones above the allowable maximum. The Central Supply Supervisor confirmed the out-of-range measurements and lack of corrective documentation, and there was no regular maintenance schedule or log for bed safety. Facility leadership acknowledged these findings.
Two residents had deficiencies in their MDS discharge assessments: one was incorrectly documented as being discharged to a hospital instead of a board and care facility, and another had a missing discharge assessment despite being discharged home under hospice care. Both the MDS Coordinator and DON confirmed these documentation errors.
A resident's drug regimen was not free from unnecessary medications as metoprolol and hydralazine were administered outside of the physician's ordered parameters. The medications were given despite the resident's blood pressure and heart rate being below the specified thresholds. Interviews with the LVN and DON confirmed the failure to adhere to the physician's orders, acknowledging the potential for negative outcomes.
A resident's request not to have a specific CNA assigned for ADL care was not consistently honored, compromising her dignity and respect. Despite a complaint and facility policy, the CNA was assigned to the resident during a night shift, leading to an incident where the CNA changed the resident's incontinence brief against her initial wishes.
A resident dependent on a respirator fell and sustained a head injury and cervical fracture when a CNA, unaware of the two-person assistance requirement, attempted to turn the resident alone. The facility's failure to follow the care plan led to the incident.
The facility failed to ensure proper storage, labeling, and disposal of medications in multiple medication carts and rooms. Expired medications, improper storage of antiseptics with medications, and mixing of oral and external use medications were observed. Unauthorized personnel were also found in the medication room without supervision, and required signatures on medication destruction forms were missing.
The facility failed to ensure that 36 of 94 residents received the proper diets and portion sizes as per the facility's menus. Deviations included not following the BBQ Chicken puree recipe, incorrect portion sizes for ground BBQ chicken and potato salad, and using bottled BBQ sauce instead of homemade BBQ sauce for CCHO diets. These issues were confirmed through observations and interviews with the RD and other staff.
The facility failed to ensure that residents on mechanically altered diets received food in a form that met their individual needs. Pureed bread was not prepared correctly, and two residents received incorrect diet textures. These deficiencies were confirmed through observations and interviews with the Dietary Services Supervisor, Registered Dietitian, and Speech Language Pathologist.
The facility failed to ensure complete entrapment assessments and measurements for six residents using side rails, leading to potential risks. The Maintenance Director and DON acknowledged inconsistent assessments and lack of documentation, contrary to the facility's policy requiring routine inspections to identify entrapment risks.
The facility failed to provide two residents with the required Notice of Medicare Non-coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055, potentially preventing them from making informed decisions regarding their Medicare services.
The facility failed to implement restraint-free periods for two residents as required by their care plans and physician orders. Observations and interviews revealed that the mittens were not consistently released for the required duration, and there was no documentation of the release periods or assessments of the residents' skin, circulation, and mobility.
The facility failed to develop a comprehensive care plan for a resident who stored perishable and nonperishable food items in their room, contrary to facility policies. An LVN confirmed the absence of a care plan addressing this issue, highlighting a lack of individualized care.
An LVN failed to follow the facility's policy and procedure for administering Flonase Allergy nasal spray to a resident, potentially impacting the resident's health due to malabsorption and reduced medication effectiveness. The LVN did not provide necessary instructions during administration, assuming the resident already knew how the medication worked.
The facility failed to ensure a resident's heel protector boots were applied as per the physician's order for wound management and prevention. During an observation and interview, it was verified by both a CNA and an LVN that the resident was not wearing the heel protectors while in bed.
The facility failed to provide the RNA services as ordered by the physician for a resident, leading to missing documentation and potential decline in the resident's range of motion and mobility. The physician's orders included PROM exercises and the application of extension splints, which were not documented as performed on specific dates. The DON confirmed the findings and stated that missed exercises could be made up on a later date.
A resident identified as high risk for falls did not have the required bilateral floor mats in place, despite a physician's order and care plan. This failure was confirmed through observations and interviews, placing the resident at risk for serious injury.
The facility failed to maintain IV accesses and develop care plans for two residents with PICC lines. Necessary measurements and physician's orders were not documented, and specific care plans were not formulated. These deficiencies were confirmed through observations, interviews, and medical record reviews.
The facility failed to provide safe respiratory care for several residents, including incorrect ventilator alarm settings, unlabeled tubing, and improper oxygen administration. Additionally, an oxygen concentrator was found dirty, contrary to facility policy. These issues were confirmed by staff and acknowledged by the DON.
The facility failed to ensure that emergency dialysis supplies were accessible at the bedside for two residents requiring dialysis care. Both residents, who had end-stage renal disease and received dialysis three times a week, did not have the necessary dialysis kits at their bedside, as confirmed through interviews and observations with staff and the Director of Nursing (DON).
The facility failed to ensure accurate reconciliation and documentation of a resident's lorazepam, an antianxiety medication. The medication was signed out but not recorded as administered on the electronic MAR, contrary to facility policies. The discrepancy was confirmed during a controlled medication reconciliation with an LVN, and the DON acknowledged the finding.
The facility failed to obtain proper informed consent and implement non-pharmacological interventions before administering psychotropic medications to two residents. One resident was given Seroquel without a complete consent form, and another was administered diazepam without the necessary signatures on the consent form.
Inaccurate Medical Record Entry After Resident Discharge
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident when documentation was entered after the resident had been discharged. The resident had been admitted to the facility and later discharged to an acute care hospital after experiencing vomiting and distress when GT feeding was resumed; 911 was called and the resident was transferred. The resident’s H&P dated 10/31/25 documented that the resident had no capacity to understand and make decisions. Despite the resident’s discharge to the hospital on 12/5/25, a progress note dated 12/14/25 at 1724 hours showed that the SSA documented calling the resident’s family member to schedule a care plan meeting. During interviews and concurrent closed record reviews, the DON and SSA confirmed that the resident had been discharged on 12/5/25 and that the SSA nonetheless documented the care plan scheduling call in the resident’s progress notes. The SSA stated she based care plan meeting schedules on the MDS calendar and would check the current census before calling families, but verified that she had called and left a voicemail for the resident’s family and recorded this in the chart after discharge, making the medical record inaccurate.
Failure to Prevent Accident Hazards and Update Care Plan After Grievance
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident was free from accident hazards, resulting in an unwitnessed fall and subsequent injury. The resident, who was nonverbal, bedbound, and dependent on staff for all mobility and hygiene needs, had a history of traumatic brain injury, anoxic brain damage, and was on multiple medications including anticoagulants. Despite a family member's grievance about the resident being positioned near the edge of the bed and the behavior of dangling legs off the bed, the facility did not adequately investigate the concern or implement additional interventions to address the identified risk. The facility's documentation showed that the grievance was received and an in-service on proper positioning was conducted for staff, but there was no evidence of a thorough investigation or individualized interventions for the resident. The fall risk assessment for the resident was found to be inaccurate, as it did not account for all relevant medication classes, resulting in an incorrect fall risk score. Staff interviews confirmed that the resident frequently dangled his legs over the bed and slid down on the mattress, but this behavior was not documented in the medical record or addressed in the care plan prior to the fall. The care plan for the resident included general fall prevention measures but was not updated to reflect the specific risk of the resident's behavior of hanging his legs over the bed, even after the family member's grievance. The lack of accurate assessment, failure to update the care plan, and insufficient investigation of the grievance led to the resident experiencing an unwitnessed fall, sustaining a subdural hematoma, and requiring hospitalization.
Delayed Emergency Response After Resident Fall with Head Injury
Penalty
Summary
A licensed vocational nurse (LVN) delayed contacting emergency services after a resident, who was on anticoagulant therapy and had a history of anoxic brain damage, diffuse traumatic brain injury, and epilepsy, experienced an unwitnessed fall and sustained a bump on the forehead. The LVN initially assessed the resident and, after consulting with the physician, was instructed to transfer the resident to an acute care hospital for evaluation. However, instead of immediately calling 911, the LVN first attempted to arrange transport through regular ambulance services, which both advised her to contact 911 due to the resident's use of blood thinners and the presence of a head injury. The delay in contacting 911 resulted in a late transfer of the resident, who was eventually transported to the hospital where a CT scan revealed a small right frontal subdural hematoma. Interviews with facility staff, including the Director of Nursing (DON), confirmed that the appropriate protocol in such cases would have been to contact 911 immediately, especially given the resident's anticoagulant use and head injury. The failure to promptly provide the necessary care and services as ordered and in accordance with the resident's needs constituted a deficiency in maintaining the resident's highest practicable well-being.
Failure to Administer and Accurately Document Medications for Two Residents
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two out of three sampled residents, as evidenced by missed and improperly documented medication administration. For one resident with complex medical conditions including anoxic brain damage, epilepsy, and chronic respiratory failure, the Medication Administration Record (MAR) showed multiple instances where scheduled medications were not documented as given. These included antiseizure medications, muscle relaxants, supplements, and other critical drugs. Additionally, the MAR indicated that several medications were documented as administered on dates when the resident was not present in the facility, having been transferred to an acute care hospital. Interviews with facility staff, including an LVN and the DON, confirmed that blank spaces on the MAR indicated medications were not administered, and that check marks were used to indicate administration. The DON verified that the resident was not in the facility during the times some medications were documented as given, confirming inaccurate documentation. The facility's policies required medications to be administered as prescribed and for staff to accurately document administration or reasons for withholding medications, which was not followed in these cases. A second resident, with diagnoses including epilepsy and carotid artery stenosis, also had missing documentation for scheduled medications on specific dates. These included artificial tears, blood thinners, supplements, and antihypertensive medications. The DON confirmed that the MAR lacked evidence of administration for these medications and acknowledged that blank spaces meant the medications were not given. The failures in medication administration and documentation were verified through medical record review and staff interviews.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plan for one resident after a fall incident. According to the facility's policy, care plans are to be updated as residents' conditions change. Medical record review showed that the resident was found on the floor after a fall and was subsequently assessed as being at high risk for falls. However, the care plan continued to reflect only a moderate risk for falls and was not updated to indicate the increased risk following the incident. This deficiency was confirmed through interviews with both an LVN and the DON, who acknowledged that the care plan had not been revised to reflect the resident's high fall risk after the event. The failure to update the care plan as required was based on direct review of the resident's records, facility policy, and staff interviews, with no evidence that the care plan was revised to address the resident's changed condition after the fall.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that medical records for two of three sampled residents were complete and accurate, as required by their own policies and accepted professional standards. For one resident, fall risk assessments contained blank entries in critical sections such as systolic blood pressure, vision status, and ambulation on multiple assessment dates. For another resident, the fall risk evaluation was inaccurate regarding the number of medication classes being taken, as the resident was documented as taking fewer classes of medications than were actually prescribed and administered according to the Medication Administration Record (MAR). These deficiencies were confirmed during interviews with facility staff, including an LVN and the Director of Nursing, who acknowledged the incomplete and inaccurate documentation. The facility's policy on charting and documentation requires that records be objective, complete, and accurate, but this standard was not met for the residents in question, potentially impacting the assessment of their care needs.
Failure to Provide Individualized Activity Program and Maintain Preferred Activities
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of three sampled residents, as required by its own policies and procedures. All three residents were cognitively intact and had clearly documented preferences for self-directed activities, particularly watching television, which was identified as very important to their well-being. Despite repeated complaints and grievances regarding non-functioning TV channels, the facility did not ensure that the residents' preferred activities were consistently available. Observations and interviews revealed that the residents experienced ongoing issues with their TVs, including missing or non-working channels for extended periods. Residents reported these problems to various staff members, including nursing staff, the Maintenance Director, and the Administrator, but the issues persisted. Facility documentation, such as grievance reports and Resident Council minutes, confirmed that the TV channel problems were a recurring concern and had not been resolved to the residents' satisfaction. The Maintenance Director and Administrator acknowledged the ongoing nature of the problem and the lack of effective resolution, with maintenance staff only attempting to reset TVs after complaints and no evidence of timely or comprehensive follow-up. Medical record reviews and staff interviews further confirmed that the residents' activity care plans did not address their TV concerns, and there was no documentation of care plan meetings or interdisciplinary discussions to resolve the issue. The facility's own policies required regular activity evaluations and individualized care planning based on residents' preferences, but these were not implemented in practice. The lack of a functioning TV, as a preferred activity, was not addressed in the residents' care plans, and staff did not provide adequate assistance or follow-up to ensure the residents' needs and interests were met.
Failure to Maintain Adequate Oxygen Supply and Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide adequate respiratory care by not maintaining a sufficient number of portable oxygen tanks for residents with physician orders for continuous supplemental oxygen therapy. On the date of the survey, there were 55 residents with active orders for continuous supplemental oxygen, but only 46 portable oxygen tanks (43 E tanks and three H tanks) were available on site. This shortfall was confirmed by the respiratory therapist, who acknowledged that in the event of an emergency requiring evacuation, there would not be enough portable oxygen tanks to meet the needs of all residents requiring continuous oxygen. Additionally, the facility did not ensure that respiratory equipment was maintained in a clean and sanitary condition for a resident using a BiPAP machine. The BiPAP machine basket and stand were observed to be overflowing with trash, used facial tissues, empty soda cans, and an unlabeled urinal. The resident reported that he had requested staff to clean the BiPAP machine, but it had not been done. There was no documentation in the medical record, medication administration record (MAR), or treatment administration record (TAR) indicating that the BiPAP machine had been cleaned as required by facility policy. Interviews with nursing staff confirmed that the BiPAP machine should have been kept clean for infection prevention and that the urinal should have been labeled and not stored on the BiPAP stand. The Director of Nursing verified the findings, and staff could not provide evidence that the required cleaning had occurred, despite facility policy outlining specific cleaning procedures for such equipment.
Failure to Assess and Maintain Adequate Portable Oxygen Supply for Emergency Evacuation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for the competent care of residents requiring continuous supplemental oxygen therapy during both routine operations and emergencies. Specifically, the facility assessment did not include information on the number of portable oxygen tanks needed to safely evacuate all residents with active physician orders for continuous oxygen in the event of an emergency, such as an earthquake. The assessment only indicated that central supply staff monitored and replenished emergency supplies but lacked details on the specific oxygen tank requirements for evacuation scenarios. At the time of review, there were 55 residents with active orders for continuous supplemental oxygen—51 in the subacute unit and four in the skilled nursing unit. However, the facility's inventory consisted of only 46 full portable oxygen tanks (43 E tanks and three H tanks), which was insufficient to meet the needs of all residents requiring continuous oxygen during an emergent evacuation. The Assistant Administrator confirmed that previous assessments had included this information, but the current assessment did not, resulting in a failure to ensure adequate resources for safe evacuation.
Failure to Address Resident Council Concerns Regarding Call Light Response
Penalty
Summary
The facility failed to address concerns raised by residents during Resident Council meetings regarding untimely responses to call lights. According to the facility's policy, concerns discussed in Resident Council meetings should be documented using a Resident Council Response Form, communicated to the relevant department within 72 hours, and resolved within a specified timeframe. However, review of Resident Council minutes from two separate meetings showed repeated complaints that call lights were not answered promptly, sometimes taking up to 20-30 minutes, and that nursing staff instructed residents to turn off their call lights with promises to return, but did not follow through. There was no documentation indicating that these concerns were addressed or resolved by the nursing department. Interviews with residents confirmed that the issue persisted and had not been resolved, with residents continuing to experience long wait times for assistance with basic needs such as toileting or retrieving items. The Activities Director acknowledged that the concerns had not been resolved and was unable to provide documentation of the required response forms or evidence of communication with the nursing staff. The DON confirmed the expectation that concerns should be communicated and addressed within the policy's timelines, but acknowledged the ongoing nature of the issue.
Pest Contamination in Resident's Food
Penalty
Summary
A deficiency was identified when a resident was observed sitting on her bed eating lunch in her room, and a pest was seen floating on the surface of her milk. The resident reported that she set her milk aside after noticing the bug, expressed feeling nauseated, and stated she would not drink the milk because of the contamination. She also mentioned having seen bugs flying around previously, though not landing on her food. A licensed vocational nurse (LVN) confirmed the presence of the insect in the milk and removed the cup from the room. The Central Supply Supervisor indicated that pest control is conducted monthly and was not previously aware of pest concerns in residents' rooms, but acknowledged the findings when informed.
Failure to Implement Non-Pharmacological Interventions and Accurate Monitoring for Psychotropic Medication Use
Penalty
Summary
Surveyors identified that the facility failed to prevent the use of unnecessary psychotropic medications and did not implement required non-pharmacological interventions for three residents. For one resident, aripiprazole and trazodone were administered daily for bipolar disorder and depression, respectively, but there was no documented evidence that non-pharmacological interventions were attempted as required by facility policy. Additionally, the resident's orthostatic blood pressure monitoring, as ordered by the physician to monitor for medication side effects, was not accurately completed or documented in the Medication Administration Record (MAR). Another resident received risperidone for schizophrenia and lorazepam for anxiety, with frequent episodes of anxiety and psychotic behavior documented. The care plan included interventions such as tallying anxiety behaviors and approaching the resident calmly, but review of the MAR and progress notes showed no documentation that non-pharmacological interventions were implemented prior to administering these medications, except for one instance where distraction was used alongside medication. The care plan also required review of behaviors and alternate therapies, but this was not consistently documented. A third resident was prescribed escitalopram for depression, with daily monitoring of depressive symptoms ordered. Despite documentation of multiple episodes of depression, there was no evidence in the MAR or progress notes that non-pharmacological interventions were provided before administering the antidepressant. Interviews with nursing staff and the DON confirmed that non-pharmacological interventions were not routinely provided or documented for residents on psychotropic medications, contrary to facility policy and physician orders.
Failure to Document and Provide Discharge Instructions for Resident
Penalty
Summary
A deficiency was identified when the facility failed to document and provide discharge instructions for one of three sampled residents reviewed for closed records. The facility's policy requires that details of a resident's transfer or discharge be documented in the medical record and that appropriate information be communicated to the receiving health care provider. However, for this resident, the Discharge Instruction Form was found to be completely blank, with no information provided in any of the required sections, including patient information, responsible parties, medication education, wound care, indwelling urinary foley catheter care, and signatures. The resident in question had a history of complex medical needs, including an indwelling urinary foley catheter, multiple wound care orders, and was discharged to home with family and home health services. The medical record review showed that the resident lacked decision-making capacity, and the family member was the legally recognized decisionmaker. Despite physician orders specifying the need for home health services for PT/OT/ST, RN/LVN services for medication management, wound care, and catheter care, there was no documentation that these instructions were communicated to the resident's representative at discharge. Interviews with facility staff, including an LVN and the Medical Records Coordinator, confirmed that the discharge instructions form should have been completed and provided to the resident's representative. The absence of documentation for medication management, wound care, and catheter care instructions, as well as the lack of signatures to confirm receipt by the legally recognized decisionmaker, was verified by both staff and the Director of Nursing.
Failure to Update PASARR Assessment for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate an assessment with the Pre-Admission Screening and Resident Review (PASARR) program for a resident who had updated diagnoses of depression, schizoaffective disorder, bipolar disorder, and anxiety disorder. Upon admission, the PASARR Level I Screening incorrectly indicated that the resident did not have a serious diagnosed mental disorder and was not prescribed psychotropic medications for serious mental illness. However, subsequent medical record reviews and the Minimum Data Set (MDS) admission assessment documented active diagnoses of anxiety, depression, and schizophrenia, as well as the use of antipsychotic, antianxiety, and antidepressant medications. Despite these updated diagnoses and medication orders, the facility did not complete a new PASARR assessment to reflect the resident's current mental health status and treatment needs. The oversight was confirmed during an interview and medical record review with the MDS Assistant, who acknowledged that a new PASARR should have been completed when the resident's diagnoses and medications were updated in the medical record and MDS assessment.
Failure to Implement Contact Isolation Precautions for C. difficile
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who had a physician's order for contact isolation precautions due to Clostridium difficile colitis. The resident was receiving Vancomycin for this condition, and the care plan included interventions for contact isolation. However, during observation, a sign for Enhanced Barrier Precautions (EBP) was posted at the entrance to the resident's room instead of the required contact isolation precautions. Staff, including an LVN and a CNA, were unaware of the correct precautions and followed the posted EBP sign rather than the physician's order and care plan. Further, the CNA entered the resident's room carrying bed linens, set them on the resident's bed, and failed to don gloves before entering, only putting on a gown after entry. The CNA confirmed she should have donned both gown and gloves before entering and was unaware of the specific contact isolation order. The DON verified that the facility did not implement the required contact precautions as outlined in the resident's care plan.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing assistant (RNA) services as ordered by physicians for multiple residents with impaired range of motion (ROM) and mobility. Physician orders and care plans for several residents required specific RNA interventions, such as passive or active-assisted ROM exercises, application of orthotic devices, and ambulation assistance, to be performed five times a week or as tolerated. Documentation revealed that these services were not consistently provided according to the orders, with several days missed for each resident. There was no documented evidence explaining the missed RNA services or any clinical justification for not following the prescribed interventions. For example, one resident with impaired ROM in all extremities and a care plan to maintain current ROM functions did not receive the required frequency of PROM exercises and orthotic device applications. Another resident with bilateral hand contractures and impaired ROM was not provided with hand rolls and PROM exercises as ordered. Additional residents with limited mobility, functional quadriplegia, or other impairments also missed multiple RNA sessions, despite clear physician orders and care plan interventions specifying the frequency and type of restorative care needed. Interviews with staff, including RNAs, RNs, and the DON, confirmed that RNA services were not provided as ordered due to staffing shortages and the reassignment of RNAs to CNA duties. Staff acknowledged the missed services and verified that documentation did not reflect the required frequency of RNA interventions. The facility's policy on restorative nursing services required individualized, resident-centered care as outlined in each resident's plan, but this was not followed for the residents reviewed.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss for one resident who experienced a 28-pound decrease within two days of admission, followed by an additional 3-pound loss over the next three days. Despite facility policy requiring weights to be retaken and verified when a significant change is noted, and immediate notification of the dietitian and physician, there was no documented evidence that the resident's weight loss was reassessed, communicated to the physician, or that any follow-up occurred. The resident's medical record did not contain an assessment or monitoring for the significant weight loss, nor was there documentation explaining the reason for the drastic change. The care plan for the resident identified a nutritional problem and risk for weight fluctuation due to dialysis and refusal of treatment, with a goal to prevent significant weight loss or gain. However, the care plan did not specify what constituted significant weight change for this resident. During interviews, the DON acknowledged the lack of documentation and monitoring following the weight loss event. The resident was observed to have a good appetite and food preferences were met, but reported a lack of appetite at meal times.
Deficiencies in GT Medication Administration, Diet Orders, and Positioning
Penalty
Summary
The facility failed to ensure appropriate care and services for residents with gastrostomy tubes (GT), as evidenced by multiple deficiencies in medication administration, diet orders, and positioning during enteral feeding. For one resident with a GT and a diagnosis of dysphagia, the physician's orders for medication administration specified the oral route, despite the resident being unable to take anything by mouth. Licensed nurses administered and documented medications as given orally, even though the resident required all medications via GT. Staff interviews confirmed that the medication orders did not accurately reflect the resident's needs and that the route should have been updated to GT. Additionally, three residents with GTs did not have physician-ordered diets in their medical records. Staff, including LVNs, RNs, and the DON, acknowledged that all residents, including those with GTs, are required to have a diet order upon admission. The absence of a diet order was verified through medical record review and staff interviews, with staff stating that the expectation is to contact the physician to obtain the appropriate order or a swallow study if one is missing. Observations revealed that two residents receiving enteral feedings via GT were not positioned with the head of bed (HOB) elevated to at least 30 degrees, as required by physician orders and facility policy. Both residents were observed with the HOB elevated less than 30 degrees during feedings. Staff interviews confirmed that the HOB should have been elevated to prevent complications such as aspiration. The DON and other nursing leaders acknowledged these findings during interviews.
Failure to Label and Timely Discontinue Peripheral IV Access
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a peripheral IV (PIV) access. Observation revealed that the resident's PIV site was not labeled as required by the facility's policy, which specifies that the dressing should include the date and time of placement, staff initials, gauge size, and catheter length. Additionally, the PIV was not discontinued after IV therapy was completed, despite the facility's policy stating that peripheral catheters should be removed if not used for 24 hours or if therapy is discontinued. The resident's IV antibiotics were discontinued, and oral antibiotics were started, yet the PIV remained in place and unlabeled. Interviews with nursing staff and the DON confirmed that there were no active physician orders for IV medication or maintenance, and that the PIV should have been discontinued after the completion of IV antibiotics. The staff acknowledged that the PIV had not been used since the previous week and that it should have been removed to prevent potential complications. The failure to follow policy regarding labeling and timely removal of the PIV was verified through observation, interview, and medical record review.
Failure to Rotate Enoxaparin Injection Sites as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident who was prescribed enoxaparin sodium injections for DVT prophylaxis. According to the physician's order, the injection sites were to be rotated, and the facility's policy and procedure for subcutaneous injections required licensed nurses to verify the order and rotate injection sites to ensure proper administration. Medical record review revealed that the injection sites for the resident were not rotated as required, with multiple consecutive injections administered to the same area of the abdomen over several days. Interviews with nursing staff, including an LVN and an RN, confirmed that they were aware of the need to rotate injection sites and that the physician's order included this instruction. Both staff members reviewed the medication administration records and verified that the injection sites had not been rotated. The DON also confirmed that the facility's policy was not followed in this instance. The failure to rotate injection sites was directly observed in the documentation and acknowledged by the staff involved.
Pharmacist Failed to Identify Missing Dose in Medication Order
Penalty
Summary
A deficiency occurred when a licensed pharmacist failed to identify and report a medication irregularity for one resident during the required monthly drug regimen review. The resident had a physician's order for docusate sodium, but the order did not specify the dose to be administered. Despite this omission, the medication was administered as one 100 mg tablet twice daily via gastrostomy tube (GT), based on the facility's available stock, without clarification from the physician. The medication administration record (MAR) and the physician's order both lacked the specified dose, and the resident had been receiving the medication in this manner since the order was written. During interviews, the LVN confirmed that the dose was assumed due to the available tablet strength and acknowledged that clarification should have been sought. The consultant pharmacist, upon review, stated that each medication order should include a specified dose and acknowledged that the missing dose was not identified during the monthly medication regimen review. The facility's policy required the pharmacist to identify such irregularities, but this was not done, resulting in the deficiency.
Medication Error Rate Exceeds Acceptable Threshold Due to Dose Verification and Administration Failures
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5%, as evidenced by a calculated error rate of 14.29% during surveyor observation. Two of four licensed nurses were observed making medication administration errors involving two residents. One nurse administered docusate sodium to a resident without verifying the specific dose, as the physician's order and the Medication Administration Record (MAR) both lacked a specified dosage. The nurse assumed the correct dose was 100 mg, based on available stock, and administered it without clarification from the physician, despite acknowledging that other dosages exist and that clarification should have been sought. Another nurse failed to ensure the full dosages of three out of nine prescribed medications were administered to a different resident. After administering the medications via gastrostomy tube (GT), inspection of the medication cups revealed residue of aspirin, vitamin D3, and multivitamins with minerals, indicating incomplete administration. The nurse verified the presence of residue in the cups after administration, confirming that the resident did not receive the full prescribed doses of these medications. The facility's policies and procedures require verification of medication orders, including dose, prior to administration, and proper preparation and administration of medications through enteral tubes. Both nurses failed to adhere to these protocols, resulting in medication errors that were directly observed and confirmed through interviews and record reviews. The Director of Nursing acknowledged these findings and confirmed that medication doses must be specified and verified before administration.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals as required by professional standards and its own policies. During an observation, a resident with a below-the-knee amputation was found with a medicine cup containing an unidentified dark liquid on her nightstand; the resident was unaware of its contents. The DON later identified the liquid as Betadine, a prescribed antiseptic solution, and acknowledged it should not have been kept at the bedside. Additionally, expired medications were found in two separate medication carts during inspections with nursing staff, including a bottle of instant hand sanitizer and a bottle of Curad iodoform packing strip, both past their expiration dates. Staff verified the presence of these expired items. Further, the facility did not ensure that medication carts were securely locked when unattended. An LVN was observed leaving a medication cart unlocked while administering medications in a resident's room, which was confirmed by the staff member. The DON acknowledged these findings during an interview. These actions and inactions demonstrate a failure to adhere to the facility's policies and regulatory requirements for safe and secure medication storage.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors identified multiple failures in food safety and sanitation practices within the facility's kitchen. During an initial tour with the Dietary Service Supervisor, it was observed that the can opener blade's coating was removed or stripped, two frying pans had grayish black residue, and a strainer had white residue. These items were stored among other clean kitchen equipment. The Dietary Service Supervisor confirmed the condition of these items during the inspection. Further observations included an opened box of gloves placed on top of clean plates in the dishwashing area, as verified by the Kitchen Dishwasher, and food residue scattered on the roof surface of a microwave used by residents, as confirmed by an LVN. The Director of Nursing (DON) later verified all these findings. These deficiencies were noted to affect 39 residents who consumed food prepared in the kitchen, as documented in the facility's matrix.
Improper Trash and Sharps Disposal Leading to Sanitation Deficiency
Penalty
Summary
The facility failed to dispose and store trash in a sanitary manner, as evidenced by multiple observations of overflowing dumpster bins and improper disposal of sharps containers. Specifically, two of five dumpster bins were found overflowing with trash, preventing the lids from fully closing, and trash such as used gloves, masks, and other debris was scattered on the ground near the bins. Additionally, seven sharps disposal containers were observed placed on top of biohazard waste bins in the Infectious Waste Matter Room, rather than being properly disposed of inside the bins. The Central Supply Supervisor confirmed that these practices did not meet facility standards for pest prevention and disease control. Further observations revealed that non-trash items, including wheelchair wheels, a wrecked filing cabinet, and a pot, were improperly stored beside the facility's generator machine instead of being disposed of in the appropriate dumpster. The Central Supply Supervisor acknowledged that these items should not have been left in that area. The DON verified all of the above findings during an interview. These deficiencies were identified through direct observation and staff interviews, and were found to be inconsistent with the US Food Code 2013 requirements for refuse storage and disposal.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, a physician's order for an NPO (nothing by mouth) diet dated 1/29/25 was not discontinued in the medical record, despite a subsequent order on 5/13/25 allowing a NAS (no added salt) diet with pureed texture and regular/thin consistency for oral gratification. Documentation showed the resident was offered oral gratification since 5/13/25, but the outdated NPO order remained active, which was confirmed by both a registered nurse and the Director of Nursing during interviews and record reviews. For another resident with a left upper arm AV shunt for hemodialysis, the facility's policy prohibited taking blood pressure on the access arm. However, medical record review revealed that blood pressure readings were repeatedly documented as being taken from the left arm over several days. The resident, who was cognitively intact, confirmed that the left arm was used for hemodialysis and that staff were not permitted to take blood pressure on that arm. Multiple licensed nurses verified that blood pressure readings had been obtained and documented from the left upper extremity, and the Director of Nursing acknowledged that this should not have occurred.
Infection Control Program Deficiencies and Lapses in Isolation and Hygiene Practices
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, resulting in multiple lapses in infection control practices for both sampled and nonsampled residents. For one resident with a physician's order for contact isolation due to Clostridium Difficile colitis, the facility did not provide a private room, did not use dedicated medical equipment, and did not post appropriate signage indicating the required isolation precautions. Staff members, including an LVN and a CNA, did not follow proper PPE protocols or hand hygiene procedures, and the Infection Preventionist (IP) provided incomplete information to the resident's physician regarding the resident's ongoing symptoms, failing to review the medical record for continued episodes of diarrhea before discontinuing isolation. Additional deficiencies were observed in the handling of enhanced barrier precautions (EBP) for other residents. Signage indicating the type of isolation precautions was missing outside rooms where residents were on EBP for multidrug-resistant organisms, despite the presence of isolation carts and PPE instructions. Staff were observed transporting soiled linens against their clean scrubs without wearing gowns, contrary to facility policy, and failing to perform hand hygiene during and after medication administration, even after removing gloves or touching equipment in the vicinity of other residents. The facility also lacked a comprehensive, facility-specific water management program as required by CMS and its own policies. The water management binder did not contain the necessary flowcharts, testing protocols, or documentation of control measures and corrective actions. Staff interviews confirmed the absence of these required elements, and the facility was unable to provide evidence of a water management program that met regulatory and policy standards.
Failure to Offer Recommended Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to offer pneumococcal conjugate vaccines (PCV 20, PCV 21, or PCV 15) to a resident who had previously received only the PPSV23 vaccine, as required by current CDC recommendations. The facility's policy stated that all residents would be assessed for pneumococcal vaccine eligibility upon admission and offered the vaccine series within thirty days if indicated, with administration to follow CDC guidelines. However, review of the resident's medical record and the California Immunization Registry (CAIR2) confirmed that the resident had only received PPSV23 and was not offered any of the recommended PCV vaccines after that dose. During an interview, the Infection Preventionist (IP) stated that vaccination status was reviewed upon admission and annually, relying on CAIR2 data and family input. The IP believed, based on pharmacy consultant advice, that a new vaccine was not needed until five years after the PPSV23 dose, which was inconsistent with updated CDC guidelines. The IP confirmed that the resident's pneumococcal vaccination status was not up to date according to current recommendations, and there was no documentation showing the resident was offered the appropriate PCV vaccine.
Failure to Maintain Medication Refrigerator and Glucometer Quality Control
Penalty
Summary
Surveyors observed that the facility failed to maintain essential equipment in a clean and safe operating condition. Specifically, the medication refrigerator in Medication Room A, used to store residents' medications, was found to have thick ice buildup in the frozen storage area, which did not have a separate door. Multiple medications for several residents were stored in this refrigerator. The RN confirmed that the refrigerator was only being defrosted monthly and acknowledged that more frequent defrosting was needed. The DON was informed and acknowledged these findings. Additionally, the facility failed to ensure that quality control checks were consistently performed for the glucometer in Medication Cart C. During inspection and document review, it was found that there was no documentation to show that glucometer calibration was performed on two specific dates, despite staff stating that calibration was supposed to occur nightly and be recorded. The DON was also informed and acknowledged this deficiency.
Failure to Maintain Bed System Safety and Compliance with FDA Guidelines
Penalty
Summary
The facility failed to ensure that bed systems, including bed frames, mattresses, and bed rails, were regularly inspected and maintained in accordance with FDA guidelines and the facility's own policies and procedures. For three residents who used bilateral side rails, measurements of gaps in the bed systems were found to exceed the maximum allowable dimensions for several entrapment zones, specifically Zones 1, 2, and 4. These measurements were verified by the Central Supply Supervisor and were not within the 4.75-inch limit established by the FDA and referenced in the facility's Bed Safety policy. There was no documentation to show that corrective actions were taken to address these out-of-range measurements. For one resident, the Bed Safety Checklist showed Zone 1 and Zone 2 gaps measured 10.5 inches and 10 inches, respectively, both exceeding the recommended maximum. Another resident's checklist showed Zone 1 at 10.5 inches, Zone 2 at 10 inches, and Zone 4 at 5.5 inches, all above the allowable limits. A third resident had a Zone 2 gap of 9.5 inches, also exceeding the standard. In each case, the Central Supply Supervisor confirmed the measurements and acknowledged that there was no evidence of follow-up or correction. Additionally, interviews revealed that there was no regular schedule or log for bed maintenance, and the Maintenance Director, who was responsible for these tasks, was unavailable for interview. The residents involved had orders and care plans in place for the use of side rails as enablers to promote independence, bed mobility, or for seizure precautions. Informed consent was documented where appropriate, and residents or their representatives were aware of the risks and benefits of side rail use. However, despite these measures, the facility did not ensure that the physical safety standards for bed systems were met, as required by both internal policy and federal guidance. Facility leadership, including the Assistant Administrator and DON, verified and acknowledged the findings during the survey.
Inaccurate and Incomplete MDS Discharge Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two of three residents whose closed records were reviewed. For one resident, the physician's order and progress notes indicated discharge to a board and care facility under palliative and hospice care, but the MDS assessment incorrectly documented the discharge as a transfer to a short-term general hospital. The MDS Coordinator confirmed this discrepancy during an interview and record review. For another resident, the physician's order showed discharge to home under hospice care, and progress notes confirmed the resident was discharged home. However, the MDS assessment for this resident was found to be incomplete, with the discharge section left blank and not completed. The MDS Coordinator acknowledged that the discharge assessment should have been completed. The Director of Nursing (DON) verified both findings during interviews.
Failure to Administer Medications Per Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not administer metoprolol tartrate and hydralazine according to the physician's orders for a resident with hypertension. The physician's orders specified that metoprolol should be held if the systolic blood pressure (SBP) was less than 110 mmHg or the heart rate (HR) was less than 60 beats per minute, and hydralazine should be held if the SBP was less than 110 mmHg. However, the resident received metoprolol when their blood pressure was 105/54 mmHg and when their heart rate was 55 beats per minute. Additionally, hydralazine was administered when the resident's blood pressure was 106/55 mmHg. Interviews with the LVN and the DON confirmed that the medications were not administered per the physician's orders and parameters. The LVN acknowledged that administering blood pressure medications outside of the ordered parameters could lead to further lowering of the resident's blood pressure and/or heart rate, potentially resulting in negative outcomes. The DON stated that nurses were expected to read and follow the physician's orders when administering medications. The AIT and DON acknowledged the findings during the interview.
Failure to Honor Resident's Request for CNA Assignment
Penalty
Summary
The facility failed to consistently honor a resident's request not to have a specific CNA assigned to her for ADL care needs, which compromised the resident's right to dignity and respect. The facility's policy on Resident's Rights, revised in December 2016, guarantees residents the right to a dignified existence and to be treated with respect. Despite this, the resident had previously complained about the CNA and requested not to have her assigned, yet the CNA was assigned to the resident during a night shift. During an interview, the resident confirmed that she had complained about the CNA and had not been cared for by her since the complaint, except for an incident on a night shift when the CNA was assigned to her and changed her incontinence brief. The resident had informed the CNA not to touch her, but the CNA insisted on checking the incontinence brief. The resident eventually gave permission for the CNA to change the brief. The facility's Assignment Binder had clear instructions not to assign the resident to the CNA, indicating a failure to adhere to the resident's request and facility policy.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to provide the necessary care and services to ensure a resident was free from accidents when it did not follow the care plan requiring two-person assistance with bed mobility. The resident, who was dependent on a respirator and had no capacity to understand or make decisions, fell to the floor while being changed and turned in bed by one CNA. This resulted in the resident sustaining a head injury with profuse bleeding and a fracture of the first cervical vertebra, necessitating transfer to an acute care hospital. The facility's policies and procedures required appropriate support and assistance with activities of daily living (ADL) and a resident-centered fall prevention plan. The resident's care plan specifically indicated the need for two-person assistance for bed mobility due to the resident's ADL deficits and risk of falling. However, the CNA, who was working with the resident for the first time and was not informed of the two-person assistance requirement, attempted to turn the resident alone, leading to the fall. Interviews with facility staff, including the CNA, LVN, DON, and others, confirmed that the resident required two-person assistance for bed mobility. The CNA admitted to not asking for assistance and attempting to change the resident alone. The DON and other staff verified that the care plan was not followed, and the CNA should have requested help. The incident highlights a failure in communication and adherence to the care plan, resulting in significant harm to the resident.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure the proper storage, labeling, and disposal of medications in multiple medication carts and rooms. During an inspection of Medication Cart A, expired medications and blood glucose strip bottles with unreadable lot numbers and expiration dates were found. Additionally, medications were improperly stored with antiseptics and supplements. Similar issues were observed in Medication Cart C, where expired luer lock caps were found, and in Medication Cart B, where odor eliminator spray was stored with oral rinse medications. Medication Cart D contained expired sore throat spray and improperly stored nasal sprays with tablets and inhalation solutions with oral suspensions. Medication Cart F had expired COVID-19 test kits, and Medication Cart G had medications stored with personal items and disinfecting wipes. Medication Cart H contained loose pills and improperly stored medications, while Medication Cart E had similar storage issues with transdermal patches and injections mixed together. Medication room [ROOM NUMBER] had expired lactulose solution and improperly stored inhalation solutions with other medications. Additionally, the Facility Medication Destruction Forms were missing required signatures for several dates, and unauthorized personnel were observed in the medication room without supervision. The facility's policies and procedures for medication labeling and storage, as well as discarding and destroying medications, were not followed. Medications were found stored in an unsafe manner, with oral medications mixed with external use medications, and expired medications were not disposed of properly. The facility's policy required medications to be stored in locked compartments under proper conditions, with clear labeling and separation of different types of medications. However, multiple instances of non-compliance were observed, including the presence of expired medications, improper storage of antiseptics with medications, and the mixing of oral and external use medications. The Facility Medication Destruction Forms also lacked the necessary signatures from licensed nurses, indicating a failure to follow the proper procedures for medication destruction. Unauthorized personnel were observed in the medication room without supervision, which is against the facility's policy that only licensed nurses should have access to medication rooms. This lapse in security could potentially lead to unauthorized access to medications. The Director of Nursing (DON) verified the findings and acknowledged the deficiencies, including the missing signatures on the medication destruction forms and the presence of unauthorized personnel in the medication room. The facility's failure to adhere to its policies and procedures for medication storage, labeling, and disposal poses a risk to the safety and well-being of the residents.
Failure to Follow Prescribed Menus and Portion Sizes
Penalty
Summary
The facility failed to ensure that 36 of 94 residents who received food from the kitchen were provided with the proper diets and portion sizes as per the facility's menus. Specifically, the facility did not follow the menu for the BBQ Chicken puree recipe, did not serve the correct portion sizes for ground BBQ chicken and potato salad, and did not provide homemade BBQ sauce for residents on CCHO diets as required. These failures were observed during food preparation and meal service, where deviations from the prescribed recipes and portion sizes were noted. For instance, Cook 1 did not measure ingredients accurately while preparing pureed BBQ chicken and used incorrect scoop sizes for serving mechanical soft texture BBQ chicken and potato salad. Additionally, Cook 1 used bottled BBQ sauce instead of homemade BBQ sauce for residents on CCHO diets, contrary to the menu specifications. The deficiencies were confirmed through interviews with the Registered Dietitian (RD) and observations during meal preparation and service. The RD verified that all recipes and menus should be followed precisely. The Director of Dietary Services (DSS), Director of Nursing (DON), and Administrator were informed of these findings and acknowledged the discrepancies. The facility's failure to adhere to the prescribed menus and portion sizes had the potential to compromise the nutritional needs of the residents, which could lead to medical complications.
Failure to Provide Properly Prepared Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that residents on mechanically altered diets received food in a form that met their individual needs. Specifically, the pureed bread was not prepared according to the recipe, resulting in a sticky, gummy texture with pieces of thickened bread throughout the product. This was confirmed by the Dietary Services Supervisor (DSS), Registered Dietitian (RD), and Speech Language Pathologist (SLP) during observations and interviews. Additionally, one resident on a mechanical soft NAS (No Added Salt) CCHO (Consistent Carbohydrate) diet received regular textured meat instead of the prescribed ground BBQ chicken, and another resident on a mechanical soft finely chopped meat diet received a pureed diet instead of finely chopped meat. The facility's documentation and menu did not include a specific diet titled mechanical soft finely chopped, leading to confusion and incorrect meal preparation. These deficiencies were observed during a lunch meal tray line observation and confirmed through interviews with the DSS, RD, and SLP. The SLP emphasized the importance of verifying terminology used to distinguish between different mechanically altered diets. The failure to follow the prescribed diets posed a risk for complications such as choking for nine residents on mechanically altered diets, including seven residents on a pureed diet and two residents on mechanical soft diets.
Failure to Complete Entrapment Assessments and Measurements
Penalty
Summary
The facility failed to ensure that residents' entrapment assessments were complete and that measurements were recorded during bed inspections for six residents. The facility's policy required assessments to determine the risk of entrapment and to measure the space between the mattress and side rails. However, the assessments for the entrapment zones were either incomplete or not documented at all. This failure was observed in multiple instances, including residents who had physician orders for side rails for security or mobility purposes but lacked proper entrapment risk assessments and measurements. For example, Resident 351 had a high-risk score for entrapment, but the assessment did not include measurements for each entrapment zone. The Maintenance Director confirmed that he did not measure the bed rails or inspect for entrapment risks. Similarly, Resident 16 had side rails for mobility purposes, but the entrapment risk assessment was incomplete. The Maintenance Director and the Director of Nursing (DON) acknowledged that the facility had inconsistent assessments and lacked documentation for entrapment risks. Other residents, such as Residents 18, 33, 61, and 62, were also observed with side rails elevated, but their entrapment assessments were either incomplete or not conducted. The Maintenance Director admitted that he only checked the side rails when staff reported problems and did not perform measurements before installation. The DON confirmed that the facility's policy required routine inspections to identify risks, including potential entrapment, but these were not consistently carried out, leading to the deficiencies noted in the report.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide two residents with the required Notice of Medicare Non-coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055. Resident 901, who was admitted and later discharged home, did not receive the NOMNC. Similarly, Resident 902, who was readmitted and later discharged home, did not receive either the NOMNC or the SNF ABN Form. This failure was identified through medical record reviews and interviews with the facility's Administrator, who confirmed the absence of these documents in the residents' records. The facility's policy, dated April 2018, mandates that a completed copy of the NOMNC be given to beneficiaries at least two days before the termination of services. However, the Administrator was unable to provide documentation showing that these notices were given to Residents 901 and 902. The Administrator attributed the oversight to the previous Social Services Director, who did not keep copies of the forms. This lapse potentially prevented the residents from making informed decisions regarding their Medicare services.
Failure to Implement Restraint-Free Periods
Penalty
Summary
The facility failed to implement the restraint-free periods for two residents, as required by their care plans and physician orders. Resident 39 had a physician order to apply bilateral hand mittens and release them every two hours for at least 10 minutes. However, observations and interviews revealed that the mittens were not consistently released for the required duration, and there was no documentation of the release periods or assessments of the resident's skin and mobility. Similarly, Resident 46 had orders to apply bilateral hand mittens and release them every two hours for at least 10 minutes. Observations and interviews confirmed that the mittens were not released for the required duration, and there was no documentation of the release periods or assessments of the resident's circulation and mobility. The facility's policy on the use of restraints mandates that residents in restraints be observed every thirty minutes and given opportunities for motion and exercise for at least 10 minutes every two hours. Despite this policy, the facility did not adhere to these guidelines for Residents 39 and 46, as evidenced by the lack of documentation and the staff's admissions during interviews. These failures posed a risk to the residents' independence and psychosocial well-being, as the required restraint-free periods were not consistently implemented or documented.
Failure to Develop Comprehensive Care Plan for Food Storage
Penalty
Summary
The facility failed to ensure a comprehensive, resident-centered care plan was developed for a resident (Resident 40) who stored perishable and nonperishable food items in their room. During an observation and interview, it was noted that Resident 40 had various food items, including chips, dehydrated soup, pastries, instant hot chocolate, canned goods, fresh potatoes, and tomatoes, stored on shelves in their room. Additionally, Resident 40 had a small refrigerator containing pudding, potato salad, butter, and cheese. The resident stated it was their right to store these food items in their room. However, this practice was not compliant with the facility's policies and procedures regarding the storage of food from the outside, and there was no care plan addressing this issue for Resident 40. An interview with LVN 11 confirmed that it was the nursing staff's responsibility to create and revise a baseline care plan for each resident as needed, quarterly, and annually. LVN 11 acknowledged that Resident 40 was not compliant with the facility's policies and procedures regarding food storage and that this should have been included in the resident's care plan. The absence of a care plan addressing the storage of food from the outside for Resident 40 indicates a failure to provide appropriate, consistent, and individualized care for the resident.
Improper Medication Administration by LVN
Penalty
Summary
The facility failed to ensure the services provided met professional standards of care when LVN 7 improperly administered medication to Resident 44. During a medication administration observation, LVN 7 was seen administering Flonase Allergy nasal spray to Resident 44 without following the facility's policy and procedure (P&P) for nasal inhalers, sprays, and pumps. Specifically, LVN 7 did not instruct the resident to press a finger against the side of the nose to close one nostril, keep his mouth closed, and sniff in through the open nostril while the nasal spray was squeezed. Additionally, LVN 7 did not instruct Resident 44 to hold his breath for a few seconds and then breathe out through the mouth after squeezing the nasal spray. In an interview, LVN 7 confirmed that he did not provide Resident 44 with any directions during the administration of the nasal spray, stating that the resident already knew how the medication worked. The Director of Nursing (DON) was informed of the findings and acknowledged the deficiency. This failure had the potential to negatively impact the resident's health due to malabsorption and reduction in the effectiveness of the medication.
Failure to Apply Heel Protector Boots as Ordered
Penalty
Summary
The facility failed to ensure the heel protector boots were applied to Resident 33's bilateral lower extremities (BLEs) as per the physician's order. Resident 33 was admitted to the facility and had a physician's order dated 3/3/24 to apply heel protector boots to the BLEs every shift for wound management and prevention while in bed. On 4/17/24, during an observation and interview, it was verified by both a CNA and an LVN that Resident 33 was not wearing the heel protectors while in bed. This failure had the potential to affect the resident's well-being.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to provide the Restorative Nursing Assistant (RNA) services as ordered by the physician for Resident 87, which had the potential to cause a decline in the resident's range of motion and mobility. The physician's orders included passive range of motion (PROM) exercises for both upper and lower extremities, as well as the application of elbow and knee extension splints, to be performed five times a week or as tolerated. However, a review of Resident 87's Restorative Record for February and April 2024 revealed missing documentation for the RNA services on specific dates, indicating that the services were not provided as ordered on 2/10, 2/24, 4/7, and 4/13/24. RNA 5 confirmed that he was not working on those days, and the Director of Nursing (DON) verified the findings, stating that missed exercises on a Saturday could be made up on the following Thursday. The facility's policy and procedure (P&P) for charting and documentation, dated July 2017, requires that treatments or services performed be documented in the resident's medical record. The failure to document and provide the ordered RNA services for Resident 87 was identified through interviews, medical record reviews, and a review of the facility's P&P. This deficiency highlights a lapse in the facility's adherence to physician orders and proper documentation practices, which are essential for maintaining and improving residents' range of motion and mobility.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident identified as being at high risk for falls (Resident 23) remained free from accident hazards. Despite a physician's order dated 8/28/23 to implement bilateral floor mats to prevent injury in the event of a fall, these mats were not in place during observations on 4/15/24 and 4/16/24. Resident 23, who was wearing a yellow wristband indicating fall risk, was observed lying in bed without the required floor mats. The resident's care plan, which included the intervention to implement floor mats, was not followed, placing the resident at risk for serious injury in the event of a fall. Interviews with LVN 3 confirmed that Resident 23 was a fall risk and that the required bilateral floor mats were not in place as per the physician's order and care plan. LVN 3 acknowledged the potential risk for injury due to the absence of the mats. The deficiency was verified through medical record reviews and direct observations, and the Director of Nursing (DON) was informed and acknowledged the findings on 4/17/24.
Failure to Maintain IV Accesses and Develop Care Plans for PICC Lines
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the IV accesses for two residents, specifically regarding the use of PICC lines. For both residents, the facility did not complete and document the PICC line external catheter and arm circumference measurements upon admission. Additionally, there were no physician's orders for the care and maintenance of the PICC lines, and no care plans were developed to address the use of the PICC lines. These deficiencies were confirmed through observations, interviews, and medical record reviews conducted by the surveyors. Resident 53 was observed with a PICC line on the right upper arm, and Resident 67 was observed with a PICC line on the left upper arm. Both residents' medical records lacked documentation of the necessary measurements and physician's orders for PICC line care. Interviews with LVN 13, RN 1, RN 6, the MDS Coordinator, and the DON confirmed these findings. The MDS Coordinator and the DON acknowledged that there should have been specific care plans formulated for the use of the PICC lines for both residents.
Deficiencies in Respiratory Care
Penalty
Summary
The facility failed to provide safe respiratory care for several residents, as evidenced by multiple deficiencies observed during the survey. Resident 16's ventilator machine was set incorrectly for high pressure alarms, and the nebulizer machine tubing was not labeled. Additionally, the ventilator machine's alarm was not audible, which was verified by a respiratory therapist (RT) who stated the resident might have coughed earlier, causing the alarm to flash without sound. The Director of Nursing (DON) confirmed these findings and acknowledged that the ventilator alarms should have been set to alert staff audibly to attend to the residents' needs promptly. Similarly, Resident 53's ventilator machine also had a flashing red light for high pressure without an audible alarm. An RT admitted to accidentally silencing the alarm and confirmed the absence of labeling on the oxygen tubing. The DON was informed of these issues and verified that the ventilator alarms should have been audible to ensure timely intervention. Additionally, Resident 10 was observed receiving more oxygen than prescribed by the physician, with the oxygen concentrator set at 2.5 liters per minute instead of the ordered 2 liters per minute. The DON acknowledged that staff should check the oxygen meter daily to ensure compliance with physician orders. Lastly, Resident 51's oxygen concentrator was found to be dirty, with black and brown stains on the exterior casing. This was confirmed by a registered nurse (RN) who stated that the concentrator should be cleaned. The facility's policy indicated that non-disposable equipment should be disinfected weekly, but this was not adhered to in Resident 51's case. These failures collectively posed a risk of poor health outcomes and delayed intervention in emergencies for the residents involved.
Failure to Provide Emergency Dialysis Supplies at Bedside
Penalty
Summary
The facility failed to ensure that emergency dialysis supplies were accessible at the bedside for two residents requiring dialysis care. Resident 10, who had a diagnosis of end-stage renal disease and received dialysis three times a week, did not have a dialysis kit at her bedside. This was confirmed through interviews and observations with the resident, LVN 7, LVN 4, and the Director of Nursing (DON). The facility's policy required that all dialysis residents have a dialysis kit at their bedside, but this was not adhered to for Resident 10, as verified by the DON during an inspection of the resident's room. Similarly, Resident 74, who also had end-stage renal disease and received dialysis three times a week, did not have an emergency dialysis kit at the bedside. This was confirmed through a concurrent observation and interview with RN 2, and later acknowledged by the DON. The absence of these kits meant that both residents were at risk of not receiving appropriate care in the event of a dialysis-related emergency, such as bleeding from the dialysis access site.
Failure to Accurately Reconcile and Document Administration of Controlled Substance
Penalty
Summary
The facility failed to ensure that Resident 39's lorazepam, an antianxiety medication, was accurately reconciled. The lorazepam tablets removed as shown on the Record of Controlled Substances were not recorded as administered on the electronic Medication Administration Record (MAR). This discrepancy was identified during a controlled medication reconciliation conducted with an LVN, who verified that the medication was signed out but not documented as administered. The facility's policies and procedures require that controlled substance inventory be monitored and reconciled to identify loss or potential diversion, and that all medications administered be documented on the MAR. However, these procedures were not followed in this instance. Resident 39, who lacked the capacity to understand and make decisions, had a physician's order for lorazepam to be administered as needed for anxiety. On the date in question, the Record of Controlled Substances indicated that lorazepam was signed out, and the medication bubble pack showed the correct number of remaining tablets. Despite this, there was no documented evidence on the electronic MAR that the lorazepam was administered. The Director of Nursing (DON) was informed and acknowledged the finding, confirming that staff are expected to sign both the narcotic count sheet and the MAR immediately after medication removal.
Failure to Obtain Informed Consent and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure informed consent was obtained and non-pharmacological interventions were implemented prior to administering psychotropic medications to two residents. For Resident 42, the facility did not complete the informed consent for the use of Seroquel, an antipsychotic medication, as the consent was undated and lacked signatures from the physician and the verifying nurse. Additionally, there were no records of non-pharmacological interventions being attempted before administering the medication. Resident 42 had the capacity to understand and make decisions, as indicated in their health and physical examination, but the facility did not adhere to its policy of using non-pharmacological approaches first unless contraindicated. Similarly, for Resident 25, the facility failed to obtain a properly signed and dated informed consent for the use of diazepam, an antianxiety medication. The consent form lacked the physician's signature and date, as well as the verifying nurse's signature. Resident 25, who had diagnoses of major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder, was administered diazepam without the necessary informed consent documentation. The Director of Nursing confirmed these deficiencies during interviews and record reviews, acknowledging that the consents were incomplete and not in compliance with the facility's policies.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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