Hollenbeck Palms
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 573 S. Boyle Ave., Los Angeles, California 90033
- CMS Provider Number
- 055115
- Inspections on file
- 30
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Hollenbeck Palms during CMS and state inspections, most recent first.
A resident with CHF, HTN, and atrial fibrillation had severely impaired cognition and was dependent for ADLs. On one evening, the resident’s BP and HR were documented as low, and an ordered dose of bisoprolol, which included parameters to hold for low systolic BP and HR, was not administered. The RN did not recheck the resident’s vitals, did not notify the MD that the medication was held or that the resident had low BP and HR, and did not document the reason for withholding the dose, contrary to facility P&P requiring MD notification and nursing documentation when ordered meds cannot be given as prescribed.
A resident with CHF and Alzheimer’s was admitted with severe cognitive impairment and dependence for eating, but the ADON entered a pureed diet with thin liquids based only on a verbal report from an unknown staff member at the sending SNF. The transfer packet contained only a facesheet and medication list, with no written diet order or order summary, and staff did not promptly request the missing discharge/transfer orders as required by facility policy. Later review of the prior facility’s records showed the resident had actually been on a fortified, soft and bite-sized, liberalized diet with thin liquids, and a subsequent ST evaluation supported a diet upgrade, confirming that the resident had received an incorrect diet for several days after admission.
The facility failed to adhere to infection control measures, including improper PPE use during medication administration via a gastrostomy tube, inadequate response to a water main break affecting the Legionella Water Management Program, and lack of hand hygiene during meal assistance. These deficiencies were observed through staff interviews and record reviews, highlighting lapses in infection prevention practices.
Three residents were at risk of scalding due to hot water temperatures exceeding 120°F in their bathrooms. Observations revealed that the water reached 128.6°F and 127.7°F, posing a burn risk. The facility failed to monitor and regulate these temperatures, despite policies requiring weekly checks. Residents with cognitive and physical impairments were particularly vulnerable.
A facility failed to maintain a medication error rate below 5%, with a 33.3% error rate observed for a resident. The resident, with significant medical conditions, received medications late, outside the permissible one-hour window. The LVN confirmed the late administration, and facility policies emphasized the importance of timely medication administration.
The facility failed to properly handle, prepare, and store food, risking foodborne illnesses for 56 residents. Observations showed unlabeled food items, expired products, and inadequate temperature monitoring. Interviews confirmed these deficiencies, highlighting lapses in food safety management.
The facility failed to properly dispose of garbage, with bins and dumpsters found uncovered and overfilled, contrary to policy. Observations revealed uncovered bins in the kitchen and overfilled dumpsters outside. Interviews with staff confirmed non-compliance with the facility's policy, which requires closed lids and clean areas around dumpsters to prevent pest attraction.
A facility failed to maintain a resident's dignity by not ensuring staff assisted the resident with eating at eye level. Despite instructions from the DSD, a CNA stood while helping a resident with multiple health issues, including Alzheimer's and COPD, during mealtime. This action violated the facility's policy on promoting dignity and respect.
The facility failed to maintain copies of advance directives in the medical charts of two residents, as required by policy. One resident, with severe cognitive impairment, and another, requiring substantial assistance, both lacked documented directives in their records. Staff confirmed the absence, highlighting the risk of not knowing residents' wishes during emergencies. The facility's policy mandates documentation of advance directives, which was not followed in these cases.
A resident with severe cognitive impairment and dependency on assistance was placed in a Geri chair without a proper restraint assessment. Despite an order for its use, facility staff, including the ADON and DON, confirmed that an interdisciplinary team assessment was not conducted, violating the facility's policy on physical restraints.
A resident dependent on staff for personal care was left soiled for an extended period, causing distress and potential harm. Despite using the call light for assistance, the resident was told to wait due to staff workload. Observations and staff interviews revealed that the CNA did not immediately address the resident's needs, nor did they seek help from other staff. The facility's policies on care and dignity were not followed, resulting in this deficiency.
A resident with severe cognitive impairment and dependence on supplemental oxygen was found with an empty oxygen tank, contrary to physician orders for continuous oxygen therapy. The facility's policy required adherence to physician orders, which was not followed, as confirmed by the ADON.
A resident did not receive their 8 AM medications on time, as they were administered at 10:22 AM, beyond the one-hour window allowed by the facility's policy. The resident, with a complex medical history, was dependent on assistance for daily activities and had several medications prescribed for conditions like hypertension and angina. The delay was confirmed by the ADON and DON, who noted the importance of timely medication administration to ensure efficacy and avoid adverse reactions.
A resident with bradycardia and hypertension was administered Amlodipine, Carvedilol, and Losartan despite having a heart rate of 59, which was below the physician-ordered parameters to hold the medications. The LVN did not recheck the vital signs or notify the physician, contrary to the facility's policy requiring verification of vital signs before medication administration.
The facility failed to post accurate and timely nurse staffing information in accessible locations, as required by policy. Observations showed outdated reports were posted, and the East wing lacked any postings. The Director of Staff Development prioritized floor coverage over updating staffing information, leading to non-compliance with the facility's policy.
A resident at high risk for falls experienced multiple falls due to the facility's failure to implement a specific fall care plan. The resident, with severe cognitive impairment, was left unsupervised, leading to significant injuries. The care plans lacked specific interventions, and staff assumed others would monitor the resident, resulting in inadequate supervision.
A resident was administered Lorazepam without a specific target behavior documented, contrary to the facility's policy. The resident had diagnoses of anxiety disorder, dementia, and depression. Staff interviews confirmed the absence of specific behavior indications in the medication order, which is necessary for appropriate administration. The facility's policy required psychotropic drugs to be used only for documented specific conditions.
A resident with anxiety disorder and dementia was restrained with a seatbelt in a wheelchair without a prior assessment. Facility staff confirmed that no physical restraint assessment was conducted, violating the facility's policy requiring such assessments before using restraints.
A resident with a history of falls and cognitive impairment was not provided with a comprehensive fall care plan, leading to a fall and subsequent hospitalization. The care plan lacked necessary interventions such as supervision and frequent checks, as required by the facility's policy. Additionally, a high-risk identification wristband was not used, contrary to the facility's procedures.
Failure to Notify MD and Document When Antihypertensive Dose Was Held for Low Vitals
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedure for medication and treatment administration and physician notification for a resident with significant cardiac conditions. The resident had chronic CHF, hypertension, and atrial fibrillation, and a care plan dated 9/22/2025 directed staff to monitor vital signs as needed and notify the physician of significant abnormalities. An MDS dated 9/25/2025 documented that the resident had severely impaired cognitive skills for daily decision making and required substantial to total assistance with transfers, mobility, and all ADLs, indicating high dependence on staff for care and monitoring. On 10/18/2025 at 7:03 PM, the resident’s BP was recorded as 72/51 mmHg and HR as 57 bpm, which were documented in the Weights and Vitals Summary and later in a progress note at 9:52 PM. The resident had an active order, dated 9/19/2025, for bisoprolol fumarate 10 mg orally every 12 hours for hypertension, with instructions to hold the medication if systolic BP was less than 110 or HR less than 60. RN 1 acknowledged in a phone interview that the evening dose of bisoprolol on 10/18/2025 was not administered because the resident’s BP and HR were low. Despite the low BP and HR and the held dose of bisoprolol, RN 1 did not notify the physician that the medication was not given or that the resident’s vital signs were low, and did not recheck the BP and HR after obtaining the low readings. The progress notes did not document any physician notification or repeat vital signs, nor did they record the reason the bisoprolol was withheld. The facility’s P&P titled Medication and Treatment Administration Records, revised 1/2026, required that medications be administered as prescribed, that the attending physician be notified when an order cannot be administered as prescribed, and that an explanation be recorded in the nurses’ notes when a routine medication is withheld. The ADON confirmed that RN 1 did not follow these requirements, resulting in the cited deficiency.
Failure to Verify and Continue Correct Therapeutic Diet on Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure a therapeutic diet was accurately clarified and continued upon admission for a resident transferred from another SNF. The resident was admitted with chronic congestive heart failure and Alzheimer’s disease and was severely cognitively impaired, requiring extensive to total assistance with mobility, ADLs, and eating. On admission, the Assistant Director of Nursing (ADON) entered an order for a pureed diet with thin liquids based solely on a verbal report from an unknown staff member at the sending facility, who stated the resident required one-on-one feeding and was on a pureed diet. The admission documentation received from the sending facility included only a facesheet and a medication list and did not contain the order summary or any written diet order. The facility’s own policy required that transfer records include nursing and dietary information in sufficient detail to provide continuity of care, and that if specified records were not received, staff were to contact the sending facility’s discharge planner or health information department to request the missing records. Despite this, no immediate effort was made at admission to obtain the resident’s complete discharge/transfer orders, including the diet order, from the sending facility. Subsequent review of the sending facility’s order summary showed that the resident’s actual diet at discharge was a fortified, soft and bite-sized, liberalized diet with thin liquids, not a pureed diet. A speech therapy evaluation was only ordered after the resident’s family later reported that the resident had not been on a pureed diet at the prior facility. The speech therapy evaluation then trialed a ground mechanical soft/thin liquids diet without signs or symptoms of aspiration and upgraded the diet accordingly. As a result of the initial failure to verify and reconcile the diet order at admission, the resident received an incorrect pureed diet for several days before the discrepancy was identified and addressed.
Infection Control Deficiencies in PPE Use, Water Management, and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its infection control measures, as evidenced by several observations and interviews. In one instance, a Licensed Vocational Nurse (LVN) did not wear the required Personal Protective Equipment (PPE) while administering medication to a resident via a gastrostomy tube. The resident, who had severe cognitive impairment and was dependent on others for daily activities, did not have an Enhanced Barrier Precaution (EBP) order, despite having an indwelling medical device. The Infection Preventionist confirmed that EBP should have been applied, and the Assistant Director of Nursing acknowledged the oversight, noting the importance of PPE to prevent infections. Another deficiency was noted in the facility's handling of a water main break, which resulted in a loss of water supply for several hours. The facility did not implement its Legionella Water Management Program policy, which required testing the water for contamination after such an incident. The Director of Nursing and the Engineer Assistant both acknowledged that the third-party company responsible for water management should have been contacted to ensure the safety of the water supply. The Infection Preventionist highlighted the potential risks of Legionella contamination due to water stagnation and temperature changes. Additionally, the facility failed to maintain proper infection control practices during meal assistance. Multiple staff members, including a Minimum Data Set Nurse, a Certified Nurse Assistant, and a Restorative Nurse Assistant, were observed assisting residents with feeding without performing hand hygiene between residents. This practice was contrary to the facility's policy, which required hand hygiene to prevent the spread of pathogens. The Director of Nursing confirmed the importance of following hand hygiene protocols to mitigate the risk of infection transmission between residents.
Unsafe Hot Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents, as hot water temperatures in their bathrooms were measured above the safe limit of 120 degrees Fahrenheit. This deficiency was identified during observations and interviews, where it was found that the water temperature in the bathrooms of three residents was significantly higher, reaching 128.6 and 127.7 degrees Fahrenheit, respectively. These temperatures pose a risk of scalding and burns to the residents, who were observed attempting to use the facilities without assistance. Resident 37, who has a history of cerebral infarction, aphasia, and hemiplegia, was observed struggling to wash her hands due to the excessively hot water. Similarly, Resident 6, with diagnoses including cerebral infarction and epilepsy, and Resident 10, with Alzheimer's disease and dysphagia, were also at risk due to their inability to independently manage the hot water temperatures. The residents' medical conditions, which include cognitive impairments and physical limitations, further increased their vulnerability to potential harm from the hot water. The facility's failure to monitor and regulate water temperatures in resident areas was highlighted by the Engineer Assistant's admission that only the boiler temperature was checked, and not the individual room temperatures. The facility's policy required weekly measurements and documentation of water temperatures to prevent such risks, but this was not adhered to, leading to the unsafe conditions observed. The lack of proper monitoring and adherence to safety protocols directly contributed to the deficiency identified by the surveyors.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by nine medication errors out of 27 opportunities, resulting in a 33.3% error rate for one resident. This deficiency was observed during a medication administration for a resident who was scheduled to receive medications at 8 AM but received them after 9 AM, outside the permissible one-hour window. The Licensed Vocational Nurse (LVN) responsible for administering the medications confirmed the late administration. The resident involved had significant medical conditions, including hemiplegia, hemiparesis, and a gastrostomy, and was dependent on assistance for daily activities. The resident's physician's orders included several medications to be administered via a gastrostomy tube, as well as nasal spray and eye drops. The LVN acknowledged the importance of timely medication administration, particularly for blood pressure medications, to prevent adverse effects on the resident's condition. The facility's policy and procedure documents indicated that medications should be administered within one hour of the prescribed time. The Assistant Director of Nursing emphasized the importance of adhering to scheduled medication times to ensure the effectiveness of the medications and prevent complications. Despite these guidelines, the late administration of medications was observed, contributing to the high medication error rate.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper handling, preparation, and storage of food, which could lead to foodborne illnesses for all 56 residents receiving food from the kitchen. Observations revealed that numerous food items in the kitchen refrigerators, freezer, and dry storage areas were not labeled with open dates, use-by dates, or expiration dates. Additionally, some food items were not sealed after opening, and there were instances of dented canned products and a cracked peanut butter jar in the dry storage area. The facility also failed to maintain cleanliness, as evidenced by a container with a dead fly and dust. Expired food products were not promptly removed and discarded, posing a risk of serving spoiled food to residents. The facility's temperature logs for kitchen refrigerators and dry storage areas were not consistently monitored and documented, with several missing temperature readings and staff initials. This lack of monitoring could result in improper food storage temperatures, further increasing the risk of foodborne illnesses. Interviews with the Kitchen Manager and Food Services Manager confirmed these deficiencies, acknowledging that the lack of proper labeling, expired food items, and inadequate temperature monitoring could lead to residents and staff becoming ill. The facility's policies and procedures were not adequately followed, contributing to these lapses in food safety management.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. On multiple occasions, garbage bins and dumpsters were found uncovered and overfilled with trash, contrary to the facility's policy. Specifically, a garbage bin without a cover was observed in the kitchen area, and several dumpsters outside the facility were overfilled and uncovered. The Food Services Manager (FSM) acknowledged that all garbage bins should have covers, and no trash should be on the floor, as this could attract pests and wildlife. Interviews with the FSM and Engineer Assistant (EA 1) confirmed that the facility's garbage disposal practices were not in compliance with their policy, which requires dumpster lids to be closed at all times and the area around dumpsters to be free of waste. The FSM and EA 1 both stated that the improper disposal of garbage could attract vermin and pose a disease threat to residents and staff. The facility's policy, revised in May 2023, clearly outlines the requirements for garbage disposal, which were not adhered to during the survey period.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to maintain or enhance a resident's dignity and respect by not ensuring that staff assisted a resident with eating at eye level. The incident involved a resident with multiple diagnoses, including Alzheimer's disease, chronic obstructive pulmonary disease, polyosteoarthritis, major depressive disorder, hypertensive heart disease with heart failure, and was under palliative care. The resident had severely impaired cognitive skills and required supervision or assistance with eating, as well as being dependent on others for personal hygiene and dressing. During a dining observation, a Certified Nurse Assistant (CNA) was seen standing while assisting the resident with eating, despite instructions from the Director of Staff Development (DSD) to sit at eye level with the resident. The CNA refused to comply with the instruction, which was against the facility's policy that promotes dignity and a pleasant environment during mealtime. The facility's policy emphasizes treating residents with dignity and respect, which includes assisting them in maintaining their self-esteem and self-worth.
Failure to Maintain Advance Directives in Resident Charts
Penalty
Summary
The facility failed to ensure that a copy of the advance directive was readily available in the medical charts of two residents, as required by the facility's policy. For Resident 6, who was admitted with serious medical conditions including cerebral infarction and epilepsy, the advance directive was not found in either the physical or electronic medical chart. Despite the resident's severe cognitive impairment and inability to make decisions, the advance directive was missing, which could lead to staff being unaware of the resident's wishes in an emergency. The Social Service Director confirmed the absence of the document and acknowledged its importance for guiding medical decisions when the resident cannot communicate. Similarly, for Resident 108, who was admitted with conditions such as cellulitis and obesity, the advance directive was also missing from both the physical and electronic medical records. Although the resident was independent in cognitive skills, they required substantial assistance for daily activities. The absence of the advance directive was confirmed by a Licensed Vocational Nurse, who emphasized the potential risk of staff acting against the resident's wishes during an emergency. The Social Service Director noted that the resident's husband had promised to provide the document but had not done so, and no follow-up was conducted. The Director of Nursing reiterated the importance of having the advance directive in the resident's medical chart, highlighting that emergencies can occur at any time and that the document is crucial for understanding the resident's preferences. The facility's policy mandates that residents be informed of their rights regarding advance directives upon admission and that any existing directives be documented in their health records. However, this policy was not adhered to in the cases of Residents 6 and 108, leading to the deficiency.
Failure to Conduct Restraint Assessment for Geri Chair Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically a Geri chair, without conducting a proper assessment. The resident, who was admitted with diagnoses including dementia, osteoporosis, and a history of falling, was observed sitting in a Geri chair. The Minimum Data Set (MDS) for the resident indicated severe cognitive impairment and dependency on assistance for daily activities, but did not document the use of a chair that prevents rising. Despite an order allowing the use of a Geri chair for comfort and positioning, there was no documented assessment to justify its use as a restraint. Interviews with facility staff, including a CNA, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that the resident had previously used a regular wheelchair and exhibited behaviors such as leaning forward and biting staff. The ADON acknowledged the lack of a restraint assessment and the DON confirmed that an interdisciplinary team assessment should have been conducted prior to using the Geri chair, as it limits movement and is considered a restraint. The facility's policy requires an assessment and attempts of less restrictive measures before using physical restraints, which was not followed in this case.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide adequate incontinent care and maintain personal hygiene for a resident who was dependent on staff assistance for personal care, toileting hygiene, and showers. The resident, identified as Resident 108, was observed in a state of distress, lying in bed and crying, due to being left soiled for an extended period. The resident reported using the call light during the night for assistance but was told by a nurse that she could wait due to the nurse's workload. The resident remained soiled for two hours before being attended to. Observations and interviews with staff revealed that a Certified Nurse Assistant (CNA) was aware of the resident's soiled condition but did not immediately address it, citing being busy with another resident's shower. The CNA did not seek assistance from other staff members to attend to Resident 108 promptly. Interviews with other staff, including a Licensed Vocational Nurse (LVN) and another CNA, indicated that the resident should have been cleaned immediately to prevent harm, such as skin breakdown and emotional distress. The Director of Nursing (DON) confirmed that leaving a resident soiled for a long period could cause physical and emotional harm. The facility's policies on AM/PM care and dignity emphasize the importance of promptly responding to residents' needs to maintain their dignity and quality of life. However, these policies were not adhered to in the case of Resident 108, leading to the deficiency noted in the report.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that a resident on continuous oxygen therapy received oxygen as ordered, which was a deficiency in providing safe and appropriate respiratory care. The resident, who had diagnoses including shortness of breath, dependence on supplemental oxygen, and anemia, was observed with an empty oxygen tank during a dining room observation. The resident's Minimum Data Set indicated severe cognitive impairment and dependence on assistance for daily activities, including continuous oxygen therapy. The deficiency was identified when the oxygen tank's gauge was observed pointing to the red area, indicating it was empty. During an interview, the Assistant Director of Nursing acknowledged the importance of administering oxygen as ordered and ensuring the oxygen tank is not empty. The facility's policy on oxygen administration, formulated in April 2023, required providing oxygen therapy per physician orders, which was not adhered to in this instance.
Late Medication Administration for a Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 35, by not administering the resident's 8 AM medications on time as per the physician's order. The medications were administered late, at 10:22 AM, which was beyond the one-hour window allowed by the facility's policy. This delay in medication administration was observed during a concurrent observation and interview with LVN 1, who acknowledged the late administration and the potential medical complications that could arise from such delays. Resident 35 had a complex medical history, including hemiplegia, hemiparesis, and a gastrostomy, and was dependent on assistance for daily activities. The resident's prescribed medications included Amlodipine, Aspirin, Carvedilol, Isosorbide, Losartan, multivitamins, Potassium, Fluticasone nasal spray, and Artificial tears, all of which were due at 8 AM. The failure to administer these medications on time was confirmed by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who emphasized the importance of timely medication administration to ensure efficacy and avoid adverse reactions. The facility's policy and procedure for medication administration required that medications be given within one hour of their prescribed time. However, the review of Resident 35's medical records and interviews with the nursing staff revealed that there was no documented justification for the late administration of the medications. The ADON and DON confirmed that the medications were administered late without any documented reason, which constituted a medication error according to the facility's policy.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by administering medications outside of physician-ordered parameters. The resident, who had diagnoses including bradycardia, hypertension, and angina, was prescribed Amlodipine, Carvedilol, and Losartan with specific instructions to hold the medications if the systolic blood pressure was lower than 100 or the heart rate was lower than 60. During a medication administration observation, it was noted that the resident's heart rate was 59, yet the medications were administered without rechecking the vital signs or notifying the physician. The Licensed Vocational Nurse (LVN) involved stated that there was no order to call for high blood pressure and a heart rate lower than 60, and admitted to not rechecking the resident's blood pressure and heart rate before administering the medications. The Assistant Director of Nursing confirmed that the LVN should have rechecked the vital signs and informed the doctor due to the parameter order to hold the medications for a heart rate less than 60. The facility's policy and procedure required that vital signs be checked and verified before administering medications, which was not adhered to in this instance.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to adhere to its policy of posting nurse staffing information in a prominent location accessible to residents and visitors. Observations on multiple occasions revealed that the Daily Report of Nursing Staff was not updated and was not posted in the designated areas, specifically at the East wing nursing station. The report dated 10/20/2024 was observed on 10/22/2024, and the report dated 10/21/2024 was still posted on 10/23/2024, indicating a lack of timely updates. The Director of Staff Development (DSD) confirmed that the staffing information was not updated as required by the facility's policy, which mandates posting within two hours of each shift's start. The DSD admitted to prioritizing floor coverage over updating the staffing information, resulting in outdated postings. The facility's policy, revised in July 2023, requires that the number of licensed and unlicensed nursing personnel responsible for direct resident care be posted daily for each shift in a clear and readable format. The failure to update and post accurate staffing information could potentially mislead residents, visitors, and staff about the actual nursing staff available for direct care.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to prevent multiple falls of a resident by not developing and implementing a fall care plan after the resident experienced actual falls on several occasions. The resident, who was at high risk for falls due to impaired cognition and other medical conditions, did not have a care plan that included specific interventions tailored to their needs. The care plans that were in place were generic and did not provide clear guidance on how to monitor or supervise the resident to prevent falls. The resident, who had a history of falls and severe cognitive impairment, experienced multiple falls resulting in significant injuries, including a right hip fracture and dislocation. Despite being identified as high risk for falls, the care plans did not include specific interventions such as constant supervision or the use of a lap belt while the resident was in a wheelchair. The lack of specific interventions and supervision led to the resident sliding from the wheelchair and sustaining injuries that required hospitalization and surgical intervention. Interviews with facility staff revealed a lack of communication and assumption of responsibility for supervising the resident. Staff members assumed that others would monitor the resident, leading to the resident being left unsupervised in the hallway, which contributed to the falls. The facility's policies and procedures required individualized care plans and interventions for high-risk residents, but these were not adequately implemented for the resident in question.
Failure to Document Specific Behavior for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically Lorazepam, by not having a specific target behavior documented for its use. The resident, who had diagnoses including anxiety disorder, dementia, and depression, was administered Lorazepam without a clear indication of the behavior it was meant to address. The medication orders for Lorazepam were incomplete, lacking specific behavior manifestations that would justify its administration. Interviews with facility staff, including an LVN and the MDS nurse, confirmed that the Lorazepam order did not specify a target behavior, which is crucial for determining when the medication should be administered. The Director of Nursing also acknowledged that specific behavior manifestations should have been included in the physician's order to ensure the PRN medication was given appropriately. The facility's policy and procedure on psychotropic drugs required that such medications be used only when necessary to treat a diagnosed specific condition documented in the clinical record.
Failure to Conduct Restraint Assessment for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints by not conducting a necessary assessment before using a seatbelt as a restraint. The resident, who had diagnoses including anxiety disorder, dementia, and a history of repeated falls, was observed with a seatbelt across her lap while in a wheelchair. The seatbelt was ordered without a prior physical restraint assessment, which is required to determine the necessity and safety of such a restraint. The resident was unable to unbuckle the seatbelt, indicating it restricted her movement. Interviews with facility staff, including a Licensed Vocational Nurse and an MDS Nurse, confirmed that no physical restraint assessment was conducted before the seatbelt's use. The facility's policy requires an interdisciplinary team to complete an assessment and attempt less restrictive measures before using physical restraints. The lack of assessment and documentation for the seatbelt's use was a deviation from this policy, potentially affecting the resident's physical and psychological well-being.
Failure to Implement Comprehensive Fall Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered fall care plan for a resident, identified as Resident 1, who was at high risk for falls. Resident 1 had a history of anxiety disorder, dementia, and repeated falls, and was readmitted to the facility with severely impaired cognitive skills and required assistance with daily activities. The resident's Morse scale score indicated a high risk for falling, yet the care plan initiated on 7/30/2024 did not include necessary interventions such as supervision and frequent visual checks, which were crucial to prevent further falls. On 8/2/2024, Resident 1 experienced a fall that resulted in severe pain and required transfer to a General Acute Care Hospital. The fall occurred when a CNA observed the resident slowly slipping from a wheelchair and was unable to prevent the fall completely. Following this incident, additional interventions were added to the care plan, but it was noted that these should have been implemented earlier, as per the facility's Fall Prevention Policy and Procedure. The policy required interventions like constant visual monitoring and offering frequent restroom breaks, which were not initially included. The facility's policy also mandated the use of a color-coded wristband to identify residents at high risk for falls, which was not applied to Resident 1. The failure to include these specific interventions in the care plan was against the facility's policy, which emphasized the need for unique interventions tailored to each resident's needs. This oversight potentially increased the risk of falls for Resident 1, as the care plan did not adequately address the resident's high fall risk status.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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