Hollywood Premier Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 5401 Fountain Ave., Los Angeles, California 90029
- CMS Provider Number
- 056489
- Inspections on file
- 63
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 42 (2 serious)
Citation history
Health deficiencies cited at Hollywood Premier Healthcare Center during CMS and state inspections, most recent first.
Two residents were involved in a physical altercation when a cognitively impaired, elopement‑risk resident with mood and psychotic disorders, who had been ordered for 1:1 supervision, entered another resident’s room without being accompanied by staff. The second resident, who had schizophrenia but intact cognition and was independent in ADLs, pushed the first resident out of the room and they grabbed each other. The DON later confirmed that the 1:1 supervision ordered in a psychiatric note was not reflected in the care plan and was not being provided at the time of the incident, despite facility policies requiring adequate supervision, comprehensive care planning, and targeted interventions for residents at risk of unsafe wandering.
A resident with dementia and severely impaired cognition, who required assistance or supervision with multiple ADLs, experienced increased confusion and disorientation and attempted to leave the facility, stating that his daughter needed him. An SBAR form documented this behavioral change and elopement attempt, but there was no documentation that any family member, guardian, or other responsible representative was notified. An LVN acknowledged that staff did not notify the family, and the DON stated that family notification and documentation are expected following such behavioral changes, consistent with facility policy requiring prompt notification of the resident representative after significant changes in medical or mental status.
A resident with severe cognitive impairment experienced a seizure, elevated heart rate, and low oxygen saturation. Nursing staff provided oxygen and left a message with the physician's answering service, but there was no documentation of a physician response or new orders. Facility policy requiring escalation to the medical director if the physician did not respond was not followed.
A resident with diabetes and severe cognitive impairment did not have their blood sugar monitored after being unable to eat for over six hours due to a dislodged nasogastric tube. Nursing staff did not perform a blood glucose check during this period, despite facility policy and the resident's care plan requiring monitoring in such situations.
A resident with multiple medical conditions and severe cognitive impairment did not receive a physician-ordered comprehensive metabolic panel (CMP) because staff failed to obtain the required blood sample and did not document the omission. Facility staff confirmed the test was not performed and no explanation was recorded, resulting in the absence of necessary laboratory information for the resident's care.
A resident with severe cognitive impairment and total dependence on staff was sexually abused by another resident who had a known history of inappropriate sexual behavior, including public masturbation and disrobing. Despite repeated documentation of these behaviors, the facility did not implement effective monitoring or interventions, nor did it conduct an interdisciplinary team meeting to address the risks. The incident was discovered by a CNA, and the abused resident was unable to communicate about the event.
A resident with a documented history of inappropriate sexual behavior, including public masturbation and disrobing, was not adequately monitored or supervised, leading to the sexual abuse of a nonverbal, fully dependent resident. Despite repeated incidents and clear documentation, staff did not convene an IDT meeting to address the behavior or implement effective interventions.
The facility did not implement its Plan of Correction requiring a third-party consultant to provide staff training and monitoring on resident-to-resident sexual abuse prevention. Despite internal in-service sessions, no staff received the mandated external training, and none of the outlined monitoring or reporting activities were initiated as required by the facility's abuse prevention program.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the plan was not prepared, reviewed, and revised by a team of health professionals as required.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment lacked proper hazard controls and sufficient monitoring, increasing the risk of accidents.
Two residents requiring special eating equipment did not receive the correct devices or proper assistance during meals. One resident with limited arm mobility had a plate guard positioned incorrectly, causing food to spill, while another resident was given a regular plate with a plate guard instead of the ordered divided plate. Staff confirmed the devices were not used as specified in care plans and physician orders.
Surveyors found that food items in a storage area were not properly labeled or dated, including meat patties, chopped meat, and other frozen products. The Dietary Supervisor confirmed that facility policy requires all opened and partially used foods to be labeled and dated before storage, but several items were missing this information or had unreadable labels.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with schizophrenia and bipolar disorder, who lacked decision-making capacity, was administered risperidone, quetiapine, and valproic acid without proper informed consent from a representative. Facility records showed only verbal consent from the resident, despite documentation of cognitive impairment, and interviews with the DON and Medical Director confirmed that required consent procedures were not followed.
A resident with severe cognitive impairment and multiple medical conditions was admitted without the facility providing advanced directive information or documentation to the responsible party, despite policy requiring this upon admission. Interviews confirmed that neither inquiry nor information about advanced directives was given to the resident's representative.
A resident with significant medical needs, including total dependence for care and a surgical wound, was found lying on a mattress placed directly on the floor without a bed frame or bedrails, despite the care plan specifying a high-low bed. Staff reported that this arrangement was unsafe and hindered proper care, and facility leadership confirmed that alternative interventions were available and that required staff training had not been provided.
A resident with multiple mobility and neurological conditions was identified as being at risk for falls, yet the facility did not develop or implement a care plan to address the resident's repeated practice of raising the bed to its highest position. Despite staff awareness of the resident's non-compliance with safety protocols and observations of the call light being out of reach, the care plan was not updated to address these specific risks.
A resident with diabetes, acute kidney failure, and severe cognitive impairment did not have a post void residual (PVR) measurement documented every six hours as ordered by the physician. Nursing staff failed to record the 6 AM PVR, contrary to both physician orders and facility policy, resulting in incomplete monitoring and documentation of the resident's treatment.
A resident with chronic pain and dementia did not receive a scheduled dose of hydrocodone-acetaminophen because the medication was not available and the nurse did not access the emergency kit as per facility protocol. The resident reported ongoing issues with medication availability, and documentation confirmed the missed dose.
Surveyors found that several medication bubble packs in use for three residents with complex medical and cognitive needs were missing expiration dates, contrary to facility policy and professional standards. During medication cart inspections, LVNs confirmed the absence of expiration dates on bubble packs containing rivastigmine, trihexyphenidyl, and lurasidone.
A resident with significant mobility and coordination impairments, who was dependent on staff for most activities of daily living, did not have their call light within reach while in bed. Observation confirmed the call light was inaccessible, and both a CNA and the DON acknowledged the resident would be unable to call for assistance. Facility policy required call lights to be accessible, but this was not followed in this instance.
Surveyors found that a room contained five beds, exceeding the maximum allowed occupancy of four. Although only four residents were present and both residents and staff reported sufficient space for care and mobility, the room setup did not comply with regulatory requirements.
A resident with a history of mental health disorders exhibited escalating behavioral symptoms, including panic attacks and aggression, but the facility did not update the care plan or conduct an IDT meeting after significant incidents. This lack of intervention led to the resident physically assaulting another resident, resulting in injury and hospitalization.
A resident was prescribed Duloxetine HCL, a psychotropic medication, without a signed informed consent. Despite being alert and oriented, the resident's chart lacked documentation of informed consent, which is required for psychotropic drugs. Facility staff acknowledged the absence of a specific informed consent policy and attributed the responsibility to the doctor, while the RN supervisor did not document obtaining consent.
A facility failed to readmit a resident after hospitalization, despite the resident being medically stable. The resident, with a history of bipolar and schizoaffective disorders, was initially transferred to a hospital under a 5150 hold. The facility cited safety concerns and an inability to meet care needs as reasons for not allowing the resident's return, despite the hospital's clearance and attempts by the social worker to facilitate the return.
The facility failed to maintain a clean and sanitary environment in two shower rooms, where soiled items and hair were found on the floor and drain. Housekeeping staff confirmed the rooms were not clean, and the DON stated they should be cleaned after each use, as per facility policy.
A resident with severe cognitive impairment and total dependence on staff was left unsupervised when a CNA was found asleep in the resident's room. This lack of supervision posed a risk of accidents, as confirmed by other staff members and the facility's policy on resident safety and supervision.
A resident on a renal diet expressed dislike for mocha mix, a non-dairy creamer, which was repeatedly included on their meal tray despite their preferences being documented. The Dietary Supervisor failed to consult with the Registered Dietitian for a substitute, leading to a breach in the facility's policy on addressing conflicts between nutritional needs and resident preferences.
A facility failed to ensure a safe and orderly discharge for a resident with multiple health conditions by not involving them or their family in the discharge planning process. The facility did not develop or review a post-discharge plan with the resident or their family, and there was no documentation of follow-up regarding the discharge plan. The family member was not offered tours of potential facilities and was not informed about the appeal process for discharge, contrary to the facility's policy.
A resident reported $40 missing, but the LTC facility failed to properly investigate the claim. Despite the resident being cognitively intact and the loss reported to an LVN, the required Theft and Loss Form was not completed, nor was the incident reported to the SSD. The facility's policy mandates prompt investigation of such reports, which was not followed.
A resident with congestive heart failure was administered Metoprolol Tartrate and Hydralazine without blood pressure parameters, contrary to professional standards. The care plan noted a risk for fluctuating blood pressure but lacked specific limits for these medications. Interviews with staff highlighted the necessity of such parameters to prevent hypotension, which was not implemented, placing the resident at risk.
The facility failed to update the care plans for two residents, leading to potential inadequate care. One resident's care plan did not reflect the current physician orders for tube feeding, while another resident's care plan was not updated to reflect the correct antibiotic dosage. The Director of Nursing acknowledged the oversight, which could result in unmet needs and inadequate care.
The facility failed to maintain yearly staff competency and mandated abuse reporting training records for two CNAs, with missing documentation spanning several years. The DSD acknowledged the issue, attributing it to previous staff misplacing files, and is working on QAPI plans to address the deficiency.
A resident with schizophrenia did not receive necessary behavioral health services due to the discontinuation of prescribed Risperidone without consulting a physician, and missed psychology consultations. The resident's care plan was not revised quarterly, contrary to facility policies, leading to inadequate care.
A facility failed to securely store medications and properly label insulin, leading to potential risks. An LVN left medications, including a controlled substance, unattended, risking diversion and exposure. Additionally, insulin for a resident was improperly labeled with two dates, causing uncertainty about its expiration and safety.
The facility failed to properly store and handle food, as evidenced by an opened and undated package of cookies found in the pantry and a cook serving food without washing hands after rinsing a towel. These actions risked contamination and potential foodborne illnesses.
A LTC facility failed to implement proper infection control measures for six residents. An RNA used inappropriate cleaning agents on a cloth gait belt, and a resident's urinals were improperly stored in a trash can. Additionally, an LPN did not disinfect medication trays and cart countertops between resident room visits, increasing the risk of infection spread. These actions were contrary to the facility's infection control policies.
A resident's room in the facility had a damaged vinyl floor with a crack and chip, creating an uneven surface that posed a fall risk. The damage had been present for several months, and staff, including a CNA and the Director of Maintenance, were aware of the issue. Despite plans to repair the floor, no specific timeframe was provided, and the facility's policy on maintaining a safe and homelike environment was not upheld.
A resident was prescribed Diflucan for fungal pneumonitis, but the facility failed to include this medication in the resident's care plan. Despite the resident's cognitive intactness and need for assistance in daily activities, the care plan was not updated to reflect the physician's order, as confirmed by the DON. This oversight contradicts the facility's policy requiring comprehensive, person-centered care plans.
A resident with stage three and unstageable pressure ulcers was found to have an incorrectly set low air loss mattress (LALM) in a LTC facility. The LALM was set for a weight of 200 lbs, while the resident weighed 145 lbs, contrary to physician orders and care plan instructions. This discrepancy was acknowledged by the Treatment Nurse and the DON, highlighting a failure in monitoring and adherence to facility policies.
A resident in an LTC facility was at risk of receiving an incorrect dosage of docusate sodium liquid due to a physician order lacking clarity on the medication's strength and dose. The resident, who required full assistance for daily activities, was observed receiving a 25 mL dose without specified strength. Interviews with staff highlighted the importance of clarifying such orders to prevent potential health risks.
The facility failed to ensure Dietary staff had the necessary skills to use QT-40 test paper for sanitizer concentration, as observed when a Dietary Aide did not follow guidelines, potentially risking cross-contamination and foodborne illness for 88 residents. The temporary Dietary Supervisor was unsure of staff competencies, despite records showing evaluations were completed. The Director of Staff Development and DON indicated a lapse in proper education and evaluation.
The facility failed to maintain a sanitary environment, leading to a fly infestation around the waste disposal area. Open trash bins filled with food leftovers attracted flies, posing a risk for infection outbreaks. Despite regular pest control visits and recommendations to cover trash, the facility did not effectively implement these measures, resulting in the observed deficiency.
A facility was found to have a room with five beds, exceeding the regulatory limit of four residents per room. Despite staff stating there was enough space for care, the room's occupancy violated standards. The facility requested a waiver, claiming adequate space for resident safety and care.
A facility failed to ensure a resident was informed of the risks and benefits of psychoactive and hypnotic medications, violating their right to make an informed decision. The resident, with impaired cognition and multiple diagnoses, was taking medications like Zyprexa and Lorazepam without documented informed consent from a physician, as required by facility policy. The DON confirmed the lack of evidence for informed consent, leading to the deficiency.
A facility failed to initiate a care plan for Zyprexa, an antipsychotic medication, for a resident with schizophrenia, depression, and type 2 diabetes. Despite a physician's order for Zyprexa to manage aggressive behavior, no care plan was developed. The DON acknowledged the oversight, highlighting the need for measurable objectives to meet the resident's needs.
A facility failed to supervise residents in the smoking patio, leading to an altercation where a resident with severe cognitive impairment hit two other residents. Despite the facility's policy requiring supervision during smoking hours, staff were not present after the receptionist left, allowing the incident to occur.
A resident with cognitive impairment poked another resident with a grabbing stick, causing pain, due to the facility's failure to monitor the resident's whereabouts as ordered. Despite previous concerns about the grabbing stick, the facility did not effectively separate the residents or document interventions after an earlier incident. Interviews indicated no changes in behavior or expressed fear from the affected resident.
A facility failed to follow physician orders for lab services for a resident on Keppra and Depakote, resulting in missed lab tests and inadequate monitoring of medication levels. Despite multiple orders and a hospital transfer, necessary tests were not performed, placing the resident at risk for adverse reactions.
The facility failed to ensure that the consultant pharmacist completed a thorough review of a resident's medical records, missing multiple lab orders for medication management. Despite active orders for seizure medications, the CP's reports consistently listed the resident with no recommendations, failing to address the missing lab work.
Failure to Provide Ordered One‑to‑One Supervision Resulting in Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent a resident‑to‑resident altercation for a resident who had been ordered for one‑to‑one supervision. Resident 1 was admitted and later readmitted with diagnoses including unspecified affective mood disorder and psychosis, with documentation of severely impaired cognition, dependence on maximal assistance for mobility and ADLs, and lack of capacity to understand and make decisions. The resident’s care plan, initiated on 9/29/2025 and revised on 2/1/2026, identified risk for elopement based on two prior attempts to leave the facility and directed staff to conduct frequent visual checks. A psychiatric narrative note dated 1/17/2026 documented multiple attempted elopements and stated that Resident 1 required close monitoring and was placed on one‑to‑one supervision to ensure safety, with a plan to continue that level of supervision. On 2/1/2026 at approximately 7:55 AM, an altercation occurred between Resident 1 and Resident 2. Progress notes for that date and time indicated that Resident 1 entered Resident 2’s room, Resident 2 pushed Resident 1 out of the room, and both residents grabbed each other. A CNA who was familiar with Resident 1 reported that Resident 1 had mood swings, might have been confused when entering another resident’s room, and that she personally observed Resident 2 push Resident 1 out of her room on that date. Resident 2’s records showed diagnoses of schizophrenia and major depressive disorder, intact cognition, and independence with mobility and ADLs. During interviews and record review, the DON confirmed that Resident 1’s care plan did not reflect the one‑to‑one supervision ordered in the psychiatric note and acknowledged that the one‑to‑one supervision was not provided on 2/1/2026. The facility’s policies on Safety and Supervision of Residents, Comprehensive Person‑Centered Care Plans, and Wandering and Elopements stated that the environment should be as free from accident hazards as possible, that resident safety and supervision to prevent accidents are facility‑wide priorities, that care plans are to be revised as resident conditions change, and that residents at risk for unsafe wandering are to be identified and protected. Despite these policies and the documented need for close monitoring and one‑to‑one supervision, Resident 1 was not under one‑to‑one supervision at the time he entered Resident 2’s room and the altercation occurred.
Failure to Notify Resident Representative After Elopement Attempt and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident representative of a significant change in condition and safety risk following an elopement attempt. A resident with a diagnosis of dementia was admitted with documentation listing him as his own responsible party. However, subsequent assessments showed that his cognitive status had declined. An MDS dated 10/6/2025 documented severely impaired cognition for decisions of daily living and noted that he required assistance or supervision with multiple activities of daily living, including oral hygiene, toileting, dressing, transfers, and mobility. A History and Physical dated 11/19/2025 further indicated that the resident did not have the capacity to understand and make decisions. On 10/5/2025, an SBAR Communication Form documented that the resident had increased confusion and disorientation and attempted to leave the facility, stating that his daughter needed him. There was no documented evidence that staff notified any family member, guardian, or other responsible representative of this attempt to leave or the change in behavior. During interviews, an LVN confirmed that staff failed to notify the resident’s family members about the episode of confusion and elopement, and the DON stated that it is important to notify family and document which family member was notified following such behavioral changes. The facility’s policy titled “Change in a Resident's Condition or Status” stated that the facility will promptly notify the resident representative of changes in the resident’s medical or mental condition or status following a significant change in physical, mental, or psychosocial status, which was not followed in this case.
Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's primary physician following a significant change of condition. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, experienced a seizure, an irregularly high heart rate (147-152 bpm), and low oxygen saturation (85%). Nursing staff provided oxygen and implemented seizure precautions, and a message was left with the physician's answering service. However, there was no documentation that the physician returned the call or that new orders were received. Interviews with staff confirmed that the physician was not reached directly and that no further action was taken to obtain medical orders or escalate the situation, such as contacting the medical director, as required by facility policy. The nurse practitioner stated that the resident should have been sent to the hospital for evaluation, and the DON confirmed that the protocol was to contact the medical director if the primary physician did not respond. The facility's policy required prompt physician response and further escalation if no timely response was received, which was not followed in this case.
Failure to Monitor Blood Sugar in Diabetic Resident During Prolonged Fasting
Penalty
Summary
A deficiency occurred when the facility failed to obtain a blood sugar level by fingerstick for a resident with diabetes mellitus who had not eaten for over six hours. The resident, who also had severe cognitive impairment and was dependent on staff for most activities of daily living, pulled out his nasogastric tube (NGT), resulting in the inability to provide nutrition from 3 p.m. to 9:30 p.m. During this period, the resident's blood sugar was not monitored, despite the care plan indicating the need to monitor blood sugar as ordered and the facility's policy requiring blood glucose checks when fasting or after significant changes in condition. Interviews with two licensed vocational nurses confirmed that the resident's blood sugar was not checked during the fasting period, even though both nurses acknowledged the importance of monitoring for hypo- or hyperglycemia in such situations. The facility's policy and procedures for diabetes care specifically indicated the need to monitor blood glucose in cases of fasting or acute changes, but this was not followed in the resident's case.
Failure to Obtain Ordered Laboratory Test for a Resident
Penalty
Summary
The facility failed to provide laboratory services as ordered by a physician for one resident. Specifically, a physician ordered a comprehensive metabolic panel (CMP) to be obtained for a resident on a specified date, but the blood sample was not collected and there was no documentation explaining why the test was not performed. Interviews with facility staff, including a licensed vocational nurse and the medical record director, confirmed that the CMP was neither completed nor documented, and the result was not available in the resident's medical record. The resident involved had multiple diagnoses, including failure to thrive, dementia, and seizure disorder, and was dependent on staff for all activities of daily living. The facility's policy required staff to process test requisitions and arrange for laboratory tests as ordered by the physician, but this process was not followed in this instance. The deficiency resulted in the resident not receiving laboratory services necessary to determine their medical and diagnostic needs.
Failure to Protect Resident from Sexual Abuse by Another Resident with Known History of Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident who had a documented history of inappropriate sexual behavior, including walking around the facility with his genitals exposed and masturbating excessively. Despite multiple documented incidents of this behavior, the facility did not implement effective interventions or closely monitor the resident exhibiting these behaviors. The care plan for the resident with inappropriate sexual behavior included a general intervention to protect the rights and safety of others, but this was not adequately followed or enforced. The resident who was abused was nonverbal, severely cognitively impaired, and completely dependent on staff for all activities of daily living, including mobility and personal care. On the night of the incident, a CNA heard noises from the resident's room and discovered the resident with a history of sexual behavior on top of the nonverbal resident, both partially undressed. The nonverbal resident was unable to communicate about the incident, and staff observed the other resident pulling up his pants and leaving the room. The facility called emergency services, and the nonverbal resident was transferred to a hospital for evaluation of sexual assault. Interviews and record reviews revealed that the facility was aware of the sexually inappropriate behaviors prior to the incident, as documented in progress notes, care plans, and medication records. However, the facility did not conduct an interdisciplinary team meeting to address the ongoing behaviors or develop more effective interventions. Staff, including the DON and Social Services Director, acknowledged that the care plan was not followed and that closer monitoring and team intervention should have occurred to prevent the incident.
Removal Plan
- The facility staff separated Resident 2 from Resident 1 and placed Resident 1 on a one-to-one supervision.
- The facility transferred Resident 1 to GACH2 via emergency services for immediate trauma evaluation.
- The facility transferred Resident 2 to GACH3 for an evaluation of inappropriate sexual behavior.
- The facility readmitted Resident 2 from GACH3 and provided one-to-one supervision.
- The facility transferred Resident 2 to GACH4 via 5150 (involuntary 72-hour psychiatric hold) due to inappropriate sexual behavior.
- The Director of Clinical and Regional Director of Operations provided training on abuse prevention education to the ADM, the DON, to all the department heads, and staff.
- The facility conducted a wide safety check for all 80 in-house residents to ask for any exposure and physical advances or touching by Resident 2.
- The licensed nurses checked seven nonverbal residents for any signs of skin discoloration to the genital areas.
Failure to Prevent and Address Sexual Abuse Due to Inadequate Monitoring and Lack of Interdisciplinary Intervention
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent sexual abuse, specifically by not closely monitoring a resident with a known history of inappropriate sexual behavior. This resident had documented behaviors of walking around the facility with his genitals exposed and masturbating excessively, as noted in multiple progress notes, care plans, and medication administration records. Despite these repeated incidents, the facility did not provide adequate supervision or interventions to prevent further inappropriate behavior. Another resident, who was nonverbal, severely cognitively impaired, and fully dependent on staff for all activities of daily living, was subjected to sexual abuse by the resident with the history of inappropriate sexual behavior. The incident was witnessed by a CNA, who observed the resident with a history of sexual behavior on top of the nonverbal resident, both partially undressed. The nonverbal resident was unable to communicate or verbalize the incident, and the event was confirmed by staff observations and subsequent medical evaluation. The facility also failed to conduct an interdisciplinary team (IDT) meeting to address the ongoing inappropriate sexual behaviors of the resident with a known history of such actions. Staff interviews and record reviews confirmed that no IDT was held to develop or implement effective interventions, despite clear documentation of repeated incidents. The lack of close monitoring and failure to convene an IDT contributed to the occurrence of sexual abuse within the facility.
Removal Plan
- The facility staff separated Resident 2 from Resident 1 and placed Resident 1 on a one-to-one supervision.
- The facility transferred Resident 1 to GACH2 via emergency services for immediate trauma evaluation.
- The facility transferred Resident 2 to GACH3 for an evaluation of inappropriate sexual behavior.
- The facility readmitted Resident 2 from GACH3 and provided one-to-one supervision.
- The facility transferred Resident 2 to GACH4 via 5150 (involuntary 72-hour psychiatric hold) due to inappropriate sexual behavior.
- The Director of Clinical and Regional Director of Operations provided training on abuse prevention education to the ADM, the DON, to all the department heads, and staff.
- The facility conducted a wide safety check for all 80 in-house residents to ask for any exposure and physical advances or touching by Resident 2.
- The licensed nurses checked seven nonverbal residents for any signs of skin discoloration to the genital areas.
Failure to Implement Required Sexual Abuse Prevention Training and Monitoring
Penalty
Summary
The facility failed to implement its Plan of Correction (POC) as required to prevent and protect residents from resident-to-resident sexual abuse. The POC, which was signed and dated, specified that a third-party consulting agency would provide directed in-service training (DIST) to staff on the prevention and appropriate response to resident-to-resident sexual abuse. The POC also outlined that monitoring and monthly activities would begin within a specific timeframe. However, documentation and interviews revealed that the third-party training had not commenced by the POC completion date, and no staff had received the required training from the outside consultant. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) confirmed that the third-party consultant had not started the abuse prevention training, and staff had not attended any such sessions. The DON acknowledged that the facility had only provided internal in-service training and that the third-party consultant had not delivered any training or monitoring as outlined in the POC. The DON also confirmed that none of the monitoring tools, clinical auditing, weekly on-site monitoring, or reporting to the state agency, as required by the POC, had been implemented. A review of facility policies indicated that staff training on abuse prevention, identification, and reporting is a required component of the facility's abuse prevention program. Despite this, the facility did not follow through with the specific actions and timelines detailed in the POC, resulting in a failure to provide staff with the necessary training and monitoring to prevent and respond to resident-to-resident sexual abuse.
Failure to Timely Develop and Review Care Plan by Interdisciplinary Team
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of appropriate hazard controls and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide and Correctly Use Special Eating Equipment for Residents
Penalty
Summary
The facility failed to provide appropriate assistance and correct use of special eating equipment for two residents who required such devices. For one resident with generalized muscle weakness, dementia, and limited range of motion in both arms, the care plan and physician orders specified the use of a plate guard during meals to prevent food spillage and assist with self-feeding. However, during observation, the plate guard was positioned incorrectly, with the opening facing the resident, resulting in food spilling onto the table. Occupational therapy notes indicated that caregivers had been educated on the proper use and positioning of the plate guard, but this was not followed during the observed meal. Another resident, diagnosed with epilepsy and dementia, had a physician order and care plan specifying the use of a divided plate during meals due to potential nutritional problems. Instead, this resident was provided with a regular plate and a plate guard, which was also positioned incorrectly. Staff interviews confirmed that the assistive devices used were not correct for these residents and that improper use could result in food spillage. The facility's policy required staff to be trained and demonstrate competency in the use of assistive devices, but this was not adhered to during the observed incidents.
Failure to Properly Label and Date Stored Food Items
Penalty
Summary
Surveyors observed that the facility failed to properly label and date food items in one of four food storage areas. During an inspection of the kitchen freezer, several items were found without food labels or dates, including light brown meat patties, a clear bag of chopped white meat, and a freezer bag with faded, unreadable labeling. Additionally, a package of unopened frozen beef chorizo and frozen ham were found with only manufacture or storage dates, lacking expiration or best-by dates. The Dietary Supervisor confirmed during the observation that all bags should have labels with the name of the contents and dates, as per facility policy, which requires all opened and partially used foods to be dated, labeled, and sealed before being returned to storage.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Obtain Informed Consent for Antipsychotic Medication Administration
Penalty
Summary
The facility failed to obtain proper informed consent for the administration of antipsychotic and mood-stabilizing medications for a resident diagnosed with schizophrenia and bipolar disorder. Upon review, the resident was readmitted with orders for risperidone, quetiapine (Seroquel), and valproic acid. Documentation showed that the resident had impaired memory recall and lacked the capacity to make medical decisions, as indicated in both the History and Physical and the Minimum Data Set. Despite this, the facility's consent forms for these medications only indicated verbal consent from the resident, with no signature from either the resident or a responsible party. Interviews with the DON and Medical Director confirmed that the resident did not have the capacity to provide informed consent and that the facility did not obtain consent from the resident's representative. The facility's policy required that informed consent be obtained from the resident or their representative prior to administering psychotropic medications, including a review of risks, benefits, and alternatives. The consent forms were completed inaccurately and did not reflect the resident's cognitive status or the need for a representative's involvement.
Failure to Provide Advanced Directive Information to Resident's Representative
Penalty
Summary
The facility failed to provide an advanced directive or information about advanced directives to the responsible party for one resident. Upon admission, the resident had diagnoses including schizoaffective disorder, developmental delay, and was recovering from colostomy surgery. The Minimum Data Set indicated the resident had severely impaired cognition and was taking antipsychotic and antianxiety medications. A review of the resident's medical records showed there was no documentation of an advanced directive or any planning related to it. Interviews with the Social Services Director (SSD) revealed that while the SSD contacted the resident's Regional Center Service Coordinator (RCSC) to request other medical forms, she did not inquire about or provide information regarding advanced directives. The RCSC confirmed that the facility did not ask about an existing advanced directive or provide information about advanced directive planning. The facility's policy requires that residents or their representatives receive written information about advanced directives upon admission, and that this information be documented in the medical record, but this was not followed in this case.
Resident Placed on Floor Mattress Without Bed Frame or Bedrails
Penalty
Summary
A deficiency occurred when a resident's mattress was placed directly on the floor without a bed frame or bedrails, contrary to the resident's care plan, which specified the use of a high-low bed in the lowest position. The resident, a female with metabolic encephalopathy, dysphagia, and a recent colostomy, was completely dependent on staff for all self-care and mobility, and had a surgical wound. Staff interviews revealed that transferring the resident from a floor-level mattress was uncomfortable and unsafe, especially when using a mechanical lift, and that this arrangement restricted staff's ability to provide appropriate care. The facility had high-low beds available that could be positioned close to the ground, but these were not utilized for this resident. Further review indicated that the facility had not provided training to staff on care practices for individuals with intellectual disabilities or on the use of floor-level mattress placement. The Director of Nursing acknowledged that alternative safety interventions were available and that the resident may have felt she was not treated equally to other residents. Facility policy required that all residents be cared for in a manner that promotes well-being, self-worth, and dignity, and that cognitively impaired residents be treated with sensitivity. The failure to provide a safe, clean, and homelike environment as outlined in the care plan led to the deficiency.
Failure to Develop and Implement Care Plan for Fall Prevention Related to Bed Height
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's preference for raising his bed to its maximum height, despite the resident being at high risk for falls. The resident had multiple diagnoses, including lack of coordination, unsteadiness, idiopathic aseptic necrosis of the femur, wrist drop, spinal cord compression, cervical spinal stenosis, COPD, and sciatica. The care plan in place identified fall risk factors such as poor balance, unsteady gait, decreased functional status, and attempts to stand unassisted, and included interventions like joint mobility assessments, ensuring the call light was within reach, and monitoring for sedation and balance issues. However, it did not address the specific issue of the resident raising his bed to the highest position, which was observed multiple times during the review period. Nursing progress notes and direct observations confirmed that the resident frequently kept his bed in the highest position and was unable to reach his call light, further increasing his fall risk. Staff interviews revealed that the resident was non-compliant with keeping the bed in a low position for safety, and the DON acknowledged that no care plan had been developed to address this behavior. The facility's policy required ongoing assessment and revision of care plans as residents' conditions changed, but this was not followed in the case of this resident's bed height preference and associated non-compliance.
Failure to Document Ordered PVR Measurements for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to provide appropriate treatment to prevent a urinary tract infection (UTI) for a resident with multiple complex medical conditions, including diabetes mellitus, acute kidney failure, and severe cognitive impairment. The physician had ordered post void residual (PVR) measurements every six hours for 24 hours, with instructions to re-insert a Foley catheter if the PVR exceeded 300 cc. Documentation showed that PVR measurements were recorded at three of the required times, but there was no documentation of a PVR measurement at the 6 AM interval as ordered. During an interview and record review, a registered nurse confirmed that the 6 AM PVR measurement was missing and acknowledged that it should have been charted, as the resident could have been retaining urine. The facility's policy required staff to monitor and document the resident's progress and responses to treatment. The lack of documentation for the ordered PVR measurement constituted a failure to follow physician orders and facility policy for monitoring and documenting treatment.
Missed Pain Medication Dose Due to Unavailable Medication
Penalty
Summary
A resident with a history of systemic lupus erythematosus, chronic pain syndrome, and unspecified dementia was admitted to the facility and had an active order for hydrocodone-acetaminophen to be administered every 8 hours for chronic pain. On the morning in question, the resident did not receive her scheduled 6 AM dose of hydrocodone-acetaminophen. Review of the Medication Administration Record confirmed the missed dose, and the nurse's progress note indicated the medication was not available and was being awaited from the pharmacy. During interviews, the resident reported that hydrocodone-acetaminophen was the only medication that effectively managed her pain and that it was not always available when requested, describing this as an ongoing issue. The nurse and DON both confirmed that the process for unavailable medications should involve contacting the pharmacy to access the emergency kit, which was not done in this instance. Facility policy indicated that effective pain management requires around-the-clock medication, but this was not achieved due to the missed dose.
Medications Lacking Expiration Dates on Bubble Packs
Penalty
Summary
Surveyors identified that the facility failed to ensure medication bubble packs for three residents were labeled with expiration dates, as required by professional standards and the facility's own policy. During observations and interviews, it was found that two bubble packs of rivastigmine prescribed for a resident with polyosteoarthritis, muscle weakness, and dementia, one bubble pack of trihexyphenidyl for a resident with schizophrenia, major depressive disorder, and bipolar disorder, and one bubble pack of lurasidone for a resident with schizophrenia, hypothyroidism, and diabetes mellitus, all lacked expiration dates. Licensed Vocational Nurses confirmed the absence of expiration dates on these medications during medication cart inspections. The residents involved had significant medical and cognitive needs, including severe cognitive impairment and requirements for moderate to maximal assistance with activities of daily living. The facility's policy on medication labeling and storage, dated 1/16/2025, specifies that medication labels must include expiration dates when applicable. Despite this, the observed bubble packs did not meet this requirement, and staff acknowledged the importance of maintaining expiration dates to prevent the administration of expired medications.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including right side sciatica, COPD, spinal stenosis, idiopathic aseptic necrosis of the right femur, cord compression, unsteadiness on feet, left wrist drop, and lack of coordination, did not have their call light within reach while in bed. The resident was dependent on staff for toileting, bathing, dressing, personal hygiene, and transferring, and was assessed as being at risk for falls due to poor balance and unsteady gait. The care plan specifically required that the call light be kept within the resident's reach and that staff respond promptly to calls for assistance. During an observation and interview, the call light was found hanging behind the head of the resident's bed, out of the resident's reach. Both the CNA and the DON confirmed that the resident would not be able to call for help or assistance if the call light was not accessible. Review of the facility's policy indicated that call lights should be accessible to residents when in bed, on the toilet, in the shower or bathing facility, and from the floor. This failure to ensure the call light was within reach constituted a deficiency in meeting the resident's needs as outlined in their care plan and facility policy.
Room Exceeded Maximum Resident Occupancy
Penalty
Summary
The facility failed to ensure that one of its resident rooms did not accommodate more than four residents, as required by regulations. During an initial tour, surveyors observed that room [ROOM NUMBER] contained five beds, although only four residents were present at the time of observation. The facility had previously submitted a waiver request to the Department of Public Health, stating that the room had ample space for wheelchairs, medical equipment, and resident mobility, and that it did not impede the ability of residents to achieve their highest practicable wellbeing. Interviews with two residents in the room revealed that they did not have complaints regarding the available space. Throughout the survey period, nursing staff were observed to have full access to provide care, administer medications, and assist residents with activities of daily living. Despite these observations and the facility's waiver request, the presence of five beds in the room constituted a failure to comply with the requirement that no more than four residents occupy a room.
Failure to Protect Resident from Physical Abuse Due to Inadequate Behavioral Management
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, resulting in one resident being physically attacked by another. A resident with a history of schizophrenia, depression, panic disorder, and anxiety disorder exhibited escalating behavioral symptoms, including panic attacks, yelling, striking objects, and grabbing staff. Despite these incidents, the facility did not revise or update the resident's behavior problem care plan after significant changes in condition, nor did it conduct an Interdisciplinary Team (IDT) meeting upon the resident's readmission following a psychiatric hold for being a danger to self and others. The care plan for the resident with behavioral issues was not updated after multiple documented episodes of panic attacks and aggressive behavior, including an incident where the resident grabbed and shook a CNA. The facility's policies required care plan revisions and IDT meetings after significant changes in a resident's condition, but these steps were not taken. As a result, the resident's ongoing behavioral risks were not adequately reassessed or managed, and individualized interventions were not updated to address the increased risk of harm to others. Subsequently, the same resident physically assaulted another resident in the facility lobby, resulting in the victim sustaining a facial injury and an orbital fracture. Witnesses and staff confirmed the altercation, and the aggressor admitted to the physical attack. The facility's failure to implement its own policies and procedures regarding behavioral assessment, care plan updates, and IDT involvement directly contributed to the occurrence of resident-to-resident physical abuse.
Lack of Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 3, had a signed informed consent for the administration of a psychotropic medication, specifically Duloxetine HCL. Resident 3 was admitted with diagnoses including anxiety disorder, major depressive disorder, and paraplegia. The resident was alert and oriented with good recall, as indicated by the Minimum Data Set. Despite being prescribed Duloxetine for polyneuropathy, the medication is classified as a psychotropic drug, necessitating informed consent. During a review, it was found that there was no informed consent documentation in either the physical or electronic chart for this medication. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) acknowledged the absence of informed consent and stated that education about the medication was provided during medication pass, but no formal consent was documented. The Director of Nursing (DON) confirmed that the facility lacked a specific informed consent policy for psychotropic medications and that the responsibility for obtaining consent was attributed to the doctor. The RN supervisor, who took the medication order, did not document obtaining informed consent. The DON recognized the risk to the resident due to the lack of documented informed consent, which should have included information on the risks and benefits of the medication.
Facility Fails to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to allow Resident 2 to return after hospitalization at a General Acute Care Hospital (GACH), despite being medically stable. Resident 2, who has a history of bipolar disorder and schizoaffective disorder, was initially transferred to the hospital under a 5150 hold due to a mental health crisis involving damaging medical equipment. After being deemed stable for discharge back to the skilled nursing facility, the facility did not permit the resident's return, citing an inability to meet the resident's care needs. Interviews with the facility's Administrator and Director of Nursing revealed concerns about the resident's safety and fire risk, which they believed could not be managed at their facility. Despite the GACH's social worker's attempts to facilitate the resident's return, the facility did not respond, leaving the resident at the hospital for over three weeks. The facility's policies on bed hold and transfer or discharge were reviewed, indicating that residents should be allowed to return post-hospitalization, regardless of payer source, but this was not adhered to in Resident 2's case.
Failure to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and accident-free environment in two shower rooms, identified as Shower Room A and Shower Room B. During an observation, a soiled and wet Mepilex dressing was found on the floor of Shower Room A, and a soiled and wet face towel along with hair on the water drain was observed in Shower Room B. These observations were made in the presence of the Social Services Director (SSD). Housekeeping staff, when called to observe the conditions, confirmed that the shower rooms were not clean and acknowledged that the Mepilex dressing, face towel, and hair should not have been left on the floor. The Director of Nursing (DON) stated that the shower rooms should be cleaned after each use, which aligns with the facility's policy and procedures. The facility's policy on Cleaning and Disinfection of Environmental Surfaces, revised in August 2019, requires that housekeeping surfaces be cleaned regularly, when spills occur, and when visibly soiled. Additionally, the policy on providing a homelike environment, reviewed in January 2024, emphasizes the importance of maintaining a safe, clean, comfortable, and homelike environment for residents. The failure to adhere to these policies resulted in the observed deficiencies.
Inadequate Supervision of Resident by CNA
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident, leading to a potential risk of accidental injuries. The resident, who was admitted with diagnoses including urinary tract infection, chronic obstructive pulmonary disease, and unspecified dementia, was observed to have severely impaired cognitive skills and was totally dependent on staff for activities of daily living. During an observation, a Certified Nursing Assistant (CNA) was found asleep in the resident's room while the resident was lying in bed with eyes closed. This lack of alertness and supervision by the CNA posed a risk of accidents, as the CNA was not in a position to respond to any immediate needs or emergencies of the resident. Interviews with staff, including another CNA and a Registered Nurse, confirmed that the CNA was asleep and acknowledged that staff should remain awake and alert while on duty to prevent accidents and respond to residents' needs. The Director of Nursing also stated that staff should not be napping while on duty, as it affects resident care. The facility's policy on Safety and Supervision of Residents emphasized the importance of training employees to identify and report accident hazards and to provide adequate supervision to prevent avoidable accidents.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences as indicated on their meal ticket, which was part of a physician-ordered diet. The resident, who was on a renal regular no added salt diet due to chronic kidney disease and depression, expressed that they did not like mocha mix, a non-dairy creamer, which was consistently included on their meal tray. Despite the resident's cognitive skills being intact and their preferences being documented as very important, the dietary staff continued to provide mocha mix, as it was incorrectly listed as a preference on the meal ticket. The Dietary Supervisor acknowledged the resident's dislike for mocha mix but did not consult with the Registered Dietitian to find an appropriate substitute, despite having alternatives available such as rice milk, soy milk, and almond milk. The facility's policy stated that the dietitian and nursing staff should address any conflicts between nutritional needs and resident preferences, but this was not followed. This oversight resulted in the resident repeatedly receiving a meal component they did not want, highlighting a failure in communication and adherence to the facility's policies regarding resident food preferences.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to provide and document preparation and orientation for a safe and orderly facility-initiated discharge for a resident. The resident, who was cognitively intact and had a history of systemic lupus erythematosus, schizophrenia, prediabetes, and major depressive disorder, was not involved in the post-discharge planning process. The family member responsible for the resident was also not involved in selecting a new location for discharge and was not offered any tours of the facilities mentioned in the discharge paperwork. The facility's policy required that a post-discharge plan be developed and reviewed with the resident and/or their family at least 24 hours before discharge. However, there was no documentation of such a plan being developed or discussed with the resident or their family member. The Director of Nursing (DON) confirmed that there was no post-discharge plan for the resident and that there was no follow-up with the resident or family member regarding the discharge plan since the initial notice was given. Interviews with facility staff revealed that the family member received a packet of discharge papers, but there was no documentation to confirm the date of receipt. The family member stated they needed more time to find a home for the resident and was not involved in the discharge planning process. The Social Service Director acknowledged the importance of offering tours and discussing the appeal process for discharge, which was not done in this case. The facility's policy emphasized the resident's right to remain in the facility and required specific criteria and documentation for facility-initiated discharges, which were not met in this instance.
Failure to Protect Resident's Belongings
Penalty
Summary
The facility failed to ensure the protection of a resident's belongings, specifically $40, which was reported missing by the resident. The resident, who was cognitively intact and had been admitted with diagnoses including congestive heart failure and chronic obstructive pulmonary disease, reported the loss on 8/17/24. A licensed vocational nurse (LVN) searched for the missing money but was unable to locate it. However, the LVN did not report the incident to the social service designee (SSD) nor fill out the required Theft and Loss Form, as per the facility's policy. The director of staff development confirmed that there was no documentation of the missing money being found and acknowledged that the proper procedure was not followed. The director of nursing was also unaware of the complaint and stated that the facility would typically replace small amounts of money if not found. The facility's policy, reviewed earlier in the year, mandates that all reports of theft or misappropriation of resident property be promptly and thoroughly investigated, which was not adhered to in this case.
Failure to Implement Blood Pressure Parameters for Medications
Penalty
Summary
The facility failed to ensure that a resident with congestive heart failure received treatment and care in accordance with professional standards of practice. The resident was administered Metoprolol Tartrate and Hydralazine without blood pressure parameters, which are essential to prevent hypotension. The resident's care plan indicated a risk for fluctuating blood pressure but did not specify acceptable limits for these medications. The Medication Administration Record documented the administration of these medications but did not include how the resident's heart rate was assessed. Interviews with the Director of Staff Development, Director of Nursing, and the Pharmacy Consultant revealed that blood pressure parameters should have been included in the medication orders to prevent the risk of hypotension. The facility's policy on medication and treatment orders emphasized consistency with safe and effective order writing, which was not adhered to in this case. The lack of parameters placed the resident at risk for low blood pressure, which could lead to serious health complications.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to potential inadequate care. Resident 33's care plan was not updated to reflect the current physician orders for tube feeding. The resident, who was admitted with diagnoses including gastrostomy, dysphagia, and chronic gastritis, was receiving tube feeding at a rate of 35 ml/hr as per the physician's order dated 7/8/2024. However, the care plan still indicated a rate of 40 ml/hr. This discrepancy was observed during a visit on 7/23/2024, where the tube feeding was running at the correct rate of 35 ml/hr, but the care plan had not been updated accordingly. Similarly, Resident 83's care plan was not revised to reflect the current physician orders for antibiotic therapy. The resident, who was readmitted with conditions including an elevated white blood cell count and a urinary tract infection, was initially receiving Meropenem and Vancomycin as per the care plan revised on 7/9/2024. However, the physician's order dated 7/20/2024 indicated a change in the Vancomycin dosage to 750 mg, which was not updated in the care plan. During an observation on 7/23/2024, the resident was receiving the correct dosage of Vancomycin, but the care plan still reflected the outdated dosage. The Director of Nursing acknowledged that the care plans for both residents were not revised to reflect the current physician orders. The facility's policy requires care plans to be updated with any change in condition, upon admission, quarterly, or as needed. The failure to update these care plans as per the physician's orders could potentially result in unmet needs and inadequate care for the residents.
Deficiency in Staff Competency and Training Documentation
Penalty
Summary
The facility failed to maintain yearly staff competency and mandated reporting training for elder and dependent adult abuse for two out of five sampled staff members. Specifically, the employee files for two Certified Nursing Assistants (CNA 3 and CNA 4) were missing records of annual competency skills checks and mandated abuse reporting training for several years. CNA 3's file lacked these records from 2018 to 2022, while CNA 4's file was missing them for 2022. This deficiency was identified during a review of employee files conducted on July 25, 2024, with the Director of Staff Development (DSD), who acknowledged the missing records and attributed the issue to previous staff members possibly misplacing the files. The DSD, who assumed her role a year prior, stated that she has been actively working on Quality Assurance Performance Improvement (QAPI) action plans to ensure all staff are trained according to standard practices and that employee files are updated. Despite these efforts, the deficiency highlights a lapse in maintaining proper documentation of staff training and competencies, which is crucial for ensuring the quality of care provided to residents. The facility's policy requires personal records, including training and performance evaluations, to be retained for at least five years, but this was not adhered to in the cases of CNA 3 and CNA 4.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with schizophrenia and heart failure. Upon admission, the resident was prescribed Risperidone, an antipsychotic medication, but the medication was discontinued the day after admission without consulting the resident's physician or psychiatrist. The Director of Nursing (DON) decided not to resume the medication as the resident did not display any behavioral issues during their stay, despite the resident's history of schizophrenia and the lack of a comprehensive evaluation. Additionally, the facility did not conduct the required psychology consultations ordered by the resident's physician on two separate occasions. The psychology evaluation was missed, which hindered the ability to determine the necessary behavioral health services for the resident. The resident's care plan, which was initiated shortly after admission, was not revised quarterly as required, nor was it updated to reflect any changes in the resident's condition or to evaluate the effectiveness of the interventions. The facility's policies and procedures for behavioral assessment, psychotropic medication use, and care plans emphasize the need for comprehensive assessments and timely revisions of care plans. However, these protocols were not followed, leading to a deficiency in providing appropriate behavioral health services to the resident. The failure to adhere to these policies resulted in inadequate care and follow-up for the resident's behavioral health needs.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of controlled and non-controlled medications for a resident during medication administration. During an observation, a Licensed Vocational Nurse (LVN) prepared ten medications for a resident and left them unattended on a medication cart countertop while attending to another resident. This included lacosamide, a controlled medication with potential for dependence and abuse. The LVN acknowledged that medications should not have been left unattended due to the risk of diversion and accidental exposure. Additionally, the facility did not ensure proper labeling of insulin for another resident, as observed during an inspection of a medication cart. The insulin vial was found with two different hand-written dates, which was not in accordance with the manufacturer's requirements and the facility's policy. This discrepancy made it unclear when the insulin was removed from the refrigerator or opened, potentially affecting its efficacy and safety. The Director of Nursing (DON) confirmed that the insulin vial should be labeled with an opened date and discarded after 28 days if stored at room temperature. The failure to properly label the insulin could lead to the administration of expired insulin, posing a risk of hyperglycemia or hypoglycemia for the resident.
Improper Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to observe proper food storage and handling practices, as evidenced by two specific incidents. During an initial kitchen tour, a package of cookies was found opened and undated on a shelf in the kitchen's pantry. The cook acknowledged that all packaged foods should be stored in a new container and dated immediately after opening to prevent spoilage and potential contamination. The Registered Dietitian confirmed that opened dry foods should be repackaged and dated to avoid contamination by insects or rodents, which could lead to foodborne illnesses if consumed by residents. Additionally, during a lunch tray line observation, a cook was seen rinsing a towel in the sink and then returning to serve food without washing his hands. The cook admitted forgetting to wash his hands, acknowledging the risk of contaminating the food. The Director of Staff Development and the Director of Nursing emphasized the importance of handwashing to prevent cross-contamination and potential foodborne illnesses. The facility's policies on food storage and hand hygiene were reviewed, highlighting the expectation for staff to adhere to safe food handling and sanitation standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for six residents. Restorative Nursing Aide 1 used inappropriate cleaning agents on a cloth gait belt after assisting a resident with walking exercises. The cloth gait belt, made of porous fabric, was cleaned with Super Sani-Cloth disposable wipes, which are only suitable for hard, non-porous surfaces. This improper cleaning method was confirmed by the Infection Preventionist Nurse, the Director of Maintenance and Housekeeping, and the Director of Nursing, who all emphasized the importance of following manufacturer instructions to prevent the spread of infection. Another deficiency was observed with Resident 85, whose urinals were found hanging on the inside of a trash can next to their bed. The resident, who required assistance for various activities and was frequently incontinent, stated that the urinals were placed there for accessibility. However, this practice was verified by a Licensed Vocational Nurse as inappropriate and potentially leading to infection control issues. The Director of Nursing confirmed that urinals should be placed in designated holders to prevent such risks. Additionally, the facility failed to disinfect medication trays and cart countertops between resident room visits during medication administration for four residents. Licensed Vocational Nurse 1 did not disinfect the trays and cart surfaces after administering medications, which was acknowledged as a lapse in infection control practices. The Director of Nursing stated that proper disinfection procedures should be followed to prevent the spread of infection, as outlined in the facility's policies and procedures.
Failure to Maintain Safe Environment Due to Damaged Floor
Penalty
Summary
The facility failed to maintain a safe and homelike environment for a resident by not repairing a damaged floor surface in the resident's room. The floor, made of vinyl, had a crack and chip running across its entire length, creating an uneven and slanted surface approximately half an inch high. This condition was observed during a survey, and the resident confirmed that the damage had been present since their admission to the room several months prior. The resident expressed dissatisfaction with the room and the facility, indicating a desire to transfer closer to family. Interviews with facility staff, including a CNA, the Director of Staff Development, the Environment Aide, and the Director of Maintenance and Housekeeping, confirmed awareness of the floor damage and its potential risk for trips and falls. The damage had been present for several months, and although the Director of Maintenance had contacted a third-party company for repairs, no specific timeframe for the repair was provided. The facility's policy on maintaining a homelike environment emphasizes providing a safe, clean, and comfortable setting, which was not upheld in this instance.
Failure to Create Care Plan for Prescribed Medication
Penalty
Summary
The facility failed to create a care plan for a resident who was prescribed Diflucan (Fluconazole) to treat fungal pneumonitis. The resident, who was cognitively intact and required varying levels of assistance for daily activities, was admitted with diagnoses including an elevated white blood cell count, adult failure to thrive, and a urinary tract infection. Despite the physician's order for Diflucan, the resident's care plan did not include this medication, which is essential for evaluating the effectiveness of the treatment and ensuring the resident is not given unnecessary medication. During a review, the Director of Nursing acknowledged the absence of a care plan for Diflucan and emphasized the importance of updating care plans when new physician orders are received. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's needs. The lack of a care plan for the prescribed medication indicates a failure to adhere to this policy, potentially impacting the resident's care and treatment outcomes.
Incorrect LALM Setting for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for Resident 190 by not ensuring the correct setting of the low air loss mattress (LALM), which is crucial for wound management. Resident 190 was admitted with a stage three pressure ulcer on the back and unstageable pressure ulcers on the right ankle and heel. The resident's care plan and physician orders specified the use of a LALM set according to the resident's weight and comfort, with checks on placement and functioning every shift. However, during an observation, it was found that the LALM was set for a weight of 200 lbs, while Resident 190 weighed 145 lbs, indicating a discrepancy in the mattress setting. The Treatment Nurse acknowledged that the LALM settings should match the resident's weight to prevent delayed wound healing and worsening of the wound. The Director of Nursing confirmed that licensed staff are responsible for monitoring the LALM settings and that incorrect settings constitute a deficient practice. The facility's policy on pressure ulcer prevention emphasizes the importance of selecting appropriate support surfaces based on various factors, including the resident's weight. The operator's manual for the LALM also specifies setting the control knob to the patient's weight, which was not adhered to in this case.
Failure to Clarify Medication Strength and Dose
Penalty
Summary
The facility failed to clarify the strength and dose on a physician order for docusate sodium liquid for a resident, which had the potential to result in the resident receiving an inadequate or excessive dosage. The resident, who was rarely or never understood and required full assistance for activities of daily living, was observed receiving a 25 mL dose of docusate sodium liquid during a medication pass. However, the physician order did not specify the medication's strength or concentration, only the volume to be administered. Interviews with the LVN and the Director of Nursing confirmed the importance of clarifying the physician order to include the dose and strength of the medication. The facility's policy and procedure documents also indicated that medication orders must include the name and strength of the drug, dosage, and frequency of administration. The lack of clarity in the physician order could lead to the resident not being treated for constipation or experiencing episodes of diarrhea, increasing the risk for hospitalization.
Inadequate Competency in Sanitizer Testing by Dietary Staff
Penalty
Summary
The facility failed to ensure that the Dietary staff had the appropriate competencies and skills, specifically in the use of QT-40 test paper for checking Quaternary Ammonium Compounds sanitizer concentration. During an observation, a Dietary Aide (DA 1) was unable to verbalize and follow the manufacturer's guidelines for the test strips, which require the strip to be left in the solution for 10 seconds before comparison. DA 1 removed the strip immediately and was unsure of the correct sanitizer concentration level, which should be 200 parts per million (PPM) according to the facility's records. This failure could potentially lead to cross-contamination and unsanitized food preparation areas, posing a risk of foodborne illness to the 88 residents receiving food from the kitchen. The Registered Dietician, serving as the temporary Dietary Supervisor, was unaware of whether all kitchen staff had completed their annual competencies, as she had only recently assumed the position. DA 1's records showed a competency evaluation was completed in December 2023, but the Director of Staff Development and the Director of Nursing indicated that the Dietary Supervisor should have ensured proper education and evaluation of the Dietary Aides. The facility's policy on infection prevention and control requires personnel to be trained on relevant procedures, but the deficiency suggests a lapse in ensuring that training was effectively implemented.
Failure to Maintain Sanitary Environment and Prevent Fly Infestation
Penalty
Summary
The facility failed to maintain a sanitary environment and prevent an infestation of flies in and around the waste segregation and disposal area. During an observation, two open trash bins were found filled with food leftovers, with trash spilled over and flies swarming around them. Interviews with the Maintenance Supervisor, Director of Nursing, Infection Preventionist Nurse, and Environment Aide confirmed that the presence of flies is a potential risk for infection outbreaks and is against the facility's infection prevention policy. The facility's pest control program, managed by a third-party company, had previously recommended covering trash to prevent pest issues. A review of the pest control company's invoices revealed multiple observations of uncovered trash and recommendations to address this issue. Despite regular pest control visits, the facility failed to implement these recommendations effectively, leading to the observed deficiency. The facility's policy on pest control emphasizes maintaining an effective program to keep the building free of insects and rodents, yet the presence of flies in the conference room and their potential to spread germs was noted during an exit conference with facility staff.
Violation of Resident Room Occupancy Limits
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents in a room to no more than four. During an initial tour of the facility, it was observed that one resident room contained five beds, which is a violation of the regulation. This deficiency was noted during a survey conducted from July 22 to July 25, 2024. The facility had submitted a letter to the Department of Public Health requesting a waiver for this room, stating that there was ample space to accommodate wheelchairs, medical equipment, and allow for the mobility of ambulatory residents. The facility claimed that the health and safety of the residents were not compromised, and the room arrangement did not impede the residents' ability to achieve their highest practicable well-being. During the survey, two residents were observed in the room with five beds, and both were not interviewable. Interviews with Certified Nursing Assistants (CNAs) assigned to the room revealed that they believed there was sufficient space to provide care and perform daily activities. CNA 5 and CNA 6 both stated that they had no concerns regarding the space in the room, and they were able to provide necessary treatments, administer medications, and assist residents with their daily routines. Despite these observations, the presence of five beds in a single room remains a violation of the regulatory standards for resident room occupancy.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident was informed in advance of the risks and benefits of psychoactive and hypnotic medications, violating the resident's right to make an informed decision. The resident, who was admitted with diagnoses including schizophrenia, depression, and type 2 diabetes, was found to have moderately impaired cognition and was taking hypnotic medication. The facility's records indicated that informed consent for medications such as Zyprexa and Lorazepam was not properly documented, as the consents did not include the name of the physician who obtained them, and there was no evidence that informed consent was obtained prior to the initiation of therapy. The facility's policy on psychotropic medication use and informed consent required that residents receive antipsychotic medication only when necessary and that the attending physician inform the resident or their representative of the medication or treatment orders, including adverse side effects. However, the Director of Nursing acknowledged the lack of documented evidence of informed consent from the physician, which was a deviation from the facility's policy. This oversight in obtaining and documenting informed consent contributed to the deficiency identified during the survey.
Failure to Initiate Zyprexa Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan for the administration of Zyprexa, an antipsychotic medication, for a resident diagnosed with schizophrenia, depression, and type 2 diabetes. The resident was admitted on 6/12/2024 and was noted to have moderately impaired cognition and lacked the capacity to understand and make decisions. Despite a physician's order dated 7/2/2024 to administer Zyprexa 5 mg at bedtime for schizophrenia manifested by aggressive behavior, no care plan was developed to address the administration of this medication. During a review on 7/11/2024, the Director of Nursing acknowledged the absence of a care plan for Zyprexa, emphasizing the importance of having measurable objectives to meet the resident's needs and desired outcomes. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to address the resident's physical, psychosocial, and functional needs, which was not implemented in this case.
Lack of Supervision in Smoking Patio Leads to Resident Altercation
Penalty
Summary
The facility failed to provide direct supervision to residents in the smoking patio, as required by their Smoking Policy. On 6/20/2024, Resident 1, who had severe cognitive impairment and a history of schizophrenia, depression, and epilepsy, was left unsupervised in the smoking patio. This lack of supervision led to Resident 1 physically assaulting Resident 2 and Resident 3, hitting them on the chin and forehead, respectively. Resident 1's medical records indicated severe cognitive impairment and a lack of capacity to make medical decisions. The resident was on antipsychotic and antidepressant medications. The incident occurred during a time when the smoking patio was supposed to be supervised, but staff were not present. Interviews with residents and staff confirmed that no staff were present in the smoking patio after the receptionist left at 5 PM, despite the facility's policy requiring supervision during smoking hours. The Director of Nursing acknowledged that staff should have been present to prevent such incidents, and the facility's policy clearly stated that residents with smoking privileges requiring monitoring should have direct supervision at all times. The absence of staff during the incident on 6/20/2024 allowed for the altercation between residents, highlighting a breach in the facility's policy and procedure for resident safety during smoking breaks.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. Resident 1, who was initially admitted on 9/5/2023 and readmitted on 3/16/2024, has diagnoses including cardiomyopathy, heart failure, and functional quadriplegia. Despite having intact cognition and the capacity to make decisions, Resident 1 required substantial assistance with daily activities. On 6/1/2024, Resident 2, who has severe cognitive impairment and lacks decision-making capacity, poked Resident 1 with a grabbing stick, causing pain to Resident 1's right knee. This incident followed a previous altercation where Resident 2 allegedly pulled Resident 1's hair. The facility's failure to monitor Resident 2's whereabouts every hour, as per the Physician's Order, contributed to the incident. The Interdisciplinary Team had previously discussed concerns about Resident 2 carrying a grabbing stick, which could be used as a weapon. Despite this, the facility did not effectively separate the residents or document interventions after the first incident. The facility's policy on abuse prevention and resident-to-resident altercations required staff to document all interventions and their effectiveness, which was not adequately done in this case. Interviews with staff and residents revealed that Resident 1 did not express fear or changes in behavior following the incident, and Resident 2's behavior remained unchanged. However, the Director of Social Services acknowledged that the incident could have been prevented with proper separation and documentation. The facility's policy aimed to protect residents from abuse and required the development and implementation of protocols to prevent such incidents, which were not fully adhered to in this situation.
Failure to Follow Physician Orders for Laboratory Services
Penalty
Summary
The facility failed to follow physician orders for laboratory services for a resident receiving two anticonvulsant medications, Keppra and Depakote. The resident had a history of dementia, bipolar disorder, and seizures, and required regular lab tests to monitor medication levels. Despite multiple orders for lab tests, the facility did not perform the required tests, placing the resident at risk for medication-related adverse reactions. The resident's last documented lab results for Keppra and Depakote were from 12/29/2022 and 5/18/2022, respectively, indicating a significant lapse in monitoring. The resident refused lab tests on several occasions, and the facility transferred the resident to a general acute care hospital (GACH) for further evaluation. However, the transfer orders were broad and did not specify the required lab tests, resulting in the GACH not performing the necessary tests for Keppra and Depakote levels. The facility's Director of Nursing (DON) acknowledged that the physician-ordered labs were not being done and that the facility missed the opportunity to obtain the needed labs during the hospital transfer. Interviews with the facility's staff, including Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), the Consultant Pharmacist (CP), and the Nurse Practitioner (NP), revealed a lack of awareness and oversight regarding the resident's lab orders. The CP admitted to overlooking the lab orders, and the NP was unaware that the labs were not being done. The facility's policies and procedures emphasized the importance of following physician orders for lab tests and monitoring anticonvulsant medication levels, but these protocols were not followed, leading to the deficiency.
Failure to Complete Thorough Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the consultant pharmacist (CP) completed a thorough review of a resident's medical records from 12/29/2022 to 5/22/2024. Specifically, the CP did not identify and report to the physician when laboratory tests ordered for medication management were not performed. This oversight involved a resident with diagnoses including dementia, bipolar disorder, and seizures, who had active orders for seizure medications Depakote and Keppra. Despite multiple lab orders placed by the prescriber to monitor the resident's medication levels and other health indicators, the CP's Medication Regimen Review (MRR) reports consistently listed the resident with no recommendations, failing to address the missing lab work. During a review of the resident's clinical records, it was confirmed that the CP did not make any recommendations regarding the unperformed lab tests. The Director of Nursing (DON) and the CP acknowledged that the lab orders should have been completed as prescribed, and the CP admitted to overlooking these orders. The facility's policy and procedures for Medication Regimen Review, which require the CP to identify and report medication-related problems, were not followed in this case, leading to a significant deficiency in the resident's care management.
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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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