Hollywood Presbyterian Medical Center D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 4636 Fountain Avenue, Los Angeles, California 90029
- CMS Provider Number
- 056311
- Inspections on file
- 33
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Hollywood Presbyterian Medical Center D/p Snf during CMS and state inspections, most recent first.
A resident with quadriplegia and chronic respiratory failure, who was unable to use their arms, was not provided with an adaptive call light system as required by facility policy. Instead, the resident had a standard call light remote they could not access and had to rely on making clicking sounds to call for help, which sometimes went unheard by staff. Facility staff confirmed that adaptive call light devices were available but had not been provided to the resident.
Two residents with severe cognitive and physical impairments did not receive physician-ordered hand rolls for contracture management, as evidenced by missing documentation and direct observation. Staff and nursing leadership confirmed the absence of hand rolls and incomplete records, despite care plans and facility policy requiring their use to maintain joint mobility.
A facility failed to provide and utilize proper PPE during patient showering, leading to infection control deficiencies. Staff used standard gurneys instead of appropriate shower gurneys, which had been broken for months. A resident with complex medical needs was showered without water-resistant PPE, increasing infection risks. The facility's policies on PPE and infection prevention were not followed, contributing to the deficiency.
The facility failed to ensure patient safety by using standard gurneys instead of shower gurneys designed for wet environments. This was observed during a showering session where a patient with severe medical conditions was at risk of falling due to inadequate gurney features. The facility's decision to use standard gurneys, despite broken shower gurneys, led to a deficiency in patient safety.
The facility failed to have a licensed administrator, with the CNO of GACH 1 acting as the administrator without the required license. Staff interviews revealed the CNO rarely visited, and there was no dedicated administrator since the previous one resigned. This potentially impacted the timely addressing of resident and family concerns.
Two residents did not receive prescribed passive range of motion (PROM) exercises and splint applications due to staffing issues, leading to missed treatments. The facility's policy required CNAs and charge nurses to carry out RNA programs in the absence of RNAs, but RNAs were often reassigned to CNA duties, preventing them from fulfilling their responsibilities.
The facility failed to provide sufficient nursing staff to ensure RNA program treatments were completed for two residents, resulting in missed PROM exercises and splint applications. The DON confirmed that staffing levels were inadequate, with RNAs often reassigned to CNA duties, leading to missed treatments on multiple occasions.
A facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate due to late administration of medications. An LVN administered 14 medications to a resident via a G-tube, completing the task over two hours late. The DON confirmed that three medications were given more than one hour past the scheduled time, violating the facility's policy for non-time-critical medications.
A resident with chronic respiratory failure, DVT, and heart disease received three significant medications two hours late due to a timing error by an LVN. The medications, Eliquis, carvedilol, and famotidine, were crucial for managing the resident's conditions. The DON confirmed the potential adverse effects of this error.
A resident with multiple serious medical conditions was unable to reach the call light, leading to delayed assistance. Staff were observed passing by the room without responding to the activated call light. The facility's policy required prompt response to call lights, which was not adhered to in this case.
A facility failed to complete and submit the MDS upon discharge for a resident with severe medical conditions, including chronic respiratory failure and dependence on a respirator. The resident was discharged without a discharge MDS being completed, which was confirmed by the MDS Coordinator and the DON. This deficiency had the potential to negatively affect the resident's care.
A resident with multiple health issues, including a stage 4 pressure ulcer, was found to be on a Low Air Loss Mattress (LALM) set incorrectly for their weight. The LALM was set for 140 lbs, while the resident weighed 104.1 lbs. This error was confirmed by an LVN and the DON, who acknowledged that incorrect settings could compromise the mattress's effectiveness in preventing skin breakdown.
Two residents with epilepsy and anoxic brain damage were found to have only one padded side rail on their beds, despite physician orders and care plans requiring two for seizure precautions. LVNs confirmed the deficiency, and the facility's policy emphasized the need for padded side rails to ensure safety during seizures.
Two residents receiving enteral feeding in an LTC facility did not receive appropriate care. One resident's bed was not elevated as required during tube feeding, increasing the risk of aspiration. Another resident's gastrostomy tube dressing was not dated, risking infection. These deficiencies were confirmed by staff and contradicted the facility's policies.
The facility failed to conduct an annual competency assessment for a Sub Acute Registered Nurse (SARN), identified as RN 2, which is necessary to ensure nursing staff have the skills to provide quality care. The last assessment was conducted in March 2023, and no assessment was on file for 2024, as confirmed by the DON. This lapse in policy adherence could potentially affect resident care quality.
The facility failed to comply with its drug disposition policy, as it did not specify the process or designate responsible personnel for disposing of discontinued medications. A nurse stated that the process did not require a witness, and the facility pharmacist confirmed the policy incorrectly referenced a regulation section.
A facility failed to clarify a physician's order for Creon, a medication for pancreatic insufficiency, as recommended by the pharmacy consultant. The order did not specify administration before meals, which is crucial for effectiveness. Despite receiving the recommendation, the order was not updated, potentially reducing the medication's effectiveness and causing discomfort for a resident.
A resident with multiple health conditions, including candida auris, experienced a breach in infection control when their condom catheter drainage bag was not properly closed, leading to urine leakage on the floor. This incident, confirmed by a CNA, highlighted poor infection control practices and was acknowledged by the DON as a potential risk for contamination and infection.
A resident with severe hand weakness and multiple medical conditions was not provided with an adaptable call light, leading to potential delays in care. Despite being able to communicate, the resident had to make a clicking noise to call for assistance. Facility staff acknowledged the deficiency, which was contrary to the facility's policy requiring assessment and provision of appropriate call light devices.
A resident with chronic respiratory failure and a tracheostomy was placed on bilateral hand mitten restraints to prevent tube removal. The facility failed to renew restraint orders daily and did not conduct required assessments from late June, leading to redness and swelling at the resident's knuckles. The DON admitted the facility's practices did not align with their policy, resulting in inadequate care and oversight.
A resident developed a stage 2 pressure injury at the facility, and the family was not informed. Additionally, the facility performed a wound debridement procedure without explaining the risks and benefits or obtaining consent from the resident's family, violating the resident's rights.
A resident with multiple diagnoses developed a stage 2 pressure injury, but the facility failed to develop a care plan, leading to the injury worsening to stage 3. The DON confirmed that the absence of a care plan delayed care and exacerbated the wound, violating the facility's wound care policy.
A facility failed to report an allegation of physical abuse involving a resident and an LVN to the Department. Despite the resident's daughter reporting the incident and requesting a meeting with the DON, Administrator, and SW, the facility did not report the allegation, justifying their inaction by stating that the daughter did not explicitly label the incident as abuse. This failure violated the facility's policies and procedures on abuse reporting.
A facility failed to thoroughly investigate an abuse allegation when a resident's daughter reported that an LVN punched the resident during tracheostomy care. The DON did not interview the resident or the CNA who witnessed the incident, and the allegation was not reported because the daughter insisted it was not abuse.
Failure to Provide Adaptive Call Light for Resident with Quadriplegia
Penalty
Summary
A deficiency occurred when a resident with quadriplegia and chronic respiratory failure, who was dependent on staff for all activities of daily living and unable to move their arms, was not provided with an appropriate adaptive call light system. Despite the resident's cognitive abilities being intact and their ability to communicate needs, the standard call light remote was placed next to the resident's head, which the resident could not access due to paralysis. The resident reported having to make clicking sounds to call for help, which sometimes went unheard by staff, resulting in delays in receiving assistance. Interviews with facility staff revealed that an adaptive call light system, such as a tap or pad that could be activated by cheek movement, was available but had not been provided to the resident. The Director of Engineering confirmed the availability of such devices and the process for installing them upon request. The Director of Nursing acknowledged that the resident should have had an adaptive call light system based on their assessment and current condition. Facility policy required that call lights be within easy reach and that adaptive devices be provided for residents with limited mobility, but this was not followed in this case.
Failure to Provide Ordered Hand Rolls for Contracture Management
Penalty
Summary
The facility failed to ensure that two residents with significant medical conditions and physician orders for hand rolls received the appropriate services to prevent a decline in range of motion (ROM) and mobility. Both residents had orders for hand rolls to be donned at all times or as tolerated for contracture management, as documented in their care plans and physician orders. However, review of the Restorative Nursing Assistant Records (RNAR) for both residents showed multiple dates where there was no documentation that hand rolls were applied, and there was no indication in the progress notes that the residents could not tolerate the hand rolls. Resident 1 had a history of chronic respiratory failure, hemiplegia, hemiparesis, cerebral infarction, contractures in both hands, and was dependent on a ventilator and gastrostomy tube. Resident 2 had chronic respiratory failure, cerebral palsy, contracture of a joint, intellectual disabilities, and was dependent on supplemental oxygen. Both residents were assessed as having severely impaired cognitive skills and were dependent on staff for all activities of daily living. Despite these needs and the clear orders for hand roll use, observations confirmed that neither resident had the required hand rolls in place during the survey, and staff interviews confirmed that the absence of documentation meant the intervention was not provided. The facility's policy required the implementation of strategies to prevent further limitations in joint mobility, with the charge nurse responsible for ensuring RNA orders were carried out. Both the Restorative Nursing Aide and the Interim Director of Nursing confirmed that the hand rolls were not in place as ordered and that there was missing documentation for their application. The lack of adherence to physician orders and care plan interventions for ROM management constituted the deficiency identified during the survey.
Inadequate PPE Use During Patient Showering
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) was supplied and utilized by staff when showering a patient, leading to a deficiency in infection control protocols. During an observation, two certified nursing assistants (CNAs) were seen showering a patient on a standard gurney instead of an appropriate shower gurney, which had been broken for several months. The CNAs were standing in water, and one was not wearing shoe covers, resulting in wet clothing. The Director of Nursing Services (DNS) confirmed that the facility had been using standard gurneys due to the unavailability of shower gurneys, despite the safety concerns. Patient 1, who was being showered at the time of the observation, had a complex medical history, including neuromuscular disease, functional quadriplegia, severe scoliosis, and dependence on a mechanical ventilator. The use of a standard gurney posed a risk of cross-contamination and increased the likelihood of infection transmission due to the lack of appropriate PPE. Interviews with staff revealed that the broken shower gurneys had been out of service for four to five months, and the facility had not been able to secure replacements or rentals. The facility's policy on PPE and infection prevention emphasized the importance of using water-resistant PPE to prevent exposure to potentially infectious materials. However, the shoe covers provided were not water-resistant, and staff reported difficulties in safely transferring patients due to the wet conditions. The Clinical Educator and Infection Preventionist were unaware of the use of standard gurneys and confirmed the necessity of appropriate PPE to minimize infection risks. The facility's failure to adhere to its own policies and procedures contributed to the deficiency in infection control.
Facility Uses Inappropriate Gurneys for Showering Patients
Penalty
Summary
The facility failed to ensure the safety of fourteen patients by using standard gurneys instead of shower gurneys designed with safety features for wet environments. This practice was observed during a showering session where a patient with neuromuscular disease, functional quadriplegia, severe scoliosis, and mechanical ventilator dependence was being showered on a standard gurney. The gurney's side rails had large gaps, and there were no barriers at the head and foot, creating a risk of the patient falling. The staff members were standing in water, and one was not wearing shoe covers, increasing the risk of slipping and infection control issues. The Director of Nursing confirmed that both shower gurneys had been broken for several months, leading to the use of standard gurneys for showering patients. Despite acknowledging the safety concerns, the facility decided to continue using standard gurneys after discussions with the facility administrator. The Director of Supply Chain Operations mentioned that there was a plan to repair the broken gurneys, but they were not found when the repair engineer arrived. Attempts to rent replacements were unsuccessful, and although new gurneys were ordered, there was no estimated delivery date. The facility's Environment of Care Safety Management Plan outlines the need to minimize safety risks, but the use of standard gurneys for showering patients contradicts this plan. The operation manual for the standard gurney used emphasizes that it should not be submerged or used inappropriately, and maintenance is required after every fifth washing. The facility's failure to address the broken shower gurneys and the decision to use inappropriate equipment led to a deficiency in ensuring patient safety during showering.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to ensure adequate administration services as the administrator did not possess an administrator's license and there was no designated administrator for the facility. The Chief Nursing Officer (CNO) of General Acute Care Hospital (GACH) 1 was acting as the facility's administrator without the required license. The CNO's job description indicated responsibilities related to nursing operations and quality patient care, but did not include holding an administrator's license. The organizational chart showed the CNO as the administrator, but there was no posted administrator license at the facility. Interviews with staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed that the CNO rarely visited the facility and there was no dedicated administrator present. The Medical Director confirmed the absence of a dedicated administrator since the previous administrator resigned, which potentially impacted the timely addressing of resident and family concerns. The facility did not provide a policy and procedure regarding administration when requested.
Failure to Provide Prescribed ROM Treatments
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion (ROM) for two residents, Resident 6 and Resident 72, as ordered by their physicians. Resident 6, who was admitted with anoxic brain injury and was dependent on a ventilator, did not receive the prescribed passive range of motion (PROM) exercises and splint applications on multiple occasions across October, November, and December 2024. The Director of Nursing (DON) confirmed that several treatments were missed, which were crucial to prevent decline in mobility and contractures. Resident 72, who was in a persistent vegetative state and also dependent on a ventilator, similarly did not receive the ordered PROM exercises and splint applications. The documentation showed that treatments were missed on several days in October, November, and December 2024. The DON confirmed these omissions and emphasized the importance of the RNA treatments in maintaining mobility and preventing contractures. The facility's policy indicated that in the absence of a Restorative Nursing Aide (RNA), Certified Nursing Assistants (CNAs) and charge nurses were responsible for carrying out the RNA program. However, RNA 1 reported that when CNAs were short-staffed, RNAs were often pulled to perform CNA duties, which prevented them from completing their RNA responsibilities. This staffing issue contributed to the failure in providing the necessary treatments to the residents.
Inadequate Staffing Leads to Missed RNA Treatments
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to ensure that the Restorative Nursing Aide (RNA) program treatments and services were completed for two residents, as indicated on the physician's orders. This deficiency was identified through interviews and record reviews, revealing that the residents did not receive the prescribed passive range of motion (PROM) exercises and splint applications on multiple occasions. The Director of Nursing (DON) confirmed that the RNA services were not provided on specific dates in October, November, and December 2024, due to insufficient staffing levels. Resident 6, who was admitted with diagnoses including anoxic brain injury and ventilator dependency, had physician's orders for RNA to perform PROM exercises and apply elbow and knee splints. However, documentation showed that these treatments were missed on several dates across three months. The DON acknowledged that the staffing levels were inadequate, with only one or two RNAs available, which was insufficient to meet the needs of the residents. The DON also noted that RNAs were often reassigned to perform Certified Nurse Assistant (CNA) duties when CNAs called off, further impacting the ability to provide RNA services. Similarly, Resident 72, who was in a persistent vegetative state and dependent on a ventilator, had orders for PROM exercises and splint applications. The resident's RNA documentation indicated missed treatments on multiple dates in October, November, and December 2024. The DON confirmed the staffing shortages and the practice of pulling RNAs to cover CNA duties, which contributed to the missed RNA treatments. The facility's policy on staffing projections indicated that the DON and Administrator were responsible for adjusting nursing hours to meet resident needs, but the current staffing levels were insufficient to ensure the delivery of RNA services.
Medication Administration Timing Error
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate due to three errors out of 25 opportunities. The errors were related to the administration of medications at the wrong time. During an observation, an LVN was seen preparing and administering 14 medications to a resident via a gastrostomy tube. The medications were due at 9 AM, but the administration was completed at 11:25 AM, indicating a significant delay. The Director of Nursing acknowledged that the administration of three specific medications—Eliquis, carvedilol, and famotidine—occurred more than one hour past the scheduled time, which was against the facility's policy for non-time-critical medications. The facility's policy stated that medications with a dosing schedule more frequent than once daily should be administered within one hour before or after the scheduled time. The delay in administration was attributed to the workload of the LVN, who was responsible for preparing and administering medications to an average of 10 residents, taking approximately 5 hours to complete the task.
Significant Medication Timing Errors in LTC Facility
Penalty
Summary
The facility failed to prevent significant medication errors for a resident during medication administration observations. Specifically, a licensed vocational nurse administered 14 medications to a resident at 11:25 AM, which were scheduled for 9 AM. Among these, three medications were identified as significant: Eliquis, carvedilol, and famotidine. The Director of Nursing confirmed that these medications were administered two hours late, which constituted a significant wrong time error. The resident involved had a complex medical history, including chronic respiratory failure with hypoxia, acute embolism, deep vein thrombosis, hypertension, and atherosclerotic heart disease. The physician's orders specified that Eliquis and carvedilol were to be administered twice daily via a gastrostomy tube, and famotidine was prescribed for gastrointestinal bleeding. The Director of Nursing acknowledged that the irregular administration of these medications had the potential to adversely affect the resident's health condition.
Failure to Ensure Timely Response to Call Light
Penalty
Summary
The facility failed to ensure that the call light device was within reach and answered in a timely manner for Resident 65, who was admitted with multiple serious medical conditions including chronic respiratory failure, polyneuropathy, and neuromuscular dysfunction of the bladder. The resident was observed with the call light placed on the bedside table, out of reach, and reported that staff did not always respond when she called for help. The resident expressed difficulty in pressing the call light due to a lack of strength and resorted to yelling for assistance, which was not always effective. During observations, staff members were seen passing by the resident's room without responding to the activated call light. A CNA acknowledged the call light was not within reach and suggested that the resident would benefit from an adaptable call light. The facility's policy required call lights to be answered promptly, within five minutes, and emphasized the importance of ensuring call lights are accessible to residents at all times. The Director of Nursing confirmed that staff should not pass by a room with an active call light and that the facility had alternative methods for residents unable to use standard call lights.
Failure to Complete and Submit Discharge MDS
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) upon discharge for a resident, identified as Resident 62. This resident was admitted with serious medical conditions including chronic respiratory failure, cachexia, a tracheostomy, gastrostomy, dependence on a respirator, and dysphagia. The resident had severely impaired cognitive skills and was dependent on assistance for various daily activities. The last MDS assessment for Resident 62 was completed on 7/18/2024, and the resident was discharged on 9/25/2024 without a discharge MDS being completed or submitted. During a review of the resident's electronic health record, it was confirmed by the MDS Coordinator that the discharge MDS was missed and should have been completed and submitted within 14 days of discharge. The Director of Nurses also confirmed that the MDS assessment should have been completed within one week of discharge and submitted to CMS within 14 days. The failure to complete and submit the MDS in a timely manner was identified as a deficiency, with the potential to negatively affect the provision of necessary care and services for the resident.
Incorrect LALM Settings for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to maintain the correct settings on a Low Air Loss Mattress (LALM) for a resident, identified as Resident 10, who was at risk for pressure ulcers. Resident 10 was admitted with multiple diagnoses, including anoxic brain damage, neuromuscular dysfunction, epilepsy, and a stage 4 pressure ulcer in the sacral region. The resident's care plan included the use of a LALM to aid in wound management and prevent further skin breakdown. However, during an observation, it was found that the LALM was set incorrectly for a weight of 140 lbs, while Resident 10 weighed 104.1 lbs. This discrepancy was confirmed by LVN 5, who acknowledged that the LALM should have been set at a level appropriate for 105 lbs. The Director of Nursing (DON) confirmed that the LALM settings were determined by the resident's weight and that incorrect settings could render the mattress ineffective in preventing skin breakdown. The manual for the LALM indicated that settings should be adjusted based on the patient's height and weight to ensure comfort and effectiveness. The failure to adjust the LALM settings according to Resident 10's actual weight had the potential to compromise the resident's skin integrity and exacerbate existing pressure ulcers.
Failure to Implement Seizure Precautions for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents diagnosed with epilepsy and anoxic brain damage. Both residents were required to have two padded side rails on their beds as a precaution against injury during seizures, as per their physician's orders and care plans. However, observations revealed that each resident only had one padded side rail, contrary to the prescribed seizure precautions. Licensed Vocational Nurses confirmed the deficiency during interviews, acknowledging the importance of having two padded side rails to prevent injuries during seizures. The facility's policy on seizure management and precautions emphasized the necessity of padded side rails to ensure resident safety during seizure activity. Despite this policy, the facility did not comply with the prescribed safety measures for the two residents, leaving them at risk of injury. The Director of Nursing also confirmed the importance of padded side rails for residents with a history of seizures, highlighting the oversight in implementing the necessary precautions as outlined in the residents' care plans and physician's orders.
Deficiencies in Enteral Feeding Care
Penalty
Summary
The facility failed to ensure appropriate treatment and services for two residents who were fed by enteral means. For one resident receiving nutrition via a gastrostomy tube (GT), the head of the bed was not elevated more than 30 degrees while the tube feeding was on, contrary to the physician's order and care plan which required the head of the bed to be elevated between 30 to 45 degrees. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the risk of aspiration if the head of the bed was not properly elevated. Another resident's gastrostomy tube dressing was not dated, which is a deviation from the facility's policy requiring dressings to be dated and initialed by the nurse. This practice is crucial to ensure that dressing changes are not skipped, which could lead to complications such as infections. During an observation and interview, an LVN confirmed the absence of a date and initials on the dressing, acknowledging the potential for missed dressing changes. The Director of Nursing (DON) confirmed the importance of maintaining the head of the bed elevation to prevent aspiration and the necessity of dating and initialing dressing changes to prevent infections. The facility's policy and procedure documents also emphasize these practices to reduce risks associated with enteral feeding tubes, highlighting the facility's failure to adhere to its own guidelines.
Failure to Conduct Annual Competency Assessment for RN
Penalty
Summary
The facility failed to complete an annual competency assessment for a Sub Acute Registered Nurse (SARN), identified as RN 2, which is required to ensure that nursing staff have the necessary skills and knowledge to provide quality care to residents. During a review of RN 2's employee file, it was discovered that the last competency assessment was conducted on 3/21/2023, and no assessment was on file for 2024. This oversight was confirmed by both the Human Resources representative and the Director of Nursing (DON), who acknowledged that the competency assessments are supposed to be conducted annually. The facility's policy mandates that all nursing staff undergo an annual competency assessment to validate their ability to perform nursing tasks effectively. The DON stated that these assessments are crucial for ensuring that staff can perform essential nursing skills, such as medication administration and suctioning, which are critical for resident care. The absence of a current competency assessment for RN 2 indicates a lapse in the facility's adherence to its own policies and procedures, potentially affecting the quality of care provided to residents.
Deficiency in Drug Disposition Policy Compliance
Penalty
Summary
The facility failed to ensure compliance with their policy on drug disposition, specifically regarding the process of returning or destroying unused medications. During an interview, a registered nurse stated that a nurse performs the disposition of discontinued medications that are not controlled substances, and this process did not require a witness. A review of the facility's policy, last revised in August 2019, indicated that discontinued medications should be disposed of in compliance with state and federal laws, but the policy did not specify the process or designate the person responsible for performing the drug disposition. Additionally, the facility pharmacist confirmed that the policy incorrectly referenced a California Code of Regulations section for drug disposition, which should have been section 72371 instead of 73369.
Failure to Clarify Creon Administration Timing
Penalty
Summary
The facility failed to clarify the physician's orders for Creon, a medication used to treat pancreatic insufficiency, as recommended by the facility's pharmacy consultant during the monthly medication regimen review. This deficiency involved a resident who was taking Creon for pancreatic insufficiency, a condition where the pancreas does not produce enough digestive enzymes. The physician's order for Creon did not specify that it should be administered before meals, which is crucial for its effectiveness. The resident, who was readmitted to the facility with multiple diagnoses including chronic respiratory failure, type 2 diabetes, and morbid obesity, was receiving Creon three times a day. However, the medication administration record did not indicate whether Creon was given before meals, as recommended by the pharmacy consultant. The Director of Nursing confirmed that the physician's order had not been updated to include this important detail, despite the recommendation being received on 11/14/2024. The facility's policy requires that recommendations from the pharmacy consultant be acted upon within two weeks, but this was not done in this case. The Director of Pharmacy stated that the recommendation should have been fulfilled promptly to ensure the medication's effectiveness. The failure to clarify the order as recommended had the potential to reduce the effectiveness of Creon and cause stomach discomfort for the resident.
Infection Control Breach Due to Improper Catheter Management
Penalty
Summary
The facility failed to observe proper infection control measures for a resident using a condom catheter, resulting in a deficiency. The resident, who had been admitted with multiple diagnoses including chronic respiratory failure, muscular dystrophy, quadriplegia, dysphagia, and a tracheostomy, was on contact isolation precautions due to candida auris. The physician's orders required condom catheter care every shift, and the care plan included checking the tubing for kinks. However, during an observation, it was found that the resident's catheter drainage bag was not properly closed, leading to urine leakage onto the floor. The incident was confirmed by a CNA who noted that the leakage was a poor infection control practice. The Director of Nursing emphasized the importance of securing urinary collection bags to prevent contamination and potential infection risks. The resident's quarterly Minimum Data Set indicated intact cognition and extensive assistance needs, highlighting the importance of diligent care. The failure to secure the catheter drainage bag properly resulted in a breach of infection control protocols, posing a risk to the resident and others in the environment.
Failure to Provide Adaptable Call Light for Resident
Penalty
Summary
The facility failed to provide an adaptable call light for a resident, identified as Resident 55, who was unable to use the standard call light due to severe weakness in both hands. This deficiency was observed during a survey where Resident 55, who had intact cognition and was able to communicate, reported that he had to make a clicking noise with his mouth to call for assistance. The resident's medical history included chronic respiratory failure, COPD, Guillain-Barre syndrome, tracheostomy, ventilator dependence, and neuromuscular dysfunction of the bladder, all of which necessitated extensive assistance with daily activities. Interviews with facility staff, including an LVN and the DON, revealed that the facility's policy required an assessment of residents' needs for appropriate call light devices upon admission and as needed. However, Resident 55 had not been provided with a tap call light, which was the alternative for residents who could not use a push call light. The lack of an appropriate call light device posed a risk of delayed care for the resident, as acknowledged by the staff.
Failure to Manage Restraint Use and Monitoring
Penalty
Summary
The facility failed to properly manage the use of physical restraints on a resident, identified as Resident 1, who was admitted with chronic respiratory failure, hypoxia, a tracheostomy, and a gastrostomy. The resident was placed on bilateral hand mitten restraints to prevent the removal of the tracheostomy and G-tubes. However, the facility did not renew the restraint orders daily as required by their policy, from May 3, 2024, to June 30, 2024. The Director of Nursing (DON) acknowledged that the facility's practice did not align with their policy, which mandates that restraint orders be renewed every 24 hours following a physician's examination. Additionally, the facility failed to conduct regular restraint assessments for Resident 1. The last documented assessment was on June 24, 2024, and no further assessments were recorded until June 30, 2024. This lack of monitoring was contrary to the facility's policy, which requires assessments every two hours to check for circulation, skin integrity, and any signs of redness or swelling. A Licensed Vocational Nurse (LVN) confirmed that such assessments were necessary to prevent injuries from restraints. As a result of these deficiencies, Resident 1 experienced redness and swelling at the knuckles, along with mild pain, which was discovered on June 30, 2024. The facility's failure to adhere to its own policies regarding restraint management and monitoring led to this adverse outcome for the resident, highlighting a significant lapse in care and oversight.
Failure to Inform Family and Obtain Consent for Pressure Injury Treatment
Penalty
Summary
The facility failed to inform the family of a resident about the development of a stage 2 pressure injury in the sacral area. The resident, who had a history of stroke, ventilator-dependent respiratory failure, dysphagia, diabetes mellitus type II, and hypertension, was admitted to the facility without any pressure injuries as indicated in the Minimum Data Set (MDS) dated 12/22/2023. However, a wound photo dated 1/9/2024 showed a stage 2 sacral wound, and the Director of Nursing (DON) confirmed that the pressure injury was acquired at the facility. The DON acknowledged that this change in condition should have been communicated to the resident's family, but there was no documentation to support that the family was notified. Additionally, the facility did not explain the risks and benefits or obtain consent from the resident's family before performing a wound debridement procedure for the stage 2 pressure injury. The wound care specialist performed an excisional debridement through subcutaneous tissue, which is considered an invasive procedure. The DON confirmed that the wound care specialist needed to obtain informed consent from the resident's family prior to the procedure, but there was no documentation of such consent in the physician's progress notes. This failure to obtain informed consent was a violation of the resident's rights as per the facility's policy and procedure on Resident's Rights and Responsibilities.
Failure to Develop Comprehensive Care Plan for Pressure Injury
Penalty
Summary
The facility failed to ensure its nursing staff developed a comprehensive care plan to address a pressure injury for a resident. The resident, who was admitted with multiple diagnoses including stroke, ventilator-dependent respiratory failure, dysphagia, diabetes mellitus type II, and hypertension, developed a stage 2 pressure injury on the sacral area. Despite the presence of this injury, no care plan was developed when the injury was discovered, as confirmed by the Director of Nursing (DON) during an interview. The lack of a care plan led to inadequate intervention and care, resulting in the pressure injury worsening to a stage 3 injury within a few days. The facility's policy and procedure on wound care, which mandates that a care plan should be individualized and initiated within 12 hours of admission for patients at risk for or with existing open or pressure wounds, was not followed. The DON acknowledged that the absence of a care plan could delay care and exacerbate the wound. This deficiency was identified during a review of the resident's history and physical records, Minimum Data Set, and wound photo assessments, which documented the progression of the pressure injury from stage 2 to stage 3.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident and an LVN to the Department. The resident, who was admitted with chronic respiratory failure, anxiety disorder, blindness, and diabetes mellitus, reported to their daughter that the LVN punched them on the face during tracheostomy care. Despite the resident's daughter reporting this incident to the Interdisciplinary Team (IDT) and requesting a meeting with the Director of Nursing (DON), Administrator, and Social Worker (SW), the facility did not report the allegation to the proper authorities. The DON and Director of Therapy Services (DTS) justified their inaction by stating that the resident's daughter did not explicitly label the incident as abuse and insisted not to call the authorities. The facility's policy and procedure on abuse or neglect clearly state that all suspected cases should be reported to the proper authorities. However, the facility did not adhere to this policy. The DON acknowledged that abuse should be reported within 24 hours but did not report the incident because the resident's daughter did not explicitly state it was abuse. The DTS also confirmed that the incident should have been reported immediately, and the employee should have been suspended pending investigation. The failure to report the allegation of abuse was a clear violation of the facility's policies and procedures, potentially placing the resident and others at risk for further abuse.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of abuse was thoroughly investigated for a resident when the facility did not obtain a statement or interview from the resident or the CNA who reportedly witnessed the incident. The resident, who was admitted with chronic respiratory failure, tracheostomy, anxiety disorder, blindness, and diabetes mellitus, had complained to their daughter that a night LVN punched them on the face during tracheostomy care. The Interdisciplinary Team (IDT) attempted to explain to the resident's daughter that the resident might have misinterpreted the procedure due to anxiety. However, the facility did not follow through with a thorough investigation as required by their policy and procedure on abuse or neglect, which mandates obtaining statements from witnesses and involved parties. The Director of Nursing (DON) did not interview the resident about the incident, citing the presence of family members during the assessment as a reason. Additionally, the CNA who was present during the tracheostomy care was not interviewed as part of the internal investigation. The DON also did not report the allegation because the resident's daughter insisted it was not abuse, despite the serious nature of the complaint. This failure to conduct a thorough investigation and obtain necessary statements from all involved parties is a significant deficiency in the facility's handling of the abuse allegation.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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