Huntington Drive Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arcadia, California.
- Location
- 400 W. Huntinton Dr., Arcadia, California 91007
- CMS Provider Number
- 055376
- Inspections on file
- 83
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Huntington Drive Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to address repeated grievances from two cognitively intact residents regarding a roommate who refused to allow use of a shared restroom or permit CNAs to obtain water there for care of roommates. One resident reported being blocked from using the in-room restroom and call light and stated that complaints to the ADM and at resident council meetings were not resolved. Another resident reported that CNAs had to use her restroom to get water to bathe the controlling resident’s roommate and that leadership was aware through council meetings. Multiple CNAs and the SSD confirmed that previous roommates complained, were redirected to other residents’ restrooms, and often requested room changes, while the DON and an RN acknowledged that roommates had the right to use the shared restroom and that follow-up and closure to the grievances had not occurred, contrary to the facility’s resident rights policy.
A resident with COPD, a history of falls, and identified fall risk had three oxygen tanks stored in the restroom and two additional tanks just outside the restroom near the bed. Staff, including an LVN, RN, and the DON, acknowledged that multiple oxygen tanks in the room and restroom were a safety, trip, and fire hazard and that only one tank for active use should be in the room, with others stored in the designated oxygen storage area. Facility policies on fire safety and resident safety explicitly prohibited storing oxygen cylinders in resident rooms or living areas and required maintaining an environment free from accident hazards, but these policies were not followed in this case.
A resident with severe cognitive impairment, gait abnormalities, and need for assistance with bed mobility and transfers had physician-ordered bilateral 1/3 bed rails as an enabler for mobility and positioning. During observation, the resident was found in bed with both rails raised, and an LVN discovered the rails were stuck and could not be lowered. A Maintenance Assistant removed and reinstalled the rails but was still unable to lower one side and acknowledged that this type of bed’s rails were not working properly. A CNA stated the rails should function because staff use them during care, and the DON affirmed beds should be in good working order. These findings showed the bed rails were malfunctioning and not maintained per facility policies requiring equipment to be safe, operable, and repaired or replaced when worn or defective.
Two residents were not treated with dignity and did not have their preferences accommodated when one resident was left sitting in a wheelchair for an extended period after a room transfer because clothes and personal belongings were left piled on the bed, preventing use of the bed, and a functional TV remote was never provided. Staff interviews confirmed that CNAs were expected to put belongings away during room moves and that the remote available was incompatible with the resident’s TV. Another resident, who valued keeping up with the news, reported that key news channels on the TV were blurred or nonfunctional, which was confirmed by the maintenance assistant. The DON acknowledged that TV remotes and channels should work so residents can watch their preferred programs.
A resident with bilateral hip osteoarthritis and a right artificial knee joint, who had intact cognition and required assistance with ADLs, had a physician’s order for RNA ambulation services three times per week using a front-wheeled walker and gait belt. Review of RNA logs and documentation, along with staff interviews, showed that ordered RNA ambulation sessions were missed on multiple days and that the resident received fewer sessions than ordered. The resident reported that RNA staff did not come as scheduled, and the DSD confirmed that undocumented RNA services were not performed. The DON stated that RNA services are important to maintain mobility and acknowledged that the resident did not have an RNA care plan, despite facility policy requiring restorative goals and interventions to be outlined in the plan of care.
Two residents with respiratory conditions did not receive oxygen therapy as ordered, with one not wearing the nasal cannula and receiving an incorrect oxygen flow rate, and another experiencing low oxygen saturation levels without physician notification. Facility staff failed to follow physician orders and facility policy regarding oxygen administration and documentation.
The facility did not maintain a safe and sanitary environment by failing to address water leaks in a hallway and a resident's room. Water damage was observed, with water leaking into bins and towels used to absorb excess water. A resident with significant medical needs reported water leaking onto personal items, and staff confirmed the presence of water damage. Maintenance staff were unaware of the issue due to a lack of proper reporting and communication, and required maintenance logs and electronic reports were not completed.
A resident received a Foley catheter without documentation of the medical indication, time of insertion, or required monitoring of intake and output, contrary to facility policy. Nursing staff and the DON confirmed that the order lacked an indication and that documentation and care planning were incomplete at the time of catheter insertion.
A resident with a history of hemiplegia and hemiparesis experienced dizziness and vomiting, which was reported to nursing staff but not documented in the medical record. Licensed staff and the DON confirmed that such symptoms should have been recorded according to the care plan and facility policy, resulting in an incomplete and inaccurate medical record.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident prescribed Ambien for insomnia did not have their hours of sleep properly documented, as required by physician orders. Instead of recording the specific number of hours slept, staff only marked check boxes on the MAR, making it unclear whether the medication was effective. Interviews with the resident, an LVN, and the ADON confirmed that this monitoring was incomplete and did not meet facility policy for psychotropic medication management.
A resident with a history of cerebral infarction and dementia reported to the DSD that she hit her head on a grab bar in the bathroom. The DSD did not notify the physician, document an assessment, or initiate a Change of Condition, and there was no evidence of monitoring or treatment in the medical record, contrary to facility policy.
A resident with a history of falls, bilateral leg weakness, and total dependence for bed mobility, who was using a low air loss mattress, experienced a fall during incontinent care when only one CNA was present. The care plan did not specify the required staff assistance or interventions needed to prevent falls during such care, despite facility policy and staff knowledge that two staff should be present for residents on a LALM.
A resident with major depressive disorder and hemiplegia was discouraged from voicing grievances after a CNA told her that continued complaints would result in no one wanting to work with her. This statement violated the facility's policy on resident rights, which ensures grievances can be voiced without fear of discrimination or reprisal. The Director of Staff Development confirmed the CNA's actions were inappropriate and not in line with the facility's policy.
The facility failed to maintain a homelike environment, as 10 resident rooms were found with chipped and peeling paint, contrary to the facility's policy. Observations confirmed the presence of unpainted patched areas, and interviews with staff, including the Maintenance Supervisor and DON, acknowledged the need for repainting. The ADM was aware of the issue, which posed a risk for an unsafe and unclean environment.
The facility failed to follow proper food handling practices, resulting in several opened and expired food items being improperly labeled or not discarded. During a kitchen tour, the Dietary Supervisor identified items like seasoning salt, ground ginger, and pasta that lacked proper labeling, and expired items like browning sauce and food coloring were found in the kitchen. The facility's policy requires labeling with delivery or use-by dates and discarding expired items, which was not adhered to, potentially exposing residents to foodborne illnesses.
The facility failed to adhere to infection control protocols, including enhanced barrier precautions and standard precautions, for multiple residents. Staff did not change gloves or perform hand hygiene after providing care, handling soiled items, or before administering medications. A resident with a permacath lacked proper signage and PPE, and staff were unaware of necessary precautions. These lapses increased the risk of infection spread.
A resident with muscle weakness and spinal stenosis was observed with food particles on their clothing, which they found bothersome. The facility's policy on dignity was not followed, as staff failed to keep the resident's clothes clean, impacting their dignity and self-worth. The RN and DON acknowledged the issue, noting the importance of maintaining cleanliness to uphold residents' dignity.
A facility failed to obtain informed consent from a resident before administering Lorazepam, a psychoactive medication. The resident, who was cognitively independent but required physical assistance, was not informed of the risks and benefits of the medication. The facility's policy requires consent prior to administering such medications, which was not followed, as confirmed by staff and the resident.
A resident with severe cognitive impairment and physical limitations did not receive timely assistance for a diaper change, despite multiple requests. The CNA prioritized other tasks, delaying care and potentially risking the resident's well-being. Facility policies on accommodating resident needs and supporting ADLs were not followed.
A resident with mobility issues was using a wheelchair with torn tires, which posed a risk of falls and injury. The maintenance department was not informed about the damage, and the facility's policy on maintaining safe equipment was not followed.
A resident with respiratory failure and COPD did not receive continuous oxygen as ordered, as the nasal cannula was not replaced after restroom use. The resident had to request assistance to have the oxygen restored, which was confirmed by an LVN as a deviation from the physician's order, risking respiratory complications.
A facility failed to adhere to a physician's order for a fluid restriction of 1200 cc per day for a resident with end-stage renal disease on dialysis. Documentation showed discrepancies in fluid intake records, with missing entries and recorded intakes exceeding prescribed amounts. The resident was observed with a full pitcher of water, and staff interviews revealed a lack of adherence to the fluid restriction protocol. The facility's policy on end-stage renal disease care was not followed.
A facility failed to assess and obtain informed consent for the use of bedside rails for a resident with a history of cerebral infarction and falls. Despite physician orders for the rails as an enabler, no consent was documented, and only two assessments were conducted. The facility's policy requires alternatives, interdisciplinary evaluation, and informed consent before using bed rails, which was not followed, placing the resident at risk.
A facility failed to coordinate hospice care for a resident with severe cognitive impairment and multiple diagnoses, including cirrhosis and congestive heart failure. The CHHA did not follow the physician's order for twice-weekly visits, and no hospice care plan was developed. The DON and DPCS acknowledged these deficiencies, which could impact the resident's comfort and quality of life.
A facility failed to ensure a resident's call light was within reach, as observed when the call light was found on the floor while the resident was in bed. The resident, with a history of cerebral infarction and falls, required substantial assistance with daily activities. Staff interviews confirmed the expectation for call lights to be accessible, aligning with the facility's policy.
A resident with a femur fracture experienced a significant delay in receiving pain medication, despite having a pain management plan in place. The resident requested medication and waited nearly two hours in severe pain before it was administered. The LVN was informed of the request but delayed administration, contrary to facility protocol requiring timely medication delivery. The DON confirmed the importance of prompt pain management and communication with residents.
A facility failed to create a comprehensive care plan for a resident who refused care from certain CNAs. Despite the resident's known behavior and diagnoses of hemiplegia, paranoid schizophrenia, and bipolar disorder, no care plan addressed her refusal of care, potentially leading to inappropriate care. Staff interviews confirmed the absence of documentation for this behavior, highlighting a failure to meet the facility's policy for person-centered care plans.
A resident who underwent a left hip hemiarthroplasty did not receive an individualized care plan addressing specific post-surgery needs. The care plan lacked essential interventions such as hip precautions and monitoring for complications. Both the DON and MDS Nurse acknowledged these deficiencies, which were not in line with the facility's policy for developing comprehensive care plans.
A resident who underwent hip surgery was not properly monitored for signs of dislocation, such as uneven leg length, by the nursing staff. Despite occupational therapy noting a leg length discrepancy, no assessment was documented by the nurse practitioner, and no change of condition was completed. The resident's pain medication was ineffective, and the resident was later diagnosed with a hip dislocation at a hospital.
A resident with dementia was subjected to verbal abuse by their roommate, who also had cognitive impairments, in an LTC facility. The incident involved cursing in Spanish during a bathroom maneuver, witnessed by multiple staff members. Despite the facility's policy to protect residents from abuse, the verbal aggression was not promptly reported by all staff, highlighting a deficiency in safeguarding residents.
A resident with dementia verbally abused another resident in a LTC facility, but the incident was not reported to the State Survey Agency, ombudsman, or law enforcement within the required 2-hour timeframe. Despite staff witnessing the abuse and recognizing it as such, the facility failed to adhere to its policy on immediate reporting of abuse incidents.
A resident's call light was not within reach, as it was found tucked behind the side rail of the bed, contrary to the care plan and facility policy. The resident, with multiple fractures and intellectual disabilities, was unable to call for assistance, posing a risk of harm. Staff interviews confirmed the deficiency, highlighting the importance of call light accessibility.
A resident with hepatic encephalopathy and type 2 diabetes reported verbal abuse by two CNAs, which was not reported to external authorities as required by the facility's policy. Interviews revealed that the Administrator and Director of Nursing were unaware of the incident, and the facility failed to follow its protocol for immediate reporting and investigation, putting the resident at risk for further abuse.
A resident with angina pectoris experienced chest pain, but the attending physician was not notified immediately, contrary to facility policy. The resident reported the pain to staff in the morning, but the physician was only informed hours later, delaying necessary care. Staff interviews confirmed the delay, and the DON acknowledged the failure to follow protocol.
A facility failed to promptly conduct a STAT EKG for a resident with chest pain, resulting in a delay of several hours. The EKG, showing a Sinus Rhythm with first-degree atrioventricular block, was not communicated to the attending physician as required by policy. Staff interviews confirmed the lack of notification and documentation, highlighting a breach in protocol for timely diagnosis and treatment.
A resident with a history of aggression hit another resident, who was moderately impaired, in the face. Despite the aggressive resident's known history, the facility failed to provide adequate supervision, leading to the incident. Observations showed a lack of staff presence in the area, and no new interventions were implemented to prevent further abuse.
A facility failed to report an alleged physical abuse incident within the required two-hour timeframe. A resident with depressive disorder and epilepsy was hit by another resident, as witnessed by a CNA. The DON attempted to report the incident but did not confirm successful transmission to the SSA, resulting in a delay. The facility's policy mandates immediate reporting within two hours, which was not adhered to.
Failure to Address Grievances and Ensure Equal Access to Shared Restroom
Penalty
Summary
The deficiency involves the facility’s failure to address resident grievances and ensure equal access to a shared restroom and related services for roommates of a cognitively intact resident. One resident with major depressive disorder and anxiety, who required varying levels of assistance with ADLs but had intact decision-making skills, reported that when previously sharing a room with another resident, she was not allowed by that roommate to use the in-room restroom or the call light. She stated she had reported these concerns to the Administrator and raised them multiple times in resident council meetings but did not feel her concerns were heard, and she believed the facility avoided assigning a roommate to the controlling resident because that resident would “raise a fuss.” Another resident with major depressive disorder and COPD, also cognitively intact and requiring assistance with ADLs, reported that the same controlling resident would not allow any roommates to use the shared restroom or allow CNAs to obtain water from that restroom to provide care to the roommates. This resident stated that CNAs instead used the restroom in her room to get water to bathe the controlling resident’s previous roommate, and that the Activity Director was aware of these concerns from resident council meetings but nothing had been done. Staff interviews corroborated that CNAs had to obtain water from other residents’ restrooms because the controlling resident would not permit use of the shared restroom, and that roommates who were able to walk were told by the controlling resident to use other residents’ restrooms rather than the shared one in their own room. The Social Services Director stated that previous roommates who could use the restroom had complained about not being allowed to use the shared restroom and often requested room changes, and acknowledged it was not acceptable for them to have to use another resident’s restroom because they had the same rights to use the shared restroom. The DON acknowledged hearing about the shared bathroom complaints during a recent resident council meeting but had not yet spoken to the controlling resident, and stated there should have been follow-up and closure provided to the residents who raised concerns. The DON and an RN both affirmed that roommates had the right to use the shared restroom and that CNAs should be able to use it to obtain water for care. The facility’s Resident Rights policy stated that residents have the right to communication with and access to services and to voice grievances and have the facility respond, but the reported and observed handling of these complaints showed that the concerns of the affected residents were not addressed or resolved.
Improper Storage of Multiple Oxygen Tanks in Resident Room and Restroom
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s environment free from accident hazards by improperly storing multiple oxygen tanks in and near the resident’s restroom and room. The resident, who had COPD, a history of falls, and was assessed as at risk for falls, was cognitively intact and required setup assistance for toileting hygiene, showering, lower body dressing, and footwear, but was otherwise independent with eating, oral and personal hygiene, and upper body dressing. During observation, surveyors noted three oxygen tanks inside the resident’s restroom and two oxygen tanks just outside the restroom near the wall on the left side of the room. Staff present acknowledged that the resident had many oxygen tanks in the room and restroom. In interviews, an LVN stated that the three oxygen tanks in the restroom and two by the foot of the bed should be removed because they could be a safety hazard for the resident. An RN stated that oxygen tanks not in use should be stored in the oxygen storage room, not in a resident’s room, and that only one oxygen tank for the resident’s use should be in the room, further stating that five oxygen tanks in the room should not be allowed because they are a safety and trip hazard. The DON stated that the five oxygen tanks stored in the resident’s room were a big hazard because the resident could trip, fall, and might hit her head on the oxygen tank, and also described them as a fire hazard that should be stored in the oxygen storage room. Review of facility policies showed that the Fire Safety and Prevention policy prohibited storing oxygen cylinders in any resident’s room or living areas, and the Safety and Supervision of Resident policy stated the facility strives to make the environment as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility-wide priorities.
Malfunctioning Bed Rails Not Maintained in Safe Working Order
Penalty
Summary
The facility failed to ensure that a resident’s bed rails were safe, functional, and in good working condition in accordance with its policies. The resident had diagnoses including lack of coordination and abnormalities of gait and mobility, and an MDS assessment documented severe cognitive impairment and a need for partial/moderate assistance with bed mobility, transfers, and sit-to-stand activities. A physician’s order authorized bilateral 1/3 bed rails as an enabler to aid in mobility, positioning, and transfer. During observation, the resident was found lying in bed asleep with both 1/3 bilateral bed rails in the raised position. When checked by a Licensed Vocational Nurse, both bed rails were found to be stuck and could not be lowered, contrary to the expectation that they should lower easily to allow the resident to get in and out of bed safely. A Maintenance Assistant subsequently examined the bed rails, removed and reinstalled them, and was still unable to lower the left bed rail. The Maintenance Assistant stated that the bed rails on this type of bed were not working properly, despite being reinstalled in the correct holes. A CNA reported that bed rails should be working properly because staff raise and lower them when changing and positioning residents. The DON stated that residents’ beds should be in good working order for residents’ safety and ease of use. Review of the facility’s Maintenance Service policy indicated that the maintenance department is responsible for maintaining equipment in a safe and operable manner at all times, and the Bed Safety and Bed Rails policy required that any worn or malfunctioning bed system components be repaired or replaced using components that meet manufacturer specifications. These observations and statements showed that the resident’s bed rails were malfunctioning and not maintained in accordance with facility policy.
Failure to Maintain Dignity and Accommodate Residents’ TV and Room-Transfer Needs
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity, self-determination, and accommodation of needs related to room transfer and television access. One resident with bilateral primary osteoarthritis of the hip and a right artificial knee joint, who had intact cognition and required varying levels of assistance with ADLs, was transferred from one room to another. During the move, the maintenance assistant placed all of the resident’s clothes and personal belongings from the prior room onto the bed in the new room and moved the resident around 1 PM. Staff, including CNAs and LVNs, acknowledged that CNAs were responsible for putting residents’ belongings away in closets or drawers during a room move so the resident could access the bed. However, the belongings were left on the bed, and the resident reported having to sit in a wheelchair for approximately 2½ hours, unable to lie down. The resident’s caregiver corroborated that, upon arrival, the resident was in the wheelchair with clothes and personal items still on the bed, and that the resident appeared upset and reported having been left waiting. The same resident also reported that he did not read and preferred to watch TV, but the facility never provided a functional TV remote control after the room transfer. The maintenance assistant stated that the remote control available was a universal controller that was not compatible with the resident’s specific TV brand and that the facility did not have a suitable remote for that TV. The DON stated that the TV remote control should be functional so residents can watch the programs they want. As a result, the resident’s stated preference to keep up with the news, documented as somewhat important on the MDS, was not accommodated because he lacked a working remote to operate the TV in his room. A second resident, with generalized muscle weakness and difficulty walking, also had intact cognition and required extensive assistance with ADLs. This resident’s MDS documented that keeping up with the news was very important. During observation and interview, the resident demonstrated that not all TV channels worked, specifically turning to a news channel and another channel that displayed blurred or unclear screens compared to other channels, and stated that it was bothersome not to be able to watch those news stations. The maintenance assistant confirmed that CNN and Channel 5 on this resident’s TV did not work and reported having informed the administrator and attempting to get management to change the cable service/company. The DON stated that all channels should work so residents can watch the programs they want. These conditions showed that the facility did not ensure residents had functional television access consistent with their expressed preferences for news programming.
Failure to Provide Ordered Restorative Nursing Ambulation Services
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing assistant (RNA) services as ordered for a resident with limited range of motion and mobility needs. The resident was admitted with bilateral primary osteoarthritis of the hip and a right artificial knee joint, and an MDS dated 9/11/2025 showed the resident had intact cognition and required varying levels of assistance with ADLs, including substantial/maximal assistance for showering and partial/moderate assistance for lower body dressing and footwear. A physician’s order dated 12/15/2025 directed that the resident receive RNA ambulation services daily, three times per week, for 60 feet with a front-wheeled walker and gait belt as tolerated. Review of RNA documentation for December 2025 and January 2026, along with interviews with RNA staff and the Director of Staff Development (DSD), showed that RNA services were not provided or documented on 12/22/2025, 12/26/2025, and 1/2/2026. During observation and interview, the resident reported that RNA sessions were supposed to occur three times per week but that staff did not come as scheduled. The RNA log and documentation reviewed with the DSD confirmed that the resident received only one RNA session during the week of 12/22/2025–12/28/2025 and two sessions during the week of 12/29/2025–1/4/2026, instead of the ordered frequency. The DSD stated that if RNA services were not documented, they were not done, and acknowledged that RNA services should be consistently provided as scheduled to maintain functional mobility and prevent decline. The DON stated that RNA services are important to help maintain residents’ mobility and that inconsistent provision could potentially cause a decline, and further stated that the resident did not have a care plan for RNA services, which should have been in place to guide staff. Review of the facility’s Restorative Nursing Services policy indicated that restorative goals and objectives are individualized, resident-centered, and outlined in the resident’s plan of care, which was not done in this case.
Failure to Provide Respiratory Care Services per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide respiratory care services in accordance with its policy and physician orders for two residents. One resident, with diagnoses including acute and chronic respiratory failure, asthma, and dementia, had a physician order for continuous oxygen at 3 liters per minute (lpm) via nasal cannula. On multiple observations, the resident was found not wearing the nasal cannula, with the oxygen tubing resting on the chest, and the oxygen concentrator set at 2.5 lpm instead of the ordered 3 lpm. Both the DON and an LVN confirmed the incorrect oxygen setting and acknowledged that the resident was not receiving oxygen as ordered. Another resident, diagnosed with COPD, anemia, and dementia, had a physician order for continuous oxygen at 2 lpm via nasal cannula and instructions to notify the physician if oxygen saturation fell below 92%. The resident's oxygen saturation was documented as 91% on three separate occasions, but there was no evidence in the medical record or SBAR documentation that the physician was notified as required. The DON confirmed the lack of documentation and stated that the licensed staff did not call the physician regarding the low oxygen saturation levels. Facility policy on oxygen administration required staff to review physician orders, observe residents to ensure oxygen is being tolerated, and document the rate, route, and assessment data in the medical record. The policy also required reporting relevant information in accordance with professional standards. These requirements were not met for either resident, as evidenced by the lack of proper oxygen administration and failure to notify the physician of low oxygen saturation.
Failure to Maintain Safe and Sanitary Environment Due to Unaddressed Water Leaks
Penalty
Summary
The facility failed to maintain the physical environment in a safe and sanitary condition by not preventing or promptly addressing water leaks in the ceiling of a hallway and a resident's room. Observations revealed a large hole with visible water damage in the ceiling of the hallway in front of the oxygen room, with water leaking into a bin and towels placed on the floor to absorb excess water. Staff interviews confirmed that the water leakage began during a period of rain, and maintenance staff were either unavailable or only began repairs after the issue had persisted for several days. The facility's policy required maintenance to be provided to all areas and for the environment to be kept in good repair, but these standards were not met during the incident. In a resident's room, grayish discoloration and watermarks were observed on the ceiling and wall, and the resident reported that water had leaked from the ceiling the previous night, soaking personal items. The resident, who had significant medical needs including congestive heart failure, chronic respiratory failure with hypoxia, and generalized muscle weakness, was at risk of being directly affected by the leak. Staff confirmed the presence of water damage and acknowledged that the resident could get wet and might not be able to sleep due to the leak. The maintenance assistant was unaware of the issue until it was pointed out during the survey, and there was no documentation of the leak in the maintenance log or the facility's electronic reporting system. Further review of facility policies indicated that maintenance requests should be logged and prioritized, with work orders picked up daily from the nurses' station. However, staff interviews and record reviews revealed that the required reporting and communication procedures were not followed, as no maintenance requests were filed for the leaks, and the maintenance assistant did not check the log as required. The lack of timely reporting and response contributed to the ongoing unsafe and unsanitary conditions in both the hallway and the resident's room.
Failure to Document Indication and Monitoring for Foley Catheter Insertion
Penalty
Summary
Staff failed to follow facility policy and procedures regarding the insertion and documentation of an indwelling (Foley) catheter for one resident. The resident was admitted with diagnoses including hypertension, osteoarthritis, and lack of coordination, and was assessed as having modified independence in cognitive skills and occasional urinary incontinence. The physician's order allowed for an in-and-out catheterization, with a Foley catheter to remain in place if residual urine exceeded 300 milliliters, but the order did not specify the indication for catheter use as required by facility policy. Upon review, there was no documentation of the indication for the Foley catheter, the time of insertion, or monitoring of intake and output in the resident's progress notes. Additionally, there was no documentation regarding the urine output, color, clarity, or the resident's tolerance of the procedure. The care plan for the Foley catheter was not developed at the time of insertion, and the required monitoring and documentation were not completed according to policy. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy and procedures were not followed. The staff acknowledged that the order lacked an indication and that documentation was incomplete. The Director of Nursing also confirmed that the comprehensive, person-centered care plan was not developed or implemented at the time of catheter insertion, as required by facility policy.
Failure to Document Change in Resident Condition
Penalty
Summary
The facility failed to document an episode of dizziness and vomiting experienced by a resident with a history of hemiplegia, hemiparesis, and left hand contracture following a cerebral infarction. The resident reported feeling dizzy and vomiting a few days prior, and stated that she informed a registered nurse about these symptoms. However, a review of the resident's nurses' progress notes revealed no documentation of these events on the relevant date. Licensed staff confirmed that such symptoms should have been recorded in the medical record to allow for appropriate follow-up and monitoring. Further review of the resident's care plan indicated that any chief complaint of dizziness should be documented, and the facility's policy on charting and documentation required that all changes in a resident's condition be objectively, completely, and accurately recorded in the medical record. The Director of Nursing confirmed that documentation of episodes and frequency of dizziness was necessary according to the care plan. The lack of documentation resulted in an inaccurate representation of the care provided to the resident.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Monitor Effectiveness of Psychotropic Medication
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident was free from unnecessary drugs by not properly monitoring the effectiveness of Ambien, a psychotropic medication prescribed for insomnia. The resident, who had diagnoses including insomnia and anxiety disorder, was admitted with cognitive skills intact and required varying levels of assistance with daily activities. Physician orders specified that the resident’s hours of sleep should be monitored every evening and night shift, particularly when Ambien was administered as needed for insomnia. Record reviews revealed that the Medication Administration Record (MAR) only included check marks for monitoring sleep, rather than documenting the specific number of hours slept as required by the physician’s order. Interviews with the resident, a Licensed Vocational Nurse, and the Assistant Director of Nursing confirmed that the MAR did not accurately reflect the number of hours of sleep, and staff acknowledged that this information was necessary to determine the medication’s effectiveness. The facility’s policy also required adequate monitoring for efficacy and adverse consequences of psychotropic medications, which was not followed in this case.
Failure to Document, Notify Physician, and Monitor Change of Condition After Resident Head Injury
Penalty
Summary
The facility failed to document an assessment, notify the attending physician, initiate a Change of Condition (CoC), and monitor the CoC for a resident who reported hitting her head in the bathroom. The resident, who had a history of cerebral infarction and dementia but was assessed as having intact cognition, informed the Director of Staff Development (DSD) that she had hit her head on a grab bar. Despite this report, there was no documentation in the resident's progress notes regarding the incident, assessment, or any subsequent monitoring or treatment. Interviews with the DSD and Director of Nursing (DON) confirmed that the DSD did not notify the resident's physician, document an assessment, or initiate a CoC as required by facility policy. The facility's policy mandates prompt notification of the physician and documentation of any changes in a resident's condition, including accidents or incidents. The DON acknowledged that the required steps were not taken, and the incident was not properly managed or recorded in the resident's medical record.
Failure to Develop Comprehensive Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, resident-centered care plan to prevent falls for a resident with significant risk factors. The resident had a history of falls, bilateral leg weakness, and was dependent on staff for bed mobility and incontinent care. The resident was also using a low air loss mattress (LALM), which increases the risk of falls due to its shifting surface. Despite these factors, the care plan did not specify the type or number of staff assistance required during incontinent care, nor did it include interventions tailored to the resident's needs while on the LALM. On the day of the incident, a CNA was providing incontinent care to the resident and prompted the resident to turn. The resident subsequently slid off the bed and fell to the floor, sustaining complaints of pain but no visible bruising or discoloration. The CNA was unaware of the recommendation that two staff members should be present during incontinent care for residents on a LALM. Interviews with other staff, including another CNA, the RN, the DON, and the MDS nurse, confirmed that the care plan lacked specific instructions regarding the required assistance and interventions to prevent falls during such care. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the care plan for this resident did not address the specific risks associated with the resident's condition and equipment, nor did it communicate the necessary precautions to staff. This omission directly contributed to the resident's fall during routine care.
Resident's Right to Voice Grievances Violated
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as required by their policy, by not allowing the resident to voice grievances without fear of discrimination or reprisal. The resident, who was diagnosed with major depressive disorder, hemiplegia, and hemiparesis, was independent in cognitive skills for daily decision-making but required substantial assistance with personal care. During an interview, the resident reported that a Certified Nursing Assistant (CNA) told her that if she continued to complain about the facility's CNAs, no one would want to work with her. This statement made the resident feel retaliated against and discouraged her from voicing future grievances. The Director of Staff Development (DSD) confirmed that the CNA admitted to making the statement, which was deemed disrespectful and contrary to the facility's policy. The facility's policy, titled 'Resident Rights,' clearly states that residents have the right to voice grievances without fear of discrimination or reprisal and that employees must treat all residents with kindness, respect, and dignity. The DSD acknowledged that the CNA's actions were inappropriate and not in line with the facility's policy, which could potentially prevent the resident from expressing any future concerns.
Facility Fails to Maintain Homelike Environment Due to Chipped and Peeling Paint
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the presence of chipped and peeling paint in 10 out of 43 resident rooms. Observations revealed that several rooms, including Rooms A, B, C, D, E, F, G, H, I, and J, had areas of chipped or peeling paint, as well as unpainted patched areas. These conditions were noted during various observations conducted by surveyors and confirmed by the Maintenance Supervisor, Director of Nursing, and Administrator. The facility's policy on maintaining a homelike environment, revised in February 2021, emphasizes the importance of providing a comfortable setting for residents, which was not adhered to in this instance. Interviews with facility staff, including the Maintenance Supervisor and Director of Nursing, confirmed the need for repainting to ensure a homelike environment. The Administrator acknowledged the issue, stating awareness of the need for repairs. The facility's maintenance policy, revised in December 2009, outlines the responsibility of maintenance personnel to keep the building in good repair, which was not fulfilled in this case. The deficient practice had the potential to create an unsafe and unclean environment, posing a risk for physical discomfort to the residents.
Improper Food Handling and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as per its policy and procedure, which resulted in several opened and expired food items being improperly labeled or not discarded. During an initial kitchen tour, the Dietary Supervisor (DS) identified several opened items, such as bottles of seasoning salt, ground ginger, pure vegetable oil, and plastic bags of pasta, that were not labeled with a proper open date and used by date. Additionally, expired items like browning and seasoning sauce and food coloring were found in the kitchen, which should have been discarded according to the facility's policy. The DS admitted to not knowing why the food items were not labeled correctly or why expired items were still stored in the kitchen. The facility's policy, as reviewed, indicated that no food should be kept beyond its expiration date and that all items should be labeled with either a delivery date or a use-by date. The failure to follow these procedures has the potential to expose residents to pathogens, increasing the risk of foodborne illnesses.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to ensure staff adhered to enhanced barrier precautions and standard precautions, leading to potential infection risks among residents. For Resident 6, staff members were observed not changing gloves and not performing hand hygiene after providing peri-care, which involved touching the resident and her wheelchair with the same gloves. This was acknowledged by the staff, who admitted the oversight could spread infection. Similarly, for Resident 88, a staff member failed to doff gloves and perform hand hygiene after emptying a urinal, subsequently touching the resident's personal belongings, which was also recognized as a lapse in infection control. Resident 28, who had a permacath for dialysis, did not have enhanced barrier precaution signage or personal protective equipment available outside the room. A Licensed Vocational Nurse (LVN) was observed taking the resident's blood pressure and heart rate without wearing gloves or a gown and did not perform hand hygiene before preparing and administering medications. The LVN admitted to not being aware of the necessary precautions for residents with central lines, and the Infection Preventionist Nurse confirmed the oversight in not including the resident on the enhanced barrier precautions list. For Resident 18, an LVN failed to perform hand hygiene before and after checking the resident's heart rate and before preparing medications. This was acknowledged by the LVN and the Director of Nursing, who emphasized the importance of hand hygiene in preventing the spread of microorganisms. Additionally, laundry staff were observed handling clean and soiled linens without performing hand hygiene, contrary to the facility's policy. These practices collectively posed a risk of spreading infections among residents and staff.
Resident Dignity Compromised by Unclean Clothing
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 49, was treated with respect and dignity by not keeping the resident's clothes clean and free of food particles. Resident 49, who was admitted with diagnoses of muscle weakness and spinal stenosis, was observed with yellow food particles on their clothing. The resident expressed discomfort with the food particles, indicating that it bothered them. The Minimum Data Set (MDS) assessment indicated that Resident 49 required assistance with eating and dressing, highlighting the need for staff support in maintaining the resident's dignity. During observations and interviews, it was noted that the resident's clothes had food particles, specifically eggs, which were acknowledged by a Registered Nurse (RN) and the Director of Nursing (DON) as inappropriate and not in line with the facility's policy on dignity. The facility's policy emphasized the importance of providing a dignified dining experience and maintaining residents' cleanliness to promote their well-being and self-esteem. The failure to adhere to this policy resulted in a deficiency related to the resident's dignity and self-worth.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 88, was informed in advance of the risks and benefits of a proposed care plan involving the use of psychoactive medication. Specifically, the facility did not obtain informed consent prior to administering Lorazepam, an antianxiety medication, to Resident 88. The resident was admitted with multiple diagnoses, including an unspecified fracture of the left fibula, dislocation of the left ankle joint, gout, and unsteadiness on feet. The Minimum Data Set (MDS) indicated that the resident was independent in cognitive skills for daily decision-making but required substantial assistance with certain physical activities. Despite this, the resident was administered Lorazepam without prior consent, as confirmed by both the MDS Coordinator and the resident himself. The deficiency was further highlighted during interviews and record reviews, where it was revealed that the facility's policy and procedure required obtaining consent from the resident or responsible party before placing an order for psychoactive medication. The Director of Nursing acknowledged that the facility should have obtained consent prior to administering the medication. The facility's policy on Resident Rights, revised in February 2021, mandates that residents be informed of and participate in their care planning and treatment, which was not adhered to in this case.
Failure to Prioritize Resident's ADL Needs
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 77, received the necessary care and services to maintain good personal hygiene, specifically in relation to activities of daily living (ADL). Resident 77, who was admitted with diagnoses including generalized muscle weakness, difficulty walking, and neuromuscular dysfunction of the bladder, was observed to have severely impaired cognitive skills and was dependent on assistance for personal hygiene and toileting. On the day of the incident, Resident 77 activated the call light multiple times requesting a diaper change, but the Certified Nursing Assistant (CNA 3) prioritized other tasks over attending to the resident's immediate needs. Despite the resident's repeated requests for assistance, CNA 3 delayed attending to Resident 77, opting instead to assist another resident and change bed sheets in a different room. This delay was noted by other staff members, including the Central Supply Director and the Infection Prevention Nurse, who were involved in trying to locate CNA 3 to address Resident 77's needs. The Director of Nursing later confirmed that staff should prioritize resident care and attend to their needs within five minutes. The facility's policies on accommodating resident needs and supporting ADLs were not adhered to, resulting in a deficiency related to unmet resident needs and potential risks to the resident's well-being.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 88, was free from accident hazards by not providing a wheelchair with properly functioning tires. Resident 88, who was admitted with a fracture of the left fibula, dislocation of the left ankle joint, gout, and unsteadiness on feet, was observed using a wheelchair with torn tires. The resident reported that the wheelchair brakes did not work well, and observations confirmed difficulty in stopping the wheelchair, posing a risk of falls and injury. Interviews with the Maintenance Supervisor and the Director of Nursing revealed that the maintenance department was not informed about the damaged wheelchair tires, which were acknowledged as unsafe for use. The facility's policy indicated that the maintenance department is responsible for ensuring equipment is safe and operable, but this was not adhered to in this instance, leading to the deficiency.
Failure to Administer Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for Resident 294 by not administering oxygen according to the physician's orders. Resident 294, who was admitted with acute and chronic respiratory failure, COPD, and CHF, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, during an observation, it was noted that the resident's nasal cannula was not in place after being assisted to the restroom by a Certified Nurse Assistant (CNA 6). The nasal cannula was found on the pillow, out of the resident's reach, and the resident had to request assistance to have it replaced. The Licensed Vocational Nurse (LVN 3) confirmed that the oxygen order was for continuous use and emphasized the importance of adhering to the physician's order to prevent complications such as shortness of breath. The facility's policy on oxygen administration requires verification and adherence to physician's orders, which was not followed in this instance. This oversight placed Resident 294 at risk for respiratory distress and other complications due to the interruption in oxygen therapy.
Failure to Implement Fluid Restriction for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to implement the physician's order for a fluid restriction of 1200 cc per day for a resident with end-stage renal disease dependent on dialysis. The care plan specified a breakdown of fluid intake between dietary and nursing, but documentation showed discrepancies in fluid intake records. There were missing entries for breakfast fluids on multiple days, and recorded fluid intakes exceeded the prescribed amounts on several occasions. Additionally, the resident was observed with a full pitcher of water at the bedside, contrary to the fluid restriction order. Interviews with the resident and staff revealed a lack of adherence to the fluid restriction protocol. The resident was aware of the fluid restriction but reported receiving pitchers of water daily, which were refilled by staff. A Licensed Vocational Nurse confirmed the risk of shortness of breath from excess fluid and acknowledged the error in providing a full pitcher of water. A Certified Nursing Assistant admitted to not knowing the exact fluid restriction amount and emphasized the importance of accurate documentation of fluid intake. The facility's policy on end-stage renal disease care was not followed, as the comprehensive care plan did not reflect the resident's needs related to dialysis care.
Failure to Assess and Obtain Consent for Bedside Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of bedside rails for one resident, identified as Resident 15. The resident, who had a history of cerebral infarction, major depressive disorder, and falls, was observed with both middle sections of the bedside rails up. Despite the presence of physician orders for the use of bedside rails as an enabler for mobility, positioning, and transfer, there was no documented consent from the resident or their family. The MDS nurse confirmed the absence of consent and stated that the family should have been informed of the risks and benefits before the use of the rails. The Director of Nursing confirmed that only two Bedside Rail Utilization Assessments were conducted, and no consent was obtained prior to the use of the rails. The facility's policy, revised in August 2022, prohibits the use of bed rails unless specific criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The failure to adhere to these protocols placed the resident at risk for potential accidents, such as entrapment or falls, due to improper use of the bedside rails.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and hospice staff for a resident, identified as Resident 76, who was receiving hospice services. The deficiency involved the failure of the Certified Home Health Agency (CHHA) staff to adhere to the physician's order to visit and provide care to the resident twice per week. The review of records indicated that the CHHA only visited once a week during two specific weeks, which was not in compliance with the physician's order. Additionally, there was no hospice care plan developed for Resident 76, which is essential for guiding hospice staff in providing appropriate care. Resident 76 was admitted to the facility with diagnoses including cirrhosis of the liver, congestive heart failure, and alcohol dependence. The resident was severely impaired in cognitive skills and required substantial assistance with daily activities. The facility's Director of Nursing acknowledged the discrepancy in the frequency of CHHA visits and the absence of a hospice care plan in the resident's hospice binder. The Director of Patient Care Service confirmed the missed visits and emphasized the importance of following the physician's order to ensure the resident received the necessary hospice care and services to promote comfort and quality of life.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, specifically Resident 15. This deficiency was identified during an observation where the call light was found on the floor, out of the resident's reach, while the resident was sleeping in bed. The facility's policy requires that call lights be within reach to allow residents to call for assistance, especially during emergencies. Interviews with staff, including a CNA, an RN, and the Director of Nursing, confirmed that call lights should be accessible to residents. Resident 15 had a history of cerebral infarction, major depressive disorder, and a history of falling, which necessitated the need for the call light to be within reach as part of their care plan. The resident's Minimum Data Set indicated they required substantial assistance with various activities of daily living, including toileting and personal hygiene, and supervision with oral hygiene. The failure to have the call light within reach could have impeded the resident's ability to call for help when needed, as outlined in the facility's policy.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who verbalized experiencing significant pain. The resident, who was admitted with a displaced subtrochanteric fracture of the left femur, difficulty in walking, and anxiety disorder, was on a pain management regimen that included opioid medications. Despite having orders for pain medications such as oxycodone and tramadol, the resident experienced a delay in receiving pain relief after requesting medication. On the day of the incident, the resident requested pain medication and had to wait almost two hours before receiving it, during which time the resident was in severe pain, rated 7 out of 10 on the pain scale. The Licensed Vocational Nurse (LVN) was informed of the request but did not administer the medication promptly, citing the resident's engagement with a surveyor as a reason for the delay. The facility's protocol required that pain medications be administered as soon as possible when requested, but this was not adhered to in this instance. Interviews with the Director of Nursing (DON) and review of the facility's policies confirmed that the facility's protocol was to administer pain medication promptly and to communicate with residents about any delays. The failure to follow these protocols resulted in the resident experiencing unnecessary pain and distress. The facility's policies emphasized the importance of timely pain management and communication with residents to prevent anxiety and discomfort while waiting for medication.
Failure to Develop Resident-Centered Care Plan for Refusal of Care
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident who exhibited behavior of refusing care from certain Certified Nursing Assistants (CNAs). This deficiency was identified during a review of the resident's care plan history, which revealed that no care plan was created to address the resident's refusal of care from CNAs she did not like. Interviews with facility staff, including a CNA and a Licensed Vocational Nurse (LVN), confirmed that the resident was known to refuse care from specific CNAs, and that this behavior was not documented in a care plan. The absence of a care plan for this behavior could lead to staff being unaware of the resident's preferences, resulting in inappropriate care. The resident in question was admitted with diagnoses including hemiplegia, paranoid schizophrenia, and bipolar disorder. Despite being assessed with intact cognition, the resident was dependent on assistance for various activities of daily living. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, including measurable objectives and timetables to meet their needs. However, the lack of a care plan addressing the resident's refusal of care from certain CNAs indicates a failure to adhere to this policy, potentially compromising the continuity and appropriateness of care provided to the resident.
Failure to Implement Individualized Care Plan for Post-Surgery Resident
Penalty
Summary
The facility failed to develop and implement an individualized resident-centered care plan for a resident who underwent a left hip hemiarthroplasty due to a left hip fracture. The resident was admitted with diagnoses including left hip hemiarthroplasty, left hip fracture, and hypertension. The Minimum Data Set (MDS) assessment indicated the resident was moderately impaired in cognitive skills for daily decision-making and required assistance with various activities of daily living. However, the care plan initiated did not include specific interventions related to the resident's hip surgery, such as hip precautions and monitoring for potential complications. During interviews, both the Director of Nursing (DON) and the MDS Nurse acknowledged the care plan's deficiencies. The DON noted the absence of specific aftercare interventions for the hip surgery, such as instructions to avoid bending and flexing the hip and monitoring leg length for potential dislocation. The MDS Nurse confirmed the care plan was incomplete, lacking necessary interventions like hip precautions and monitoring for unrelieved pain or symptoms of pulmonary embolism. The facility's policy requires a comprehensive, person-centered care plan to be developed within a specific timeframe, but this was not adequately followed for the resident in question.
Failure to Monitor Post-Surgical Resident Leads to Hip Dislocation
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident who had undergone a left hip hemiarthroplasty due to a left hip fracture. The licensed nursing staff did not monitor the resident for signs of hip dislocation, such as uneven leg or hip length. There was no documented evidence that the resident's bilateral hips and legs were assessed during a nurse practitioner's visit, and a change of condition was not completed when the resident was assessed as having asymmetrical hips and legs. The resident was admitted to the facility with diagnoses including a left hip hemiarthroplasty and hypertension. Occupational therapy notes indicated a length discrepancy in the resident's left leg, and nursing was informed. However, the nurse practitioner did not document any assessment of the resident's bilateral lower extremities, and no new doctor's orders were placed. The resident's pain medication was noted as ineffective, and the resident eventually went to a hospital where a left prosthetic hip dislocation was diagnosed. Interviews with facility staff, including the director of nursing, revealed that there was no specific policy for post-hip surgery care, and the licensed nurses were only monitoring for pain, swelling, and discoloration. The staff failed to assess and monitor the symmetry of the resident's legs and hips, which could indicate a hip dislocation. The facility's policy and procedure for surgery-related management did not specifically address monitoring for leg length discrepancies, and the change in the resident's condition was not documented or communicated effectively to the physician.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, a form of mental abuse, as per their policy and procedure. The incident involved two residents, where one resident, diagnosed with dementia and severely impaired cognitive skills, was subjected to verbal aggression by their roommate. The roommate, also diagnosed with Alzheimer's disease and dementia, was heard cursing in Spanish while attempting to maneuver to the bathroom, which was obstructed by the other resident's bedside table. This altercation was documented in the facility's records, indicating that the Director of Nursing was notified of the verbal aggression. Multiple staff members, including the Medical Records Assistant, Certified Nursing Assistant, Laundry Personnel, and Maintenance Supervisor, confirmed witnessing or hearing about the verbal abuse incident. The Laundry Personnel reported hearing the abusive language daily but did not report it due to fear of getting in trouble. The Maintenance Supervisor emphasized the importance of reporting such incidents, aligning with the facility's policy that mandates reporting and investigating all possible incidents of abuse. The facility's policy, titled 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program,' revised in April 2021, clearly states the residents' right to be free from abuse and the necessity to protect them from abuse by anyone, including other residents. Despite this policy, the facility failed to prevent the verbal abuse incident, as evidenced by the repeated occurrences and lack of timely reporting by some staff members. The Director of Nursing acknowledged the verbal aggression and the need for reporting to ensure resident safety.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an allegation of verbal abuse within the required 2-hour timeframe to the State Survey Agency, the state ombudsman, and local law enforcement. This deficiency involved a resident-to-resident altercation where one resident verbally abused another. The incident was documented in a Post-Event Review form, which indicated that the Director of Nursing was notified of the verbal aggression. However, the required reporting to the appropriate authorities was not completed in a timely manner. Resident 1, who was the victim of the verbal abuse, was admitted to the facility with diagnoses including diabetes mellitus, dementia, and hypertension. The Minimum Data Set (MDS) for Resident 1 indicated severely impaired cognitive skills and a need for substantial assistance with daily activities. The altercation occurred when Resident 2, who also had severely impaired cognitive skills and required moderate assistance, became verbally aggressive towards Resident 1 due to frustration over a blocked bathroom door. Multiple staff members, including the Medical Records Assistant, Certified Nursing Assistant, Laundry Personnel, and Maintenance Supervisor, witnessed or were aware of the verbal abuse. Despite recognizing the behavior as verbal abuse, the incident was not reported to the necessary authorities within the required timeframe. The facility's policy and procedure on abuse reporting clearly stated that such incidents should be reported immediately, defined as within 2 hours, but this protocol was not followed in this case.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, identified as Resident 1. This deficiency was observed during a survey when the call light was found tucked in and hanging from the top of the side rail at the head of the bed, making it inaccessible to the resident. Resident 1, who was admitted with multiple fractures and intellectual disabilities, was noted to lack the capacity to understand and make decisions. The care plan for Resident 1 specifically indicated that the call light should be within reach due to the resident's risk for further decline in function and increased dependence in activities of daily living (ADLs). Interviews with facility staff, including a Certified Nurse Assistant (CNA2), the Director of Nursing (DON), and a Charge Nurse (CN), confirmed the deficiency. CNA2 acknowledged that the call light was not within reach and emphasized the importance of having it accessible to the resident. The DON and CN both stated that the call light should be within reach to prevent potential harm, such as the resident attempting to reach for it and risking a fall. The facility's policy on answering call lights, revised in October 2023, also indicated that call lights should be accessible to residents in various locations, including in bed.
Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its policy for abuse prevention and reporting, specifically in the case of a resident who alleged verbal abuse by two CNAs. The resident, who was admitted with hepatic encephalopathy and type 2 diabetes, reported the incident to the facility's Case Manager. The resident described the CNAs using foul language during assistance, which was communicated to the facility's leadership team but not reported to the appropriate external authorities as required by the facility's policy. Interviews with facility staff, including the Administrator, Director of Nursing, and other nursing staff, revealed a lack of awareness and action regarding the incident. The Administrator, who is the facility's abuse coordinator, was not informed of the incident, and the Director of Nursing only became aware during the survey. Staff members acknowledged that the use of foul language constitutes verbal abuse and should have been reported and investigated immediately, but this did not occur. The facility's policy mandates immediate reporting of abuse allegations to various authorities, including the state licensing agency, ombudsman, and law enforcement, within two hours. However, this protocol was not followed, resulting in the failure to report and investigate the alleged verbal abuse, thereby putting the resident at risk for further abuse. The facility's policy also requires thorough investigation and documentation of such incidents, which was not adhered to in this case.
Failure to Notify Physician of Resident's Chest Pain
Penalty
Summary
The facility failed to immediately notify the attending physician regarding a resident's left-sided chest pain, which was a violation of the facility's policy. The resident, who was admitted with a diagnosis of angina pectoris and had moderately impaired cognitive skills, reported chest pain at 8:48 AM. However, the attending physician was not notified until 11:50 AM, resulting in a delay in obtaining a stat electrocardiogram order. Interviews with staff revealed that the resident had communicated the chest pain to multiple staff members, including a CNA and a case manager, but the licensed vocational nurse (LVN) responsible did not prioritize notifying the physician or seeking assistance from the Director of Nursing (DON). The facility's policy requires prompt notification of the attending physician for any change in a resident's condition, such as chest pain, which is considered a significant change. Despite this, the LVN did not follow the protocol, leading to a delay in care. The DON and other staff members acknowledged that the chest pain should have been reported immediately to prevent potential worsening of the resident's condition. The failure to act promptly on the resident's reported chest pain was identified as a deficiency by the surveyors.
Failure to Promptly Conduct and Communicate STAT EKG Results
Penalty
Summary
The facility failed to promptly act on a STAT electrocardiogram (EKG) order for a resident who was admitted with a diagnosis of angina pectoris. The physician's order for the EKG was placed due to chest pain, but the test was not conducted until several hours later, at 9:35 PM, despite being ordered at 12:07 PM. This delay in conducting the EKG test could potentially lead to a delay in diagnosis and treatment for the resident's abnormal EKG result, which showed a Sinus Rhythm with first-degree atrioventricular block. Furthermore, the facility did not notify the attending physician of the EKG results once they were available, as required by the facility's policy. Interviews with staff, including the Director of Nursing and Licensed Vocational Nurses, revealed that the EKG results were not communicated to the physician, and there was no documentation of such notification in the resident's medical records. The facility's policy mandates that diagnostic test results be promptly communicated to the attending physician to ensure timely diagnosis and treatment, which was not adhered to in this case.
Failure to Prevent Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On April 17, 2024, Resident 2 hit Resident 1 on the right cheek. Resident 1, who was moderately impaired with cognitive skills for daily decision-making, was wheeling himself to his room when Resident 2 stopped his wheelchair, used offensive language, and struck him. Resident 2 had a history of aggressive behavior, including incidents on January 1, 2023, April 1, 2024, and April 6, 2024, where Resident 2 was aggressive towards staff and other residents. Despite Resident 2's known history of aggression and cognitive impairment, the facility did not provide adequate supervision or monitoring to prevent further incidents. Interviews with staff, including CNAs and the Director of Nursing, revealed that Resident 2 was not being supervised at the time of the incident. The Director of Nursing acknowledged that Resident 2 should have been monitored to prevent aggressive behavior towards others. Observations conducted on May 7, 2024, showed that there was no staff presence in the nursing station or hallway near the rooms of Residents 1 and 2 at various times throughout the day. The facility's policy on abuse, neglect, exploitation, or misappropriation requires the administrator to determine necessary actions for resident protection upon receiving abuse allegations. However, no new interventions were implemented for Resident 2, except for medication orders, indicating a lack of proactive measures to prevent further abuse.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse within the required two-hour timeframe to the State Survey Agency (SSA). This incident involved Resident 1, who was hit on the right cheek by another resident, Resident 2, as witnessed by a Certified Nursing Assistant (CNA 1). The incident occurred on 4/17/2024 around lunchtime, but the report was not successfully sent to the SSA within the mandated time. The Director of Nursing (DON) attempted to send the report on the same day but did not verify if the facsimile transmission was successful, resulting in a delay in reporting. Resident 1, who has a history of depressive disorder and epilepsy, was moderately impaired in cognitive skills for daily decision-making, according to the Minimum Data Set (MDS) dated 5/1/2024. The facility's policy, revised in 9/2022, requires immediate reporting of abuse allegations within two hours. However, the Administrator confirmed that the report was not sent within the required timeframe, acknowledging that if the fax line was busy, repeated attempts should have been made until confirmation of successful transmission was received.
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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