La Brea Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 505 N. La Brea Avenue, Los Angeles, California 90036
- CMS Provider Number
- 056195
- Inspections on file
- 66
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at La Brea Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow WCS treatment plans and facility wound care policies for two residents with multiple pressure injuries and other wounds. One resident with advanced cancer and several unstageable pressure injuries did not have ordered calcium alginate or PRN dressing changes entered on the OSR or TAR, even though dressings were frequently soaked with blood and drainage and changed only once daily, and wound assessment documentation was missing. Another resident with cellulitis, hidradenitis suppurativa, and candidiasis had physician orders for daily wound care and a WCS plan for BID and PRN dressing changes, but only daily treatments were ordered, dressings were often wet with drainage by morning, and wound assessments were not documented on multiple dates. The DON acknowledged that WCS orders were not being followed and that required wound assessment documentation was incomplete.
A resident with severe cognitive impairment and total dependence for ADLs, identified as high risk for falls, experienced multiple unwitnessed falls—including one resulting in injury—due to the facility's failure to initiate an individualized fall prevention care plan upon admission, update interventions after each fall, and adhere to fall prevention protocols. Staff did not consistently analyze causes or revise care plans, leading to repeated incidents and injury.
A resident with diabetes, end stage renal disease, and heart failure experienced a high blood sugar reading that was not properly managed according to facility policy. After receiving insulin, the resident's blood sugar was not rechecked, the physician was not notified, and the oncoming nurse was not informed during shift hand-off. Later, the resident was found unresponsive with low blood sugar, but this was not documented. Nursing staff and the DON confirmed that required monitoring, documentation, and communication protocols were not followed.
A resident with severe cognitive impairment and a history of falls was administered Haldol without a current physician order and was physically restrained without proper assessment or documentation. The resident's care plan included restraint use, and the family provided consent after being informed of aggressive behavior and frequent falls. The resident was found unresponsive and with visible injuries, while facility policy requiring assessment, physician order, and documentation for restraints was not followed.
A resident with severe cognitive impairment and a history of falls did not receive an individualized care plan that included all physician-ordered fall prevention interventions, such as floor mats, despite being at high risk for falls. The care plan lacked specific, measurable actions tailored to the resident's needs, and staff did not implement all required safety measures.
Two residents did not receive appropriate reassessment or care plan updates related to pain management. In one case, a nurse applied diclofenac gel to the knees instead of the hands as ordered, with no documentation or assessment of knee pain. In another, a nurse withheld diclofenac gel for a resident's shoulder pain based on the resident's report of no pain, but did not notify the physician or update the care plan. The DON confirmed that care plans and assessments were incomplete or not updated as required.
Three residents with or at risk for pressure ulcers were found to have their Low Air Loss Mattress (LALM) settings incorrectly set, not matching their actual weights as required by manufacturer guidelines and physician orders. This was confirmed by facility staff, including the DON and an LVN, who acknowledged the settings did not follow care plans or operational manuals.
Nursing staff did not properly document medication administration for two residents, including a failure to record missed doses and the administration of a controlled substance, as required by facility policy. Additionally, home medications belonging to a discharged resident were not returned, and the facility lacked a policy for handling such medications at discharge.
Three medication errors were observed during med pass, including missed doses and incorrect application sites, resulting in a medication error rate above 5%. Nurses failed to administer medications as ordered, such as not giving a blood pressure medication, omitting a topical pain medication, and applying a gel to the wrong body part, contrary to facility policy.
A resident's doxazosin 2 mg bubble pack was labeled for administration at bedtime, while the physician's order and MAR specified a 9 AM dose. An LVN discovered the discrepancy during a medication cart review, and the DON confirmed the correct schedule. The pharmacy had dispensed the medication with the incorrect administration time, and there was no documentation of communication regarding this change, contrary to facility policy.
Surveyors identified multiple failures in food storage, labeling, temperature control, and sanitation, including unlabeled and expired food, improper separation of raw and cooked items, unsanitary equipment, and missing temperature logs. Staff did not consistently follow cleaning, sanitizing, or hand hygiene protocols, and food brought in for residents was not properly labeled or monitored, affecting the majority of residents receiving facility food.
The facility did not maintain an effective pest control program, as evidenced by the presence of live cockroaches in the utility room where medical supplies and resident food are stored. Observations and interviews confirmed the pests, and records showed that pest control services were not consistently performed inside the building, with food debris also found in key areas, contributing to the deficiency.
Two residents were not provided care that promoted dignity: one did not have a privacy curtain of adequate length to ensure privacy during care, and another had a urinary catheter bag left uncovered in their room. Staff and the DON acknowledged these issues could affect resident dignity, and facility policy requires privacy and coverage of such devices.
A resident with a history of polypharmacy and risk for adverse reactions was found with Debrox ear drops at the bedside, brought in by a friend, without a physician's order. The medication was not identified or authorized by facility staff, and the LVN and DON confirmed that medications should not be kept at the bedside without proper orders, in accordance with facility policy.
A resident with multiple medical conditions was discharged to a senior living facility with home health services, but the MDS discharge assessment incorrectly documented the discharge as being to a short-term hospital. Both the MDS Assistant and DON confirmed the inaccuracy, which did not align with facility policy requiring accurate discharge assessments.
A resident with multiple medical conditions, including a gastrostomy and dysphagia, did not have an individualized, person-centered care plan addressing tube feeding needs. Staff and the DON were unable to locate a comprehensive care plan for enteral feeding, despite physician orders and facility policy requiring such plans.
The facility failed to revise and update care plans for four residents, including improper use of a low air loss mattress for wound care, incorrect application and documentation of pain medication, inadequate guidance for G-tube care, and outdated plans for seizure and behavioral precautions. These deficiencies were identified through observations, interviews, and record reviews, and were not consistent with the facility's policy for ongoing care plan assessment and revision.
A resident with type 2 diabetes and moderate cognitive impairment received insulin injections in the same arm at consecutive times, rather than rotating sites as required by physician orders and facility policy. Both nursing staff and the DON confirmed that injection sites were not rotated on multiple occasions, contrary to the facility's insulin administration guidelines.
A resident with a gastrostomy and multiple complex medical conditions was ordered to receive enteral tube feeding at 65 mL/hr, but staff set the feeding pump to 45 mL/hr, contrary to the physician's order and facility policy. The error was discovered during observation, and both the RN and DON confirmed that the incorrect rate could contribute to malnutrition and skin breakdown.
Two residents with end stage renal disease and dialysis fistulas did not have required emergency kits at their bedside, despite being on anticoagulant therapy and having care plans that identified a risk for bleeding. Nursing staff and the DON confirmed the absence of the kits and acknowledged the need for them in case of bleeding emergencies.
A nurse applied diclofenac gel to a resident's knees without a physician's order, as the order specified use on the hands only. The DON confirmed the medication was given to an area not authorized by the prescriber, contrary to facility policy requiring written orders for all medications.
Two residents were not served meals in accordance with their documented dietary intolerances and cultural preferences. One resident with lactose intolerance and a dislike for sweets was served chocolate ice cream, while another resident who avoided pork for religious reasons was served pork sausage. Staff interviews and observations revealed inconsistent adherence to meal ticket information and facility policy, leading to these errors.
Two residents with significant medical and cognitive needs were found with their call lights out of reach, despite facility policy requiring accessibility. One resident with seizures and lack of coordination was observed with the call light on the bed, out of reach while in a wheelchair. Another resident with impaired vision and a history of falls had the call light dangling off the bed, not accessible. Staff acknowledged the call lights should have been within reach and described ways they could have been made accessible.
A resident with significant mobility and cognitive impairments was left in a bed with a broken footboard on the floor for several hours, resulting in the resident's feet dangling and sliding down the bed. Multiple staff observed the hazard but did not report it or request maintenance, and the issue was not identified during routine rounds. Facility policy required immediate reporting of such hazards, but this was not followed.
A resident with cognitive and mental health diagnoses was admitted with a pair of shoes documented in their personal effects inventory. After readmission, the shoes were missing and could not be located by staff, causing the resident distress. The DON acknowledged the loss and noted the facility's policy required inventory updates, but the shoes were not accounted for as required.
A resident with cognitive and mental health diagnoses was admitted with a pair of shoes documented in their personal inventory. Later, staff were unable to locate the shoes, and the resident reported being upset about their loss. The DON acknowledged the missing item and noted the facility's policy required updated inventories, but the shoes were not accounted for, resulting in the resident's distress.
The facility failed to document medication administration immediately after giving medications to three residents, as required by policy. A nurse was observed signing the MAR hours after administering 9:00 a.m. medications, which was confirmed by the Quality Assurance Nurse as a violation of the facility's documentation policy.
A resident with rectal carcinoma and a colostomy, who required moderate assistance for daily activities, repeatedly refused basic care. Despite staff being aware and notifying the charge nurse, there was no documentation or physician notification of these refusals, violating the facility's policy.
A resident with cancer and mobility issues refused basic care multiple times, but the facility failed to document these refusals in a care plan. Despite staff reporting the refusals to the charge nurse, no care plan was initiated, violating the facility's policy to update care plans with changes in a resident's condition.
A resident with paraplegia, diabetes, and osteomyelitis, who was at high risk for pressure ulcers, had their LAL mattress improperly set at 200 lbs instead of their actual weight of 149 lbs. This discrepancy was confirmed by the Treatment Nurse and the Director of Staff Development, contrary to the facility's policy requiring weight-based settings for pressure redistribution surfaces.
A facility failed to change a resident's nasal cannula tubing and humidifier for oxygen therapy according to policy, risking infection. The resident, with conditions like COPD and respiratory failure, required continuous oxygen. Staff confirmed the equipment was overdue for replacement, and the humidifier was empty, contrary to the facility's guidelines.
The facility failed to manage pain effectively for two residents, leading to significant discomfort and complications. One resident, with severe cognitive impairments, experienced severe knee pain and was transferred to a hospital after family intervention. Another resident, admitted for pain management, suffered from inadequate pain relief due to inconsistent medication administration. The facility did not adhere to its policies on pain management and changes in residents' conditions, resulting in unnecessary pain and discomfort.
A resident with severe cognitive impairments and multiple diagnoses experienced significant knee pain and swelling, which was not promptly addressed by the LTC facility. Despite family concerns and worsening symptoms, the facility delayed escalating the situation, leading to the resident's transfer to the ER. The facility's policy on notifying physicians and family of significant changes was not followed.
A resident with a history of mental health issues was transferred to a hospital due to suicidal ideation and aggressive behavior. The facility failed to notify the resident's responsible party about the transfer and the reasons for discharge, violating their policy requiring notification and orientation for facility-initiated discharges.
A resident with a history of mood problems was not adequately monitored, leading to physical abuse of two other residents in the activity room. Despite staff presence, the facility failed to prevent the incident, resulting in injuries to one resident who required hospital evaluation. The facility's policies lacked specific references to abuse prevention.
The facility failed to implement care plan interventions for two residents after an altercation. One resident with hemiplegia was not monitored for conduct changes as required, and another resident with peripheral vascular disease was not monitored for mood problems. The DON confirmed the lack of monitoring, which was against the facility's policies on care plans and documentation.
A resident missed a scheduled ophthalmology appointment due to the facility's failure to arrange transportation. The LVN scheduled the appointment and completed a transportation request form but did not inform the SSD, who was responsible for coordinating transportation. This communication breakdown led to the missed appointment, despite the facility's policy requiring coordination with Social Services for such arrangements.
A facility failed to complete a baseline care plan within 48 hours for a resident with encephalopathy and type two diabetes, who required assistance with daily activities. The care plan lacked sections on skin care, bowel/bladder needs, and other critical areas, potentially delaying necessary care.
The facility failed to provide and document necessary wound care for two residents with pressure injuries, as per physician orders. One resident did not receive treatment for an unstageable pressure injury on the hip, while another missed treatment for a Stage IV pressure ulcer on the coccyx. The lack of documentation in the Treatment Administration Record indicated these treatments were not performed, as confirmed by the Treatment Nurse and Interim Director of Nursing.
The facility failed to implement comprehensive care plans for three residents who refused vaccinations, including COVID-19, pneumonia, and influenza vaccines. Despite the residents' varying cognitive impairments and medical conditions, no care plans were developed to address the potential health risks associated with their refusals. A registered nurse confirmed the absence of these care plans, which are essential for guiding licensed nurses in managing the residents' care.
The facility failed to implement physician-ordered transmission-based precautions for three residents who tested positive for COVID-19, as there was no signage indicating the necessary precautions outside their rooms. Additionally, Dietary Staff 1 did not wear a fit-tested N95 respirator during a COVID-19 outbreak, as required by the facility's policy. These deficiencies indicate a lack of adherence to infection prevention and control measures, potentially increasing the risk of infection transmission.
A resident's POLST form was incomplete due to the absence of a physician's signature, violating the facility's policy and the resident's rights. The resident, admitted with acute kidney failure and hypertension, was found hypoxic and unresponsive, necessitating CPR. A review confirmed the POLST was not signed, which is required to ensure the form's accuracy. The facility's policy mandates that residents' CPR preferences be documented and signed by a physician.
A facility failed to report a resident's unexpected death within the required timeframe, delaying an inspection by the Department of Public Health during a COVID-19 outbreak. The resident, who had acute kidney failure and hypertension, tested positive for COVID-19 but showed no signs of distress before passing. The facility did not adhere to its policy of reporting unusual occurrences to the State Survey Agency within 24 hours.
The facility failed to ensure that the Controlled Drug Record (CDR) matched the Medication Administration Records (MAR) for four residents. Medications like Norco, Ativan, and Lyrica were administered without proper documentation in the CDR. Licensed Vocational Nurses admitted to forgetting to sign out the medications due to being in a rush. The Director of Nursing confirmed that documentation should occur at the time of administration, as per facility policy.
A resident with severe cognitive impairment was administered Ativan after the physician's order had expired, due to an LVN's failure to verify the order and document the administration. The DON highlighted the necessity of following the five rights of medication administration and having an active order.
The facility inaccurately posted Direct Care Services Hours Per Patient Day (DHPPD) by using projected rather than actual staffing hours for two days. Interviews with the DSD and DON confirmed that the actual staffing numbers were not calculated within two hours of each shift's start, contrary to facility policy.
A resident experienced severe, unrelieved pain in the hands, legs, and stomach due to inadequate pain management by the facility. Despite repeated requests for pain medication and high pain ratings, the facility did not administer the maximum allowed doses or notify the physician in a timely manner. The resident's pain was not effectively managed, leading to physical and psychosocial decline.
The facility failed to document Advance Directives for two residents, one with severe cognitive impairment and another with intact decision-making capacity. Despite the policy requiring documentation upon admission, the forms were missing, potentially affecting the residents' medical treatment preferences.
The facility failed to label and date food items in accordance with professional standards and its own policies, placing 127 residents at risk for foodborne illnesses. Unlabeled and undated items included potatoes, frozen breaded fish, and creamer. The Dietary Supervisor and DON confirmed the importance of proper labeling to prevent foodborne illness.
A resident, admitted with acute kidney failure, diabetes, and heart failure, had not received a shower in two months despite being cognitively intact and dependent on staff for bathing. The CNA did not provide a shower due to a lack of assistance with the Hoyer lift and did not seek help, leading to the resident feeling unclean and uncomfortable. The facility's policies emphasize treating residents with dignity and supporting their rights, including personal grooming preferences.
Failure to Follow Wound Care Orders and Document Pressure Ulcer Management
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate pressure ulcer and wound care for two residents admitted with existing pressure injuries. For one resident with advanced breast cancer, sepsis, cellulitis, and multiple unstageable pressure injuries, the Wound Care Specialist (WCS) ordered silver alginate dressings for a fungating chest wall mass and several pressure injuries. However, the resident’s Order Summary Report and Treatment Administration Record did not contain an order for calcium alginate or any as-needed wound dressing changes when dressings became soiled. The treatment nurse reported that this resident’s wound dressings were often soaked with blood and drainage at the start of the morning shift and were changed only once daily. Review of the resident’s Wound Care Forms for multiple dates showed no documented wound assessments, despite facility policies requiring detailed documentation of wound appearance, drainage, assessment data, and resident tolerance. For the second resident, who had cellulitis of the buttock, hidradenitis suppurativa, candidiasis, and multiple draining wounds, the Minimum Data Set showed intact cognition and total dependence on staff for ADLs. The physician’s orders directed daily wound care, including packing bilateral hips with NS-moistened kerlix and applying xeroform to the sacrum. The WCS later documented a plan of care specifying that dressings should be changed twice daily or as needed if soiled. Despite this, the resident’s Treatment Administration Record did not include any as-needed wound treatment orders, and the Order Summary Report as of early March only reflected daily wound dressing orders. The treatment nurse stated that this resident’s dressings were frequently wet with yellowish and pinkish drainage by the time he arrived in the morning, and he changed the dressings once daily. Across both residents, the facility did not follow its own policies and procedures for wound care and documentation. The Wound Care Forms for the second resident on multiple dates lacked any recorded wound assessments, and the DON acknowledged that the facility did not have complete documentation of wound assessments for either resident during wound care management as required by the Dressings, Dry/Clean, and Wound Care policies. The DON also stated that staff were not following the WCS treatment plans and that medications and treatments ordered by the WCS were not in place. These actions and omissions resulted in incomplete implementation of ordered wound treatments and inadequate documentation of wound status for both residents with pressure ulcers and other wounds.
Failure to Initiate and Update Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident who was assessed as high risk for falls and dependent in activities of daily living (ADLs). Upon admission, the resident was identified as having a high fall risk, but no individualized care plan addressing this risk was initiated. Documentation showed that the resident was totally dependent on staff for mobility, toileting, and other ADLs, with severe cognitive impairment and medical conditions affecting coordination and gait. Despite these risk factors, the admission care plan did not include fall prevention interventions, and no baseline care plan for fall risk was documented within the required timeframe. Following an unwitnessed fall, the facility did not update the care plan or implement new interventions as required by policy. The resident experienced multiple unwitnessed falls, including incidents where the resident slid out of bed or was found on the floor, sometimes attempting to use a urinal independently. After each fall, staff failed to analyze the causes, revise the care plan, or implement additional safety measures. Interviews with nursing staff and the DON confirmed that care plans were not updated after falls, and interventions such as frequent checks, floor mats, or medication reviews were not consistently implemented. As a result of these failures, the resident suffered multiple falls, one of which resulted in a laceration to the forehead, thoracic spine strain, and left shoulder contusion, requiring transfer to an acute care hospital. The facility's own policies required prompt assessment, care plan updates, and implementation of interventions after falls, but these procedures were not followed. The lack of timely and individualized care planning, failure to update interventions after repeated falls, and inadequate adherence to fall prevention protocols directly contributed to the resident's injuries.
Failure to Monitor and Communicate Blood Glucose Management in Diabetic Resident
Penalty
Summary
A deficiency occurred when facility staff failed to follow professional standards of practice and the facility's policy for managing, assessing, and monitoring a resident with diabetes mellitus. The resident, who had a history of type II diabetes, end stage renal disease, and congestive heart failure, was found to have a blood sugar level of 348 mg/dl in the morning. Despite this elevated blood sugar, the nurse on duty administered insulin but did not recheck the resident's blood sugar, notify the physician, or communicate the high blood sugar to the oncoming nurse during shift hand-off. There was also a lack of documentation regarding the interventions taken in response to the high blood sugar reading. Later that day, the resident was found unresponsive, lethargic, and difficult to arouse, with labored breathing and high blood pressure. Upon assessment, the oncoming nurse found the resident's blood sugar had dropped to 70 mg/dl, indicating hypoglycemia. However, this critical blood sugar reading was not documented, and the nurse acknowledged that it should have been. The facility's policy required immediate provider notification for hypoglycemia and prompt notification for blood glucose values over 250 mg/dl, as well as documentation of interventions and changes in the resident's condition, none of which were followed in this case. Interviews with nursing staff and the Director of Nursing confirmed that the required monitoring, documentation, and communication protocols were not adhered to. The staff failed to recheck blood sugar after insulin administration, did not notify the physician or the next shift about the resident's condition, and did not document key interventions or changes in the resident's status, all of which contributed to the deficient practice.
Failure to Prevent Unnecessary Physical and Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary physical and chemical restraints. The resident, who had severe cognitive impairment and a history of falls, was administered Haloperidol (Haldol) beyond the physician's ordered timeframe. The medication order was to be discontinued on a specific date, but the medication was still present in the medication cart and being administered after the order had expired. The Director of Nursing confirmed that there was no current physician order for the medication, yet it remained available and in use. Additionally, the resident was subjected to physical restraint without proper assessment or documentation. The care plan included an intervention to apply restraints, and the resident's family member confirmed that consent was given for restraint use after being informed by staff about the resident's aggressive behavior and multiple falls. The family member observed the restraint tied around the resident's abdomen and secured to the bed, which the resident was unable to remove. The resident was also observed to be unresponsive to verbal and physical stimuli and had visible bruises and scabs on both arms and legs. The facility's policy required a pre-restraining assessment, physician order, and documentation of the episode leading to restraint use, none of which were fully adhered to in this case. The policy also specified that restraints should not be used for fall prevention or staff convenience, but only for the treatment of medical symptoms after less restrictive interventions had failed. The Director of Nursing acknowledged that the care plan guides staff actions and that restraints should only be applied with a physician's order after careful monitoring, which was not followed in this instance.
Failure to Develop and Implement Individualized Fall Prevention Care Plan
Penalty
Summary
A resident with a history of diabetes mellitus, hyperlipidemia, severe cognitive impairment, and a documented history of falls was admitted and subsequently readmitted to the facility following an unwitnessed fall that resulted in a laceration above the right eyebrow. The resident required substantial to maximal assistance with activities of daily living and was identified as being at high risk for falls. Physician orders specified the use of low bed positioning and floor mats on both sides of the bed as fall prevention interventions. Despite these orders and the resident's high fall risk, the care plan developed for the resident did not include all individualized interventions, specifically omitting the use of floor mats as ordered by the physician. Observations confirmed that floor mats were not present at the bedside, and staff interviews revealed that this intervention was not implemented. The care plan included general fall prevention measures such as frequent visual monitoring and ensuring the call light was within reach, but failed to address all specific needs and physician-ordered interventions for the resident. The Director of Nursing acknowledged that the care plan was not individualized to include all necessary interventions, and that the physician's order for floor mats was neither carried out nor reflected in the care plan. Facility policy required comprehensive, individualized care plans with measurable objectives and timetables, but this was not achieved for the resident, resulting in a failure to fully address the resident's fall risk.
Failure to Reassess and Update Care Plans for Pain Management
Penalty
Summary
The facility failed to reassess and reevaluate residents' needs and changes in condition, resulting in deficiencies in medication administration and care planning for two residents. In one instance, a nurse applied diclofenac sodium gel to both knees of a resident, despite the physician's order specifying application to both hands. Review of the resident's care plan revealed no documentation specifying which joints required pain management, nor any assessment regarding knee pain. The Director of Nursing confirmed that the care plan lacked details about pain in the hands or knees and that no assessment had been documented for knee pain. In another case, a nurse did not administer a resident's ordered diclofenac gel for right shoulder pain, as the resident had not requested it and reported no pain in the shoulder for at least two weeks. The nurse referenced the medication administration record, which showed a pain level of zero for the resident's shoulders. However, there was no reassessment of the resident's condition or notification to the physician regarding the change, and the care plan had not been updated to reflect the absence of shoulder pain. Facility policy requires care plans to be updated when there is a significant change in a resident's condition, but this was not done.
Failure to Maintain Correct LALM Settings for Pressure Ulcer Management
Penalty
Summary
The facility failed to maintain appropriate settings on Low Air Loss Mattresses (LALM) for three residents who were at risk for or had existing pressure ulcers. For one resident, the LALM was set at 230 lbs. despite the resident weighing 140 lbs., as observed by the Director of Nursing (DON). The DON confirmed that the setting was incorrect and should have matched the resident's actual weight, as per the manufacturer's guidelines. The DON acknowledged that the incorrect setting could potentially lead to the redevelopment of pressure ulcers. Another resident's LALM was found set at 350, while the resident's actual weight was 162 lbs. This discrepancy was identified during an observation with a Licensed Vocational Nurse (LVN), who admitted not knowing the resident's weight without checking the electronic medical record. The DON confirmed that the staff did not follow the care plan or manufacturer guidelines, and that the excessively high setting could worsen the resident's wounds. A third resident's LALM was observed set at 200 lbs., while the resident's weight was 159 lbs. The DON verified that this setting was incorrect and did not align with the physician's order or the manufacturer's instructions, which required the mattress to be set according to the resident's weight. In all three cases, the failure to set the LALM according to the residents' actual weights was directly observed and confirmed by facility staff, and the operational manuals for the devices specified that settings should be based on patient weight.
Medication Documentation and Return of Personal Medications Deficiencies
Penalty
Summary
Nursing staff failed to properly document medication administration for two residents. In one case, a nurse did not administer a prescribed diclofenac gel for pain management to a resident for at least two weeks, yet the Medication Administration Record (MAR) indicated all doses were given, with no documentation of missed or refused doses. The Director of Nursing (DON) confirmed that the MAR should have been annotated if the medication was not administered, but the required documentation was absent. In another instance, the administration of a controlled substance (Dilaudid) was not documented for a resident, and the DON acknowledged that the nurses forgot to record the administration on the MAR, contrary to facility policy requiring immediate documentation after each medication is given. Additionally, the facility failed to return home medications brought in by a discharged resident. Twelve oral syringes of lorazepam, a controlled substance, were found stored in a locked drawer for disposal, even though these were personal medications that should have been returned to the resident or their family upon discharge. The DON stated there was no facility policy on handling home medications at discharge, and the existing personal property policy did not address this situation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 33 observed opportunities during medication administration, resulting in a 9.09% error rate. In one instance, a nurse did not administer doxazosin 2 mg to a resident as ordered at 9 AM, because the medication was not found in the cart at the time of administration. The medication was later located in a drawer designated for evening medications. In another case, a nurse did not apply diclofenac sodium gel to a resident's right shoulder as ordered, stating that the resident did not request it, despite the order not being PRN (as needed). Additionally, a nurse applied diclofenac gel to a resident's knees instead of the hands as prescribed, following the resident's request, which was not in accordance with the written order. These incidents were observed during medication passes and confirmed through interviews and record reviews. The facility's policy requires medications to be administered as prescribed, including verifying the correct dosage, time, and route, but these procedures were not consistently followed, leading to the identified medication errors.
Medication Labeling and Administration Time Discrepancy
Penalty
Summary
A deficiency was identified when a bubble pack containing doxazosin 2 mg for a resident was found labeled for administration at bedtime, while the physician's order and the medication administration record (MAR) specified the medication should be given at 9 AM. This discrepancy was discovered during an observation of the medication cart, where a Licensed Vocational Nurse (LVN) noted the mismatch between the label on the medication and the scheduled administration time in the MAR. The resident's medical order, effective since 5/25/2025, clearly indicated the medication was to be administered once daily at 9 AM. Further review revealed that the pharmacy had dispensed the medication with instructions to give it at bedtime, contrary to the physician's order. The Director of Nursing (DON) confirmed that the medication was scheduled for 9 AM and stated that the pharmacy should have communicated any changes to the order. However, there was no documentation or paper trail of such communication from the pharmacy to the facility regarding a change in the administration time. The facility's policy requires that only authorized, licensed practitioners write orders, and that any changes be properly communicated and documented.
Widespread Food Storage and Sanitation Deficiencies in Kitchen and Resident Areas
Penalty
Summary
The facility failed to ensure safe and sanitary food storage, preparation, and handling practices in the kitchen and resident food storage areas, affecting the majority of residents who received food from the facility. Surveyors observed multiple instances of improper food labeling and storage, including an opened container of cottage cheese in the kitchen refrigerator that was not labeled with an open date, and a staff member's personal lunch stored in the same refrigerator. Additionally, time/temperature control for safety (TCS) foods, such as previously cooked rice, were found stored above the required cold holding temperature, and cooked breakfast sausage was stored next to raw chicken and beef, creating a risk for cross-contamination. Further observations revealed unsanitary conditions in the dry storage area, with food debris and dust present, expired cookies stored on shelves, and bottles of cooking sauces covered in sticky residue. The kitchen's toaster oven was also found to be unclean, with breadcrumbs accumulated inside and on surrounding surfaces. Staff did not consistently follow cleaning and sanitizing procedures, as evidenced by a cook failing to clean and sanitize a food preparation sink after handling raw chicken, which was then used by another staff member to wash vegetables. In the dishwashing area, a dietary aide did not wash hands or change gloves when transitioning from handling dirty to clean dishes, contrary to facility policy. In the resident refrigerator, food brought in from outside was not consistently labeled or dated, and the temperature log for the refrigerator was missing for the month of June. Several items, including an unopened package of cheese past its expiration date and multiple bags of undated food, were found stored in unsanitary conditions. Additionally, food brought in for specific dietary needs, such as kosher meals, was not properly labeled or separated. These deficiencies were confirmed through staff interviews and review of facility policies, which require proper labeling, dating, and storage of all food items, as well as routine cleaning and temperature monitoring.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program for its 136 residents, resulting in the presence of live cockroaches in the utility room where medical supplies, a resident refrigerator for outside food, and the unit ice machine are located. During observations and interviews, a live cockroach was seen traveling from under the counter and under the resident refrigerator. Both the Nurse Supervisor and the Director of Staff Development confirmed the presence of the cockroach and indicated they would notify maintenance and housekeeping. The Maintenance and Housekeeping Director stated that pest control services were scheduled monthly, with the process typically including both exterior and interior inspections and trap monitoring. However, a review of pest control records revealed that for the month of May, pest control services were only performed outside the building and garage, with no interior inspection conducted. Additionally, a pest control report indicated the discovery of a dead German cockroach in the utility room and noted the presence of food debris in both the employee lounge and utility room, which can create conditions conducive to pest infestations. The facility's policy requires an ongoing pest control program to keep the building free of insects and rodents, but the observed lapses and incomplete service contributed to the deficiency.
Failure to Maintain Resident Dignity Through Adequate Privacy and Device Coverage
Penalty
Summary
The facility failed to provide care in a manner that promoted or enhanced the dignity of two residents by not ensuring adequate privacy and protection of personal medical devices. For one resident with severe cognitive impairment and multiple medical conditions, including encephalopathy, dysphagia, schizophrenia, and depression, the privacy curtain in the resident's room was observed to be too short to provide full privacy during care activities. Both a restorative nurse assistant and the maintenance director confirmed that the curtain was insufficient in length to cover the resident's living area, and the DON acknowledged that this could compromise the resident's dignity. For another resident with a history of infection, dementia, and an indwelling urinary catheter, the urinary catheter bag was observed hanging on the bed without a cover. The care plan for this resident specified that the catheter bag and tubing should be positioned away from the entrance room door, but did not mention a cover. During observation, a CNA confirmed that the urine bag was not covered and stated that this could affect the resident's dignity. The DON also stated that an uncovered urine bag could impact a resident's dignity. The facility's policy and procedure on dignity, dated December 2024, requires that each resident be cared for in a manner that promotes well-being, self-worth, and self-esteem, and specifically prohibits practices that compromise dignity. The policy also instructs staff to help residents keep urinary catheter bags covered and to maintain bodily privacy during personal care and treatment procedures.
Unauthorized Medication at Bedside Without Physician Order
Penalty
Summary
A resident was found to have Debrox ear wax removal drops at their bedside without a physician's order. The medication was brought in by a friend, and the resident could not recall when it was received. The resident had a history of lack of coordination, bed confinement, and falls, and was at risk for adverse reactions due to polypharmacy, as documented in their care plan. The resident was assessed as having intact cognitive function and the capacity to make decisions. During medication administration, a Licensed Vocational Nurse (LVN) did not initially notice the ear drops at the bedside and later confirmed that friends and family should be educated about bringing medications into the facility. The facility's policy required that all medications be identified and ordered by a physician, and the Director of Nursing (DON) stated that medications should not be kept at the bedside due to safety concerns. The facility failed to ensure that the resident did not keep medication at the bedside without proper authorization, as required by policy.
Inaccurate MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) discharge assessment was accurately completed for one of seven sampled residents. The resident in question was admitted with multiple diagnoses, including chronic kidney disease, lack of coordination, difficulty walking, a history of falls, and a displaced fracture of the left femur. According to the resident's records, she was discharged to a senior living facility with home health services and accompanied by her family. However, the MDS discharge assessment inaccurately documented that the resident was discharged to a short-term general hospital. Interviews with the MDS Assistant and the Director of Nursing confirmed that the MDS assessment did not reflect the actual discharge destination, as the resident was not sent to a hospital but to a senior living facility. Both staff members acknowledged that the MDS should accurately represent the resident's status at discharge. The facility's policy requires comprehensive and accurate assessments at discharge, including completion of the MDS, but this was not followed in this instance.
Failure to Develop Individualized Care Plan for Tube Feeding
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address the tube feeding needs of a resident with multiple complex medical conditions. The resident was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, type 2 diabetes mellitus, gastrostomy, dysphagia, gastro-esophageal reflux disease, and muscle weakness. The resident's Minimum Data Set indicated moderate cognitive impairment and that eating ability was not assessed due to medical or safety concerns. Despite having physician orders for enteral feeding via gastrostomy tube, the care plan did not appropriately address the resident's tube feeding requirements. During interviews and record reviews, staff, including an LVN and the DON, were unable to locate a comprehensive care plan specifically addressing the resident's tube feeding. The care plan on file only referenced the presence of a gastrostomy tube, without detailing the necessary care and feeding protocols. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, but this was not in place for the resident's tube feeding at the time of the survey.
Failure to Revise and Update Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans for four residents, resulting in deficiencies related to the provision of care and services. For one resident with multiple stage 4 pressure ulcers and immobility, the care plan included the use of a low air loss mattress (LALM) set to the resident's weight. However, the LALM was observed to be set at an incorrect setting of 350, which did not correspond to the resident's actual weight of 162 lbs. Nursing staff were unaware of the correct weight and did not follow the care plan instructions, potentially compromising wound management. Another resident receiving diclofenac gel for pain management had an order specifying application to the hands, but nursing staff were observed applying the medication to the knees. The medication administration record (MAR) showed inconsistent documentation of application sites, with some entries indicating use on both lower extremities and others lacking documentation. The care plan did not specify which joints required pain management, and the order was not clarified until after the deficiency was identified. A third resident with a gastrostomy tube (G-tube) for enteral feeding had a care plan that did not provide adequate guidance for nursing staff on G-tube care, despite the resident's complex medical history including hemiplegia, diabetes, and dysphagia. Additionally, a resident with a seizure disorder and behavioral health diagnoses had care plans for falls, behaviors, and seizure precautions that were not revised to reflect current needs, despite ongoing changes in the resident's condition. These failures to revise and update care plans were confirmed through interviews and record reviews, and were not in accordance with the facility's own policy requiring ongoing assessment and care plan revision.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to rotate insulin injection sites as required for a resident with type 2 diabetes who had moderate cognitive impairment. Review of the resident's Medication Administration Records (MAR) over two months showed that insulin was repeatedly administered in the same arm at consecutive times, rather than rotating injection sites as per physician orders and facility policy. Both a Licensed Vocational Nurse and the Director of Nursing confirmed during interviews and record reviews that the injection sites were not rotated on multiple occasions. The facility's policy on insulin administration, dated December 2024, specifies that injection sites should be rotated to ensure safe administration. Despite this, the MARs indicated repeated use of the same injection sites for the resident, contrary to established guidelines. This failure was acknowledged by facility staff during interviews and was identified as having the potential to cause skin infection.
Failure to Administer Correct Enteral Tube Feeding Rate
Penalty
Summary
The facility failed to provide the correct enteral tube feeding rate for one resident who had a gastrostomy and was dependent on tube feeding due to multiple diagnoses, including encephalopathy, dysphagia, seizures, aspiration pneumonia, and dementia. The resident was ordered by the physician to receive enteral tube feeding at a rate of 65 mL per hour. However, during observation, the tube feeding machine was found to be set at 45 mL per hour, contrary to the physician's order and the label on the feeding tube. Staff initially stated the label was incorrect, but upon review of the order, it was confirmed that the machine should have been set to 65 mL per hour. The resident's medical records indicated a history of gradual weight loss and a recent five-pound loss, with the dietician noting the need for increased calories and protein from tube feeding. The facility's policy required staff to check the enteral nutrition label against the physician's order before administration, including verifying the rate of administration. Despite this policy, the error in the feeding rate was not identified until observed by surveyors, and both the RN and DON acknowledged that the incorrect rate could place the resident at risk for malnutrition and skin breakdown.
Failure to Provide Emergency Kits for Dialysis Residents
Penalty
Summary
The facility failed to provide emergency kits at the bedside for two residents who required dialysis and had a dialysis fistula or shunt. Both residents had diagnoses including diabetes mellitus type 2 and end stage renal disease, and were dependent on renal dialysis. Their care plans and physician orders indicated the presence of a fistula or shunt and the use of anticoagulant medications, which increased their risk for bleeding. Despite these documented risks, observations confirmed that neither resident had an emergency kit at their bedside, as verified by interviews with licensed nursing staff. The absence of the emergency kits was acknowledged by the nursing staff, who stated that the kits were necessary to manage potential bleeding from the dialysis access sites. The Director of Nursing also confirmed that the lack of emergency kits placed the residents at risk for continuous bleeding from their dialysis fistulas. The deficiency was identified through a combination of record review, direct observation, and staff interviews.
Medication Administered Without Proper Physician Order
Penalty
Summary
A Licensed Vocational Nurse (LVN 3) applied diclofenac sodium 1% external gel to both knees of Resident 45 during a medication administration, despite the physician's order specifying application only to the resident's hands. This action was observed and later confirmed through interviews with LVN 3 and the Director of Nursing, who acknowledged that the medication was administered to an area not covered by the physician's order and without a proper evaluation. Review of facility policies indicated that medications must be administered only with a written order from an authorized prescriber and that unnecessary drugs include those used without adequate indications for use.
Failure to Accommodate Resident Food Preferences and Intolerances
Penalty
Summary
The facility failed to provide food that accommodated the documented allergies, intolerances, and preferences of two residents. One resident with lactose intolerance and a dislike for sweets was served chocolate ice cream, despite these restrictions being listed on the resident's meal ticket. Observations showed that dietary staff prepared and served the incorrect dessert, and the resident expressed frustration, stating that such mistakes occurred frequently and that desserts were often returned to the kitchen. Staff interviews revealed a lack of clarity and consistency in checking meal tickets and ensuring diet accuracy before tray delivery. Another resident, who had documented cultural and religious preferences to avoid pork and ham, was served pork sausage for breakfast. The resident, who identified as Muslim, had these preferences noted in multiple records, including the nutritional screening, dietary slip, and care plan. Despite these clear indications, the resident reported being served pork on at least one occasion, and the dietary supervisor acknowledged the error, attributing it to new staff. Facility policies required that resident preferences and intolerances be accommodated and that food trays be inspected for accuracy. However, observations and interviews indicated that these procedures were not consistently followed, resulting in residents receiving food items contrary to their documented needs and preferences.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents with significant medical and cognitive needs. One resident, admitted with diagnoses including seizures, Parkinson's Disease, HIV, weakness, and anxiety disorder, was observed asleep in her wheelchair with the call light placed on the bed out of her reach. The resident's records indicated a lack of coordination and a need for safety precautions, and a nurse had previously instructed her to use the call light for assistance. A certified nursing assistant confirmed during observation that the call light should have been within the resident's reach and repositioned it accordingly. Another resident, with a history of end stage renal disease, falls, diabetes, muscle wasting, encephalopathy, and dementia, was found sleeping in bed with the call light dangling off the bed and not within reach. This resident was noted to have highly impaired vision and was always incontinent. Staff interviews revealed that the call light could have been pinned to the resident's gown or pillow to make it accessible, and the Director of Nursing acknowledged that the call light should have been within reach. The facility's policy required that call lights be easily accessible to residents in bed or confined to a chair, and that residents unable to use the call light be checked frequently.
Failure to Address Broken Bed Footboard and Resident Safety Hazard
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for mobility and had significant cognitive and physical impairments, was left in a bed with a broken footboard that had detached and remained on the floor for several hours. During this time, the resident's feet were observed dangling at the foot of the bed, and the resident was sliding down due to the absence of the footboard. Multiple staff members, including a CNA, LVN, and RNA, observed the broken footboard and the resident's compromised position but did not immediately report the issue or request maintenance. The CNA, who was assigned to the resident, acknowledged seeing the broken footboard at the start of the shift but failed to notify the charge nurse or maintenance. The maintenance manager confirmed that no repair request had been submitted until much later, and the RN supervisor, who was responsible for conducting room rounds, had not identified the issue during their checks. The resident's medical history included unspecified abnormalities of gait and mobility, encephalopathy, and myocardial infarction, and the resident required maximal assistance for bed mobility and transfers. Facility policy required staff to report environmental hazards and ensure resident safety, but these procedures were not followed, resulting in the resident being left in a hazardous situation for an extended period. Interviews with facility leadership, including the DON and DSD, confirmed that staff were trained to report such hazards immediately, and the failure to do so was recognized as a significant lapse in standard care.
Failure to Safeguard Resident's Personal Belongings
Penalty
Summary
A deficiency occurred when the facility failed to safeguard a resident's personal belongings, specifically the resident's shoes. The resident, who had diagnoses including dementia, depression, and schizophrenia, was admitted and later readmitted to the facility. Upon admission, the resident's inventory of personal effects included one pair of shoes, but upon readmission, the inventory did not list any shoes. Staff interviews confirmed that the resident had shoes earlier in the month, but subsequent searches in the resident's room were unsuccessful in locating them. The resident expressed being upset about the loss of his shoes and not having any to wear. The facility's Director of Nursing (DON) acknowledged the missing shoes and discussed the possibility that they may have been left at the hospital, but no one had been informed. The facility's policy required that personal belongings be inventoried and documented upon admission and updated as necessary. Despite this policy, the resident's shoes were not accounted for, and the loss was not promptly addressed, resulting in the resident's distress.
Failure to Safeguard Resident's Personal Belongings
Penalty
Summary
A deficiency was identified when the facility failed to safeguard a resident's personal belongings, specifically the resident's shoes. The resident, who had diagnoses including dementia, depression, and schizophrenia, was admitted and later readmitted to the facility. Upon admission, the resident's inventory of personal effects included one pair of shoes, but a subsequent inventory did not list any shoes. Staff interviews confirmed that the resident had shoes earlier in the month, but they could not be located during a later search of the resident's room. The resident expressed being upset about the loss of the shoes and not having any to wear. The facility's Director of Nursing (DON) acknowledged the missing shoes and suggested they may have been left at the hospital, but no one had been informed. The facility's policy required that personal belongings be inventoried and documented upon admission and updated as necessary. Despite this policy, the resident's shoes were not accounted for, and the loss was not promptly addressed, resulting in the resident's distress.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On 5/19/25, the resident #1 shoes were immediately replaced. Resident expressed satisfaction and contentment with the replacement. F 557
Failure to Timely Document Medication Administration
Penalty
Summary
The facility failed to timely document administered medications per facility policy for three residents, leading to a deficiency in pharmaceutical services. Resident 6, who was readmitted with diagnoses including pneumonia, congestive heart failure, and gastrostomy, had an unsigned scheduled administration of multiple medications at 9:00 a.m. on the Medication Administration Record (MAR) as of 12:32 p.m. Resident 7, with diagnoses including diabetes mellitus and gastrointestinal bleed, also had an unsigned scheduled administration of several medications at 9:00 a.m. Resident 8, diagnosed with multiple sclerosis and COVID-19, similarly had an unsigned scheduled administration of medications at 9:00 a.m. During an observation and interview, Registered Nurse 2 was found about to sign the MAR for the 9:00 a.m. medications at 12:32 p.m., confirming that the medications were administered on time but not documented immediately as required by the facility's policy. The Quality Assurance Nurse confirmed that the facility's policy mandates that medication administration must be documented immediately after it is given, and it was unacceptable to delay signing the MAR until hours after administration.
Failure to Notify Physician of Resident's Refusal of Care
Penalty
Summary
The facility staff failed to ensure proper physician notification for a resident's change of condition, specifically when the resident refused basic care multiple times. The resident, who was admitted with diagnoses including rectal carcinoma and colostomy, had intact cognition and required moderate assistance for daily activities. Despite the resident's repeated refusals of care, there was no documentation of these incidents in the medical record, nor was there evidence that the physician was notified as required by the facility's policy. Interviews with staff, including CNAs and the Director of Staff Development, confirmed that the resident had refused care and that the charge nurse was informed. However, the charge nurse did not report these refusals to the physician or document them as a change of condition. The Quality Assurance Nurse also validated the absence of documentation regarding the refusals, which was a breach of the facility's policy to notify the physician and document any changes in a resident's condition promptly.
Failure to Implement Care Plan for Resident's Refusal of Care
Penalty
Summary
The facility staff failed to develop and implement a comprehensive care plan for a resident who had multiple episodes of refusing basic care. The resident, who was admitted with diagnoses including carcinoma in the rectum, a colostomy, and abnormalities of gait and mobility, required moderate assistance for activities of daily living. Despite having intact cognition for daily decision-making, the resident's refusals of basic care were not documented in a care plan, which is a requirement according to the facility's policy and procedures. Interviews with facility staff, including CNAs and the Director of Staff Development, confirmed that the resident had been refusing basic care and that these refusals were reported to the charge nurse. However, the charge nurse did not document these refusals in a care plan, nor was there any indication that the refusals were reported to the medical doctor as required. The Quality Assurance Nurse also validated the absence of a care plan addressing the resident's refusals, highlighting a failure to adhere to the facility's policy of updating care plans when there is a change in a resident's condition.
Improper Setup of LAL Mattress for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with the resident's needs and professional standards of care by improperly setting up a low air loss (LAL) mattress for a resident. The resident, who was admitted with diagnoses including paraplegia, diabetes mellitus, and osteomyelitis, was identified as having a pressure ulcer and was at high risk for developing additional pressure ulcers. The resident's Minimum Data Set indicated the need for a pressure-reducing device for the bed, and a physician's order specified the use of an LAL therapy bed to be monitored every shift. During an observation and interview, it was found that the LAL mattress was set at a weight of 200 pounds, despite the resident's actual weight being 149 pounds. The Treatment Nurse confirmed that the mattress should have been set according to the resident's current weight. The Director of Staff Development also stated that the LAL mattress should be set based on the resident's weight. The facility's policy on support surface guidelines indicated that individuals at risk for pressure ulcers should be placed on a redistribution support surface, which was not properly adhered to in this case.
Failure to Change Oxygen Therapy Equipment as Per Policy
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not ensuring the nasal cannula tubing and humidifier for oxygen therapy were changed according to the facility's policy. The resident, who was admitted with diagnoses including pneumonia, COPD, and acute on chronic respiratory failure, required continuous oxygen therapy to maintain oxygen saturation levels between 88-92%. During an observation, it was noted that the nasal cannula tubing and humidifier bottle were dated two weeks prior, and the humidifier bottle was empty, indicating that the equipment had not been changed as required. Interviews with facility staff confirmed the oversight. A Licensed Vocational Nurse acknowledged that the equipment needed to be changed and recognized the risk of infection due to the oversight. A Registered Nurse further confirmed that the facility's policy required the nasal cannula tubing and humidifier to be replaced weekly or as needed if soiled or empty. The facility's policy also stipulated checking the water level of the humidifier every 48 hours and changing it when low. The failure to adhere to these guidelines had the potential to cause complications associated with oxygen therapy.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to effectively and timely manage pain for two residents, leading to significant discomfort and complications. Resident 2, who had severe cognitive impairments and was dependent on assistance for daily activities, experienced severe pain in the left knee. Despite complaints of pain and visible symptoms such as swelling and warmth, the facility did not escalate the situation promptly. The resident's family intervened, leading to the resident being transferred to a hospital emergency room. The facility's policy required prompt notification of changes in a resident's condition, which was not adhered to in this case. Resident 3, admitted for pain management due to neoplasm-related pain, also suffered from inadequate pain management. The resident experienced severe pain affecting appetite and sleep, and the prescribed pain medication was not administered consistently as ordered. Despite the resident's discomfort and the family member's concerns about retaliation, the facility did not adjust the pain management plan effectively. The facility's policy on administering medications emphasized the importance of following prescriber orders and considering the resident's needs, which was not followed. Interviews with staff and family members highlighted the facility's failure to adhere to its policies and procedures regarding pain management and changes in residents' conditions. The staff did not use a consistent approach to assess and manage pain, and the facility did not ensure that pain management was tailored to the residents' cognitive levels and needs. This resulted in unnecessary pain and discomfort for the residents, impacting their quality of life.
Delayed Response to Resident's Knee Pain
Penalty
Summary
The facility failed to ensure timely assessment and care for a resident experiencing severe left knee pain. The resident, who was admitted with diagnoses including a urinary tract infection, dementia, and hyperlipidemia, was noted to have severe cognitive impairments and was dependent on assistance for all activities of daily living. Despite the resident's family member reporting knee pain and swelling, the facility delayed in escalating the situation and providing appropriate medical intervention. On October 31, 2024, an SBAR communication tool noted edema and inflammation in the resident's left leg, prompting a request for an X-ray, which showed no fractures. However, the resident continued to experience pain and swelling, which was not adequately addressed. By November 2, 2024, the resident's condition had worsened, with the left knee being warm to touch and painful, leading the family member to call emergency services for hospital transfer. Interviews with facility staff revealed that the resident's condition should have been escalated sooner, given the worsening symptoms. The facility's policy required prompt notification of the resident's physician and family in the event of significant changes in the resident's condition, which was not adhered to in this case. The delay in addressing the resident's pain and swelling resulted in unnecessary suffering for the resident.
Failure to Notify Responsible Party of Resident's Discharge
Penalty
Summary
The facility failed to notify the responsible party of a resident about the reasons for the resident's discharge and transfer to a hospital. The resident, who had a history of paranoid schizophrenia, cerebral palsy, bipolar disorder, and anxiety disorder, exhibited suicidal ideation and aggressive behavior, leading to multiple hospital transfers. On the day of the incident, the resident attempted to harm themselves and others, prompting the facility to call emergency services for a transfer to the hospital. Despite these events, there was no documentation indicating that the resident's responsible party was informed about the transfer or the reasons for the discharge. The facility's policy requires that any facility-initiated transfer or discharge must meet specific criteria, including notifying and orienting the resident or their representative. However, in this case, the responsible party was not informed about the transfer or the reasons for the resident's non-readmission to the facility. Interviews with the hospital social worker and the resident's responsible party revealed that the responsible party was willing to consider a transfer to a different facility but needed to be informed about the new facility beforehand, which was not done.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in injuries. Resident 3, who had a history of non-compliance and mood problems, was not adequately monitored according to their care plan. This lack of monitoring led to Resident 3 physically assaulting Resident 1 and Resident 2 in the activity room, despite staff presence. Resident 1 sustained a bloody lip and jaw pain, requiring transfer to a hospital for evaluation. Resident 3's care plan indicated a need for monitoring due to mood problems, but there was no documentation of such monitoring. The Minimum Data Set (MDS) for Resident 3 showed no issues with depression or lack of interest, which contradicted the care plan. After the incident, Resident 3 expressed remorse but was discharged to a lower level of care facility. The facility's failure to monitor Resident 3's mood and behavior as per the care plan contributed to the incident. Interviews with staff and residents revealed that the altercation occurred in the activity room where supervision was present. The assistant activities director witnessed the incident and attempted to intervene. Despite the presence of staff, the facility's policies lacked specific references to abuse prevention, focusing instead on investigation and reporting. The administrator confirmed that the incident was reported to relevant authorities, but the facility's failure to prevent the abuse was evident.
Failure to Implement Care Plan Interventions After Resident Altercation
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for two residents following an altercation. Resident 2, who has a history of hemiplegia and altered mental status, was involved in an altercation with another resident. Despite the care plan indicating that Resident 2 should be monitored for changes in conduct, there were no progress notes documenting such monitoring after the incident. The Director of Nursing confirmed that Resident 2 was not monitored every shift as required by the care plan. Resident 3, diagnosed with peripheral vascular disease and cellulitis, also had a care plan that required monitoring for mood problems. However, there were no progress notes indicating monitoring for episodes of sadness or loss of interest. The Director of Nursing stated that the nurses did not monitor Resident 3 for this care plan due to the absence of a psychiatric diagnosis. The facility's policies on care plans and documentation require that all services and changes in the resident's condition be documented, which was not adhered to in these cases.
Failure to Arrange Transportation for Resident's Eye Appointment
Penalty
Summary
The facility failed to provide necessary social services to a resident by not following up on an ophthalmology evaluation appointment. The resident, who had intact cognition for daily decision-making and required varying levels of assistance with daily activities, missed a scheduled eye care specialist appointment due to the facility's failure to arrange transportation. The resident had been admitted with multiple diagnoses, including schizophrenia, acute kidney failure, diabetes mellitus, and depression. The deficiency occurred because the Licensed Vocational Nurse (LVN) scheduled the appointment and completed a transportation request form but did not inform the Social Services Director (SSD) as per the facility's process. The SSD, responsible for coordinating transportation, was not aware of the appointment and thus did not arrange transportation. The Director of Nursing (DON) was also unaware of the missed appointment, indicating a breakdown in communication and follow-up between the LVN and SSD. The facility's policy required coordination with the Department of Social Services for such appointments, which was not effectively executed in this case.
Incomplete Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a complete baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with diagnoses including encephalopathy and type two diabetes mellitus, had severely impaired cognitive skills and required assistance with various daily activities. Despite these needs, the baseline care plan was initiated but not fully completed, missing critical sections such as skin care, bowel/bladder needs, discharge goals, ethical/cultural preferences, nail care, equipment, meal location preference, and special treatments/procedures. Interviews with the LVN and the Interim Director of Nursing confirmed that the baseline care plan was not completed thoroughly, which was against the facility's policy that mandates a complete baseline care plan within 48 hours of admission. The incomplete care plan had the potential to delay necessary care and services for the resident, as it did not provide the minimum healthcare information necessary to properly care for the resident until a comprehensive care plan could be developed.
Failure to Administer and Document Wound Care for Residents
Penalty
Summary
The facility failed to provide necessary treatment and services for two residents, Resident 3 and Resident 5, consistent with their needs and professional standards of practice. Resident 3, who was admitted with multiple pressure injuries, including an unstageable pressure injury on the right posterior hip, did not receive the prescribed wound treatment on two occasions. The treatment involved applying Santyl ointment, cleaning with Normal Saline, and covering with a foam dressing, as per the physician's order. However, documentation in the Treatment Administration Record (TAR) indicated that the treatment was not administered on the specified dates. Similarly, Resident 5, who had a Stage IV pressure ulcer on the coccyx, did not receive the prescribed wound treatment on four occasions. The treatment plan included applying Medi honey paste, cleansing with Normal Saline, and covering with bordered gauze. The TAR for Resident 5 showed missing documentation for these treatments, indicating they were not performed as ordered by the physician. Both residents had severely impaired cognitive skills and required significant assistance with daily activities, increasing their vulnerability to further skin breakdown and infection. Interviews with the Treatment Nurse and Interim Director of Nursing confirmed the lack of documentation and acknowledged that if a treatment is not documented, it is considered not done. The facility's policies on wound care and documentation emphasize the importance of recording all treatments and services provided to residents. The failure to adhere to these policies resulted in the potential for worsening of the residents' pressure injuries and possible infection.
Failure to Implement Care Plans for Vaccine Refusals
Penalty
Summary
The facility failed to implement a comprehensive care plan for three residents who refused vaccinations, including COVID-19, pneumonia, and influenza vaccines. Resident 1, who was admitted with acute kidney failure and hypertension, had mildly impaired cognitive skills and refused these vaccines on multiple occasions. Despite these refusals, no care plan was developed to address the potential health risks associated with the lack of vaccination. Similarly, Resident 2, with intact cognitive skills and diagnoses of type two diabetes mellitus and osteomyelitis, refused the COVID-19 vaccine, yet no care plan was initiated to manage this refusal. Resident 4, who had chronic obstructive pulmonary disease, a urinary tract infection, and asthma, also refused the COVID-19, pneumonia, and influenza vaccines. The resident's cognitive skills were moderately impaired, but again, no care plan was developed to address the refusal of vaccinations. During a review, a registered nurse confirmed the absence of care plans for these residents, acknowledging that such plans are necessary to guide licensed nurses in managing the residents' care and monitoring for signs and symptoms of diseases they are more susceptible to due to their refusal of vaccines.
Failure to Implement COVID-19 Precautions and PPE Compliance
Penalty
Summary
The facility failed to implement physician-ordered transmission-based precautions for three residents who tested positive for COVID-19. Resident 4, who was admitted with chronic obstructive pulmonary disease, urinary tract infection, and asthma, required maximal assistance for activities of daily living and was ordered to be on droplet isolation precaution for 10 days. However, there was no signage outside Resident 4's room indicating the type of transmission-based precaution, as observed during a survey. Similarly, Resident 5, with cerebrovascular disease and epileptic seizures, and Resident 6, with diabetes mellitus and pulmonary embolism, were also ordered to be on droplet isolation precaution, but their rooms lacked the necessary signage. The facility's policy on infection prevention and control measures, revised in January 2023, mandates that signage on the use of specific personal protective equipment (PPE) be posted in appropriate locations, such as outside a resident's room. During an interview, a registered nurse confirmed that the residents who tested positive for COVID-19 should have had signage outside their doors to inform staff and visitors of the necessary precautions. The absence of such signage indicates a failure to adhere to the facility's policy and the physician's orders, potentially increasing the risk of infection transmission. Additionally, the facility did not ensure that Dietary Staff 1 wore a fit-tested N95 respirator, as required during a COVID-19 outbreak. Instead, DS 1 was observed wearing a KN95 mask, which is not approved for healthcare use in the United States. The dietary supervisor and RN 1 confirmed that all staff must wear N95 respirators during an outbreak. The facility's policy, revised in June 2024, specifies that source control measures, including the use of NIOSH-approved N95 respirators, are to be utilized during high community transmission levels. The failure to comply with these requirements further compromised infection control efforts within the facility.
Incomplete POLST Form Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident's clinical record was updated in accordance with its policy and procedure regarding the Physician Orders for Life-Sustaining Treatment (POLST). The deficiency involved a resident who was admitted with acute kidney failure and hypertension. The Minimum Data Set (MDS) indicated that the resident had mildly impaired cognitive skills for daily decision-making, and the POLST form in the resident's chart was incomplete. Specifically, the POLST was not signed by the physician, which is necessary to confirm the accuracy and validity of the form. The incident was highlighted when the resident was found hypoxic and unresponsive, with an oxygen saturation of 87%, leading to the administration of cardiopulmonary resuscitation (CPR). During a review, a registered nurse confirmed that the POLST was incomplete due to the lack of a physician's signature. The facility's policy requires that the Social Service Department and nursing staff ensure residents' desires regarding CPR are documented, and the physician must sign the POLST and write an order for the resident's code status. The failure to complete the POLST form violated the resident's right to be fully informed and could potentially lead to conflicts with the resident's healthcare wishes.
Failure to Report Resident Death Timely
Penalty
Summary
The facility failed to adhere to its policy and procedure for incident reporting regarding an unusual occurrence involving a resident's death. The resident, who had been admitted with acute kidney failure and hypertension, tested positive for COVID-19. Despite being alert and oriented with no signs of respiratory distress or impending death, the resident passed away unexpectedly. The facility did not report this unusual occurrence to the State Survey Agency within the required 24-hour timeframe, nor did it send a written report within 48 hours as mandated by their policy. This deficiency resulted in a delay of an onsite inspection by the Department of Public Health, which could have potentially affected other residents during a COVID-19 outbreak. Interviews with nursing staff revealed that the resident showed no signs of distress or impending death prior to passing, and the facility's policy required such events to be reported promptly to appropriate agencies. The failure to report the resident's death in a timely manner was a breach of the facility's own procedures and state regulations.
Failure to Document Controlled Drug Administration
Penalty
Summary
The facility failed to ensure that the Controlled Drug Record (CDR) coincided with the Medication Administration Records (MAR) for four of five sampled residents. This discrepancy was observed during a survey, where medications that are considered to have a strong potential for abuse were not properly documented in the CDR after being administered to the residents. The medications involved included Norco, Ativan, and Lyrica, which were administered to residents without being signed out on the CDR at the time of administration. Resident 7, who had intact cognition, was administered Norco for pain management, but the medication was not signed out on the CDR. Similarly, Resident 9, with moderately impaired cognition, received Ativan for anxiety, but the CDR did not reflect its removal from storage. Resident 11, with severely impaired cognition, was given Lyrica for nerve pain, but the doses were not recorded on the CDR. Lastly, Resident 13, with intact cognition, was administered Ativan, but the CDR was not updated accordingly. In each case, the responsible Licensed Vocational Nurses (LVNs) admitted to forgetting to sign out the medications due to being in a rush. The Director of Nursing (DON) confirmed that medication administration and narcotic documentation should occur at the time of administration and removal from storage, respectively. The facility's policy and procedure for administering medications and controlled drugs require immediate documentation on the narcotic drug record after a dose is administered. The failure to adhere to these procedures resulted in discrepancies between the MAR and CDR, potentially leading to medication errors and drug diversion.
Failure to Administer Medication According to Physician's Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering Ativan as per the physician's order. The resident, who was admitted with diagnoses including major depressive disorder, anxiety disorder, and Alzheimer's disease, had an order for Ativan 0.5 mg to be given every 12 hours as needed for anxiety, which expired after 14 days. However, the medication was administered after the order had expired, indicating a lapse in following the physician's directive. The Licensed Vocational Nurse (LVN) involved did not notice that the Ativan order had expired and administered the medication without verifying the physician's order. Additionally, the LVN failed to document the administration of Ativan in the Medication Administration Record (MAR). The Director of Nursing (DON) emphasized the importance of having an active physician's order and verifying the five rights of medication administration before giving medications. The facility's policy required checking the medication label three times and documenting in the MAR, which was not adhered to in this instance.
Inaccurate Posting of Direct Care Staffing Hours
Penalty
Summary
The facility failed to ensure the accuracy of the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care on two sampled days. On both 8/1/2024 and 8/2/2024, the Direct Care Services Hours Per Patient Day (DHPPD) posted on the wall indicated incorrect actual PPD hours of 3.58 and 3.61, respectively. These postings included information about total staff and starting census for each shift but were based on projected hours rather than actual hours worked. Interviews with the Director of Staff and Development (DSD) and the Director of Nursing (DON) revealed that the facility's practice was to post projected staffing hours rather than actual hours. The DSD confirmed that the actual number of staff working was not calculated within two hours of the beginning of each shift, as required by the facility's policy. The DON acknowledged that the posted DHPPD hours were inaccurate and that the actual number of staff and total census should have been calculated and updated within the specified timeframe.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 436, who experienced severe, unrelieved pain in the hands, legs, and stomach. Despite the resident's repeated requests for pain medication and reports of pain to the staff, the facility did not address these concerns effectively. The resident was observed grimacing and expressing distress due to pain, which was not adequately managed from May 11, 2024, to May 22, 2024. The resident's pain was rated as high as 8 out of 10 on the pain scale, yet the facility did not administer the maximum allowed doses of prescribed pain medication. The facility's staff, including Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs), were aware of the resident's pain but failed to notify the resident's physician or the interdisciplinary team about the ineffectiveness of the pain management interventions. The resident's physician was only informed of the situation on May 22, 2024, despite the ongoing pain issues. The facility's policy required notification of the physician within 24 hours of a change in the resident's condition, which was not adhered to in this case. The resident, who had a history of conditions such as unspecified cirrhosis and anxiety disorder, was at risk of physical and psychosocial decline due to unmanaged pain. The facility's failure to evaluate the effectiveness of the pain medication and to consult with the physician for alternative pain management strategies contributed to the resident's continued suffering and inability to perform daily activities, such as walking with a walker, due to severe leg pain.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that two out of twelve sampled residents had Advance Directives or Advance Directives Acknowledgement forms documented in their active medical records. Resident 1, who was initially admitted with severe cognitive impairment and multiple diagnoses, did not have an Advance Directive or Acknowledgement form in their chart. This was confirmed during a review with the Registered Nurse Supervisor, who acknowledged the importance of having such documentation to honor the resident's wishes in critical conditions. Similarly, Resident 15, who had intact cognitive skills and the capacity to make medical decisions, also lacked a completed Advance Directive Acknowledgement form. The Medical Records Director and Social Services Assistant confirmed that the form was blank and not completed, despite the social service department being responsible for this task upon admission or readmission. The absence of this documentation could result in the resident's medical treatment preferences not being honored. The facility's policy required that residents or their representatives be provided with information about their rights to accept or refuse medical treatment and to formulate an advance directive. This information was to be provided in a manner easily understood by the resident or representative. However, the policy was not followed, as evidenced by the missing documentation for Residents 1 and 15, which was confirmed by the Director of Nursing and other staff members.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to adhere to professional standards and its own policies regarding the labeling and dating of food items, which placed all 127 residents at risk for foodborne illnesses. During an observation of the facility's kitchen, it was noted that a box containing 13 potatoes in the dry storage section was not labeled or dated. Additionally, one opened and two unopened packages of frozen breaded fish in freezer 1, as well as an opened bottle of creamer in the refrigerator, were also found without labels or open dates. The Dietary Supervisor confirmed these items were unlabeled and undated, acknowledging that food labeling is essential to prevent foodborne illness. The Director of Nurses reiterated the importance of labeling and dating all food stored in the kitchen to ensure the safety of the residents and prevent food poisoning. A review of the facility's policies and procedures indicated that all food items in storage areas must be labeled and dated, with specific guidelines for dry goods, refrigerated, and frozen items. The facility's failure to comply with these guidelines and procedures led to the deficiency, as observed by the surveyors.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor the shower preferences of Resident 58, who was admitted with diagnoses including acute kidney failure, diabetes, and heart failure. Despite being cognitively intact and capable of making decisions, Resident 58 had not received a shower in two months, leading to feelings of discomfort and uncleanliness. The resident was dependent on staff for bathing and had not rejected care, yet the facility did not provide the requested shower, instead offering a bed bath. Certified Nursing Assistant 2 (CNA 2) admitted to not providing a shower due to a lack of assistance with the Hoyer lift, which was necessary for transferring the resident. CNA 2 did not seek help for the transfer and was unaware of how long it had been since the resident last received a shower. The Director of Nursing confirmed that residents should be showered unless a medical condition prevents it. The facility's policies emphasize treating residents with dignity and supporting their rights, including self-determination and personal grooming preferences.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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