La Crescenta Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in La Crescenta, California.
- Location
- 3050 Montrose Ave, La Crescenta, California 91214
- CMS Provider Number
- 055960
- Inspections on file
- 41
- Latest survey
- July 19, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at La Crescenta Healthcare Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk for residents.
A resident with multiple chronic conditions did not receive a scheduled 9 AM medication pass on time, resulting in a delay of over two hours. The resident became angry and frustrated due to the wait. The LVN responsible admitted to being late because of attending to other residents, and the medication administration record confirmed that 20 medications, including those for hypertension and atrial fibrillation, were given late. Nursing staff and the DON acknowledged that this was not in accordance with facility policy, which requires medications to be administered within 60 minutes of the scheduled time.
Surveyors observed that waste dumpsters were overflowing and left with lids open, contrary to facility policy requiring closed lids and a clean trash area. The Administrator acknowledged the issue, noting that heavy lids sometimes prevented staff from closing them after use.
Staff members, including the Activity Director and Director of Staff Development, were observed serving and preparing food trays and making direct contact with six residents during meal service without performing hand hygiene before and after each interaction. The residents involved had complex medical conditions, and staff interviews revealed a lack of awareness regarding the facility's hand hygiene policy. Facility policies require hand hygiene between resident contacts, but this was not followed, resulting in a deficiency in infection prevention and control.
The facility's dishwasher was found to be operating without dispensing the required chlorine sanitizer, as confirmed by repeated testing that showed no color change on chlorine test strips. The Dietary Supervisor acknowledged that foodware cleaned after the last successful check may not have been sanitized, and a technician later identified a disconnected sanitizer line as the cause.
A resident was allowed to self-administer over-the-counter nasal spray and eye drops without an assessment, physician order, or proper documentation. The resident stored these medications at the bedside in an unsecured manner, and staff were unaware of the self-administration. Facility policy requiring assessment, monitoring, and secure storage for self-administered medications was not followed.
Two residents with significant physical and cognitive impairments were found with their call lights out of reach, contrary to facility policy and individualized care plans. Staff confirmed that both residents, who were dependent on assistance and at high risk for falls or had visual deficits, could not access their call lights to request help when needed.
A resident with multiple medical conditions repeatedly refused podiatric care for fungal nail infection and an ingrown toenail, but staff failed to develop or implement a care plan addressing these refusals. Nursing staff were unaware of the ongoing refusals, and there was no documentation of education, risk discussion, or alternative treatments as required by facility policy. The DON confirmed that no interdisciplinary team meeting or care plan was created to address the resident's needs.
A resident with respiratory and other chronic conditions did not receive supplemental oxygen as ordered when their oxygen saturation dropped below the physician-specified threshold. Staff failed to monitor and document pulse oximetry or administer oxygen as needed, resulting in the resident being without oxygen for over 30 minutes and experiencing low oxygen saturation, which was only corrected after intervention.
Surveyors identified that the facility exceeded the acceptable medication error rate, with errors including a nurse failing to check a resident's heart rate before administering blood pressure medications as required by physician orders, and another instance where a nurse prepared the wrong dose of Vitamin B12 for a resident. Both errors were identified before the medications were administered, and facility policy requires verification of medication orders and vital signs prior to administration.
A nurse failed to check a resident's heart rate before administering Hydrochlorothiazide and Verapamil, despite physician orders requiring both blood pressure and heart rate to be assessed prior to administration. The omission was identified during a medication pass observation, and the nurse acknowledged the oversight. Facility policy requires vital signs to be checked as ordered before giving such medications.
Staff failed to discard two insulin pens for a resident with diabetes after the required 28-day period, leaving expired medications in a medication cart despite facility policy and staff awareness. The resident had severely impaired cognition and no capacity for decision-making, and the expired insulin pens included one that was no longer ordered.
Surveyors found that nutritional supplements, including an opened and undated Ensure Plus and an improperly stored Vital Cuisine Milkshake, were kept in medication carts without proper labeling or storage as required by facility policy. The DON confirmed that these practices did not meet the facility's food storage standards and could result in food spoilage.
A resident with dementia and other medical conditions experienced a violation of rights when their family member's grievances about care inconsistency and registry staff assignments were not promptly resolved. Despite multiple grievances, the facility failed to update the resident's care plan or provide written resolutions, leading to continued assignment of registry staff against the family's wishes.
A resident with dementia and a history of skin issues was not provided with Geri sleeves as required by her care plan, despite being at risk for skin damage due to self-pinching and scratching. Staff interviews and observations confirmed the absence of these protective measures, which were supposed to be in place to prevent further skin damage.
A resident reported that their assigned LVN did not administer blood pressure medications directly, instead delegating the task to CNAs or other nurses, contrary to facility policy. The resident, who was cognitively intact and capable of making healthcare decisions, expressed concerns about the LVN's competence and felt neglected. Interviews confirmed the LVN's delegation of medication administration due to a poor relationship with the resident, violating the facility's policy that only licensed personnel may administer medications.
A resident with dementia experienced increased agitation and combative behavior due to the facility's failure to implement a person-centered care plan that respected her preference to avoid registry staff of a certain ethnicity. Despite repeated grievances filed by a family member, the facility continued to assign registry staff, leading to episodes of agitation and physical harm. Additionally, the resident was not consistently wearing the correct identification bracelet, as required by facility policy.
A resident with a history of cerebral infarction, cardiac pacemaker, atrial fibrillation, and dementia did not receive meals according to their prescribed very low-carbohydrate, double protein, 1200-calorie diet. Observations showed the resident was served meals that did not match dietary requirements, such as receiving toast, a whole banana, and juice, while missing the required double portion of protein. The facility's dietary supervisor and registered dietitian confirmed the meals did not align with the ordered menu card, leading to an unintentional weight gain.
A resident with Alzheimer's, a history of falls, and impaired cognitive skills was found without a required personal safety alarm (PSA) on their bed, despite facility policy and physician orders mandating its use. Staff confirmed the absence of the PSA, which was crucial for alerting them when the resident attempted to get out of bed unassisted. This oversight occurred despite the facility's policy requiring regular checks for PSA placement.
A resident with a history of cerebral infarction, depressive disorder, and anxiety disorder was subjected to a diaper change despite her refusal, leading to an accidental injury. The staff, including an LVN and CNAs, did not follow the care plan protocol to notify the family, who could have calmed the resident. The facility's policy on refusal of care was not adhered to, resulting in a violation of the resident's rights.
A resident in a LTC facility received their lunch tray 45 minutes late, affecting the meal's palatability and temperature. The delay was due to the kitchen's difficulty in locating the tray, as observed by the DSD. The resident, who requires assistance with eating and has multiple health conditions, consumed less than 50% of the meal. The facility's policy mandates timely meal delivery to ensure proper food temperature and palatability, which was not adhered to in this instance.
A resident with a history of fractures and thrombocytopenia was found with unexplained bruising and rib fractures. Despite facility policy requiring immediate reporting of suspected abuse, the incident was not reported to authorities within the required timeframe. Staff interviews revealed lapses in documentation and communication, contributing to the delay.
The facility failed to properly dispose of garbage and refuse, with three metal dumpsters found uncovered and overflowing, along with additional trash left on the ground. This was confirmed by the Housekeeping and Maintenance Supervisors, and interviews with staff highlighted the health risks associated with pests. Facility policies on Pest Control and Sanitation were not followed.
The facility failed to ensure that Advance Directives (AD) and Physician Orders for Life-Sustaining Treatment (POLST) were offered, obtained, and accessible in the medical records for four residents. This deficiency was confirmed through interviews and record reviews, revealing that the AD acknowledgment forms and POLSTs were missing or incomplete, potentially impacting the residents' treatment preferences during emergencies.
The facility failed to provide required ROM and mobility treatments for three residents, including missing RNA treatments, not applying splints as ordered, and failing to complete quarterly rehabilitation screens, potentially leading to further decline in their functional mobility and ROM.
The facility failed to ensure resident safety by not keeping heating units free of potentially flammable items. One resident had paper books on their heating unit, and another had plastic containers stored on theirs. Staff confirmed that these practices are fire hazards and against facility policy.
The facility failed to ensure that controlled drug administrations were documented in the eMAR for two residents and did not have a policy for accurate usage of the Emergency Medication Supplies (E-kit), leading to missing entries in the E-kit logbook.
A facility failed to lock a medication cart when left unattended in the hallway, making various medications accessible to unauthorized individuals. RN2 acknowledged forgetting to lock the cart, which contained medications like Aspirin, Vitamin C, and Plavix. This action violated the facility's medication management policies.
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency, leading to incorrect procedures for testing chlorine concentration, Quat sanitizer concentration, and improper cooling of food. These failures had the potential to result in cross-contamination, ineffective dish machine sanitation, unsanitized food preparation areas, and bacterial growth in food, posing health risks to 85 medically compromised residents.
The facility failed to follow the menu for 32 residents on a Regular texture diet by not adhering to the specified portion size for paprika chicken. Observations revealed inconsistent chicken sizes, with some portions exceeding the prescribed 3 ounces. This practice was contrary to the facility's menu spreadsheet and policies, placing residents at risk of not meeting their nutritional needs.
The facility failed to ensure safe and sanitary food storage and preparation practices, including maintaining clean equipment, preventing cross-contamination, and proper food storage. Observations revealed rust-like discoloration on storage racks, dirty storage containers, and unclean floors and vents. Additionally, dented cans, improperly stored utensils, and staff not following proper sanitization procedures were noted. Cracked trays, improper cooling of food, and expired food were also found, posing potential health risks to residents.
The facility failed to obtain informed consent for psychotropic drugs for a resident with dementia, psychotic disorder, and depression. The resident's informed consent form was incomplete, lacking the physician's name, signature, and date. This oversight was confirmed through interviews and record reviews, revealing a violation of the resident's rights to be informed and make decisions about their care.
The facility failed to provide reasonable accommodations for the needs and preferences of two residents by not ensuring the overhead light cord was within their reach. Both residents, who have significant medical conditions, were unable to turn the light on or off without assistance, contrary to their care plans and the facility's policy on Quality of Life - Dignity.
The facility failed to provide adequate lighting for a resident, leading the resident to spend most of the time in the hallway due to the dark room. Despite the resident's high risk for falls and a care plan emphasizing a safe environment, the facility did not address the resident's lighting preferences.
The facility failed to develop individualized resident-centered care plans for two residents. One resident's care plan lacked measurable objectives for activity participation, while another's care plan did not specify why the resident could not attend group activities. Both care plans were found to be non-specific and not resident-centered, potentially affecting the residents' psychosocial wellbeing.
The facility failed to provide necessary care and services to a resident dependent on staff for ADLs by not maintaining grooming and personal hygiene, specifically neglecting to shave long facial hairs. Staff interviews and facility policies confirmed the importance of grooming for dignity and quality of life, but the facility did not adhere to these guidelines.
The facility failed to provide sufficient hydration to a resident with severe cognitive impairment, who was found without a water cup or pitcher at her bedside despite her care plan's directives. Staff interviews revealed inconsistencies in hydration protocols, and the facility's policy on hydration was not followed.
A resident's call light was found stuck and unreachable, preventing her from calling for assistance. The resident, who had a history of falls and required assistance with ADLs, was observed struggling to put on a sweater and stated she was cold. Staff confirmed that the call light should always be within reach for safety and assistance.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Late Administration of Scheduled Medications
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including multiple sclerosis, hypertension, atrial fibrillation, prostate cancer, and anxiety disorder, did not receive his scheduled 9 AM medications within the facility's required timeframe. The resident was alert, oriented, and had intact cognitive skills, with care plans in place for hypertension, constipation, and cardiac function deficit, all of which included the intervention to administer medications as ordered. Despite these care plans, the resident's 9 AM medications were administered at 11:11 AM, more than two hours late. Observation and interviews revealed that the resident was visibly angry and frustrated due to the delay. The LVN responsible for administering the medications acknowledged the delay, stating she was busy with other residents and recognized the importance of timely medication administration, especially for managing the resident's depression, muscle spasms, and hypertension. The medication administration record confirmed that 20 different medications, including those for blood pressure and atrial fibrillation, were given late. Further interviews with nursing staff and the DON confirmed that the facility's policy requires medications to be administered within 60 minutes of the scheduled time to optimize drug therapy and ensure resident well-being. The late administration of medications was acknowledged as a deviation from both professional standards of practice and the facility's own policies, resulting in the resident's anger and frustration and the potential for his blood pressure to be affected.
Improper Disposal and Storage of Facility Waste
Penalty
Summary
During an observation in the facility's trash area, surveyors found that the blue waste dumpster was overflowing with trash and its lid was not closed, and one of the two black waste dumpsters also had its lid open. The Administrator confirmed responsibility for monitoring the trash area and stated that staff had reported the overflowing dumpster and open lids, leading to housekeeping cleaning the area later that day. The Administrator also noted that the dumpsters were large and had heavy lids, which sometimes prevented staff from closing them after disposing of trash. Facility policy requires that the dumpster area be kept clean and lids closed, but this was not followed at the time of the surveyor's observation.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
During a dining observation in the facility's Front Dining Room, the Activity Director (AD) and Director of Staff Development (DSD) were observed serving and preparing food trays, as well as touching the shoulders and hands of six residents, without performing hand hygiene before and after direct contact with each resident. This occurred despite the facility's policy requiring hand hygiene before and after direct contact with residents, after contact with objects in the immediate vicinity of the resident, and before and after assisting a resident with meals. The AD and DSD both indicated during interviews that they were unaware of the requirement to perform hand hygiene between each resident during mealtime service. The residents involved had significant medical histories, including conditions such as cerebral infarction, diabetes, chronic kidney disease, congestive heart failure, muscle wasting and atrophy, benign prostatic hyperplasia, white matter disease, iron deficiency anemia, peripheral autonomic neuropathy, hypertension secondary to renal disorders, and cardiac arrhythmias. These conditions were documented in their admission records and highlight the vulnerability of the population affected by the deficient practice. Interviews with the Registered Nurse (RN), Infection Preventionist Nurse (IPN), and Director of Nurses (DON) confirmed that staff are expected to perform hand hygiene between residents during mealtime to prevent cross-contamination. The facility's policies and procedures, as reviewed, emphasize the importance of hand hygiene as the primary means to prevent the spread of infection and require all personnel to adhere to these procedures. The failure to follow these protocols was directly observed and acknowledged by staff, constituting a deficiency in the facility's infection prevention and control program.
Dishwasher Failed to Dispense Chlorine Sanitizer
Penalty
Summary
The facility failed to maintain its dishwasher in proper operating condition, resulting in the dishwasher not dispensing chlorine sanitizer at the required concentration. During an observation, the dishwasher's water temperature was found to be 120°F, but when the Dishwasher Aid checked the chlorine level using a testing strip, the strip did not change color, indicating that the chlorine concentration was not within the required 50-100 PPM range. This was confirmed by repeating the test, which again showed no color change. The Dishwasher Aid reported that the last successful check of the chlorine level was approximately three hours earlier, at which time the reading was 50 PPM. The Dietary Supervisor confirmed that the dishwasher was expected to sanitize foodware at all times and acknowledged that items cleaned after the last successful check might not have been properly sanitized. The facility's policy required chemical low temperature dish-machines to maintain a water temperature of 120°F-140°F and a chlorine concentration of 50-100 PPM. The deficiency was further substantiated by a technician's report, which found that the sanitizer line was not reaching the chlorine chemical, preventing proper sanitization.
Failure to Assess and Monitor Resident Self-Administration of Medications
Penalty
Summary
The facility failed to follow its own policy and procedure for self-administration of medications for one resident. The resident, who had a history of a right leg wound, left leg fracture, and hypertension, was not assessed for the ability to self-administer medications prior to being allowed to do so. Despite having intact cognition and independence in self-care activities, there was no documented assessment by the interdisciplinary team or nursing staff to determine the resident's competency in self-administering medications, as required by facility policy. During observations, the resident was found storing and self-administering over-the-counter nasal spray and eye drops at the bedside without staff knowledge or oversight. The medications were not kept in a locked container, and the resident reported purchasing and using these medications independently for over a month. Nursing staff were unaware of the resident's self-administration practices, and there were no physician orders or documentation in the medical record for these specific medications. Additionally, there was no log or monitoring of the resident's self-administration, contrary to facility policy. Interviews with nursing staff and the DON confirmed that the facility's policies require an assessment, physician order, and proper storage of self-administered medications. The policies also mandate that self-administration be tracked and that medications stored at the bedside be secured to prevent access by other residents. These procedures were not followed, as evidenced by the lack of assessment, absence of orders, unsecured medication storage, and no monitoring or documentation of the resident's self-administration activities.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents by not ensuring that their call lights were within reach, as required by facility policy and care plans. For one resident with encephalopathy, bone density disorder, and atherosclerotic heart disease, who was assessed as high risk for falls and dependent on staff for most activities of daily living, the call light was observed hanging six inches from the floor and not accessible while the resident was in bed. Both a licensed vocational nurse and a registered nurse confirmed that the call light was not within reach and acknowledged that the resident could not use it to request assistance when needed. Similarly, another resident with dementia, Parkinson's disease, osteoarthritis, a history of fractures, and severely impaired cognition was found lying in bed with the call light hanging on the side of the bed, out of reach. The resident called for help, and a certified nursing assistant confirmed that the call light was not accessible to the resident, who otherwise knew how to use it. The facility's policies and care plans for both residents specifically required that call lights be kept within reach to address their high risk for falls and visual deficits. Interviews with staff, including the Director of Nursing, confirmed the expectation that call lights should always be within reach as per policy.
Failure to Develop and Implement Care Plan for Repeated Refusal of Podiatric Treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's repeated refusal of podiatric treatment for onychomycosis and an ingrown toenail. The resident, who had a history of postherpetic trigeminal neuralgia, secondary parkinsonism, and peripheral autonomic neuropathy, was assessed multiple times by a podiatrist and consistently refused toenail care and treatment on four documented occasions. Despite a physician's order for podiatry services and ongoing issues with the resident's toenails, including a partially black left great toe and reports of intermittent bleeding, there was no evidence that the refusals were addressed in the care plan. Interviews with nursing staff revealed a lack of awareness regarding the resident's repeated refusals of toenail care and treatment. The registered nurse assigned to the resident was not informed of the refusals, and the podiatrist's assistant typically reported to the charge nurse, but it was unclear if this information was communicated effectively. The RN Supervisor confirmed that there was no care plan in place to address the resident's refusals or to provide education about the risks associated with refusing care. A review of facility policies indicated that when a resident refuses treatment, staff are required to discuss risks and benefits, assess the reasons for refusal, provide education, and offer alternative treatments, all of which should be documented in the care plan. However, the Director of Nursing confirmed that there was no documentation of an interdisciplinary team meeting, no care plan addressing the refusals, and no evidence that alternative treatments or education were provided to the resident. This lack of action resulted in the resident's needs not being comprehensively addressed as required.
Failure to Provide Ordered Oxygen Therapy and Monitor Pulse Oximetry
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including pneumonia, chronic kidney disease, and peripheral autonomic neuropathy, did not receive oxygen therapy as ordered by the physician. The physician's order specified that the resident should receive 2 liters of oxygen as needed for shortness of breath or if oxygen saturation fell below 93 percent, and that oxygen saturation should be recorded. The resident's care plan also included interventions to provide supplemental oxygen as ordered for respiratory issues and anemia. During an observation, the resident was found in bed with the oxygen machine on and the nasal cannula placed on the bed rather than connected to the resident for over 30 minutes. Staff present, including an LVN, CM, and RN, confirmed that the resident should have been receiving oxygen via nasal cannula and that pulse oximetry should have been checked prior to administering oxygen. The LVN admitted to not remembering or recording the resident's pulse oximeter reading at the beginning of the shift. When checked, the resident's oxygen saturation was 85 percent on room air, which increased to 95 percent after oxygen was administered as ordered. A review of the resident's electronic health record and medication administration history showed no documentation that pulse oximetry was checked or that supplemental oxygen was administered as needed on the day in question. The facility's policies required monitoring of pulse oximetry and administration of oxygen therapy when indicated, but these were not followed. The DON confirmed that the resident should have had pulse oximetry checked at the beginning of the shift and received supplemental oxygen as ordered.
Medication Error Rate Exceeds 5% Due to Failure to Follow Physician Orders and Dosage Verification
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less during a medication pass, resulting in a cumulative error rate of 10% based on three errors out of 30 opportunities. During medication administration, a nurse prepared to give two medications, Hydrochlorothiazide and Verapamil, to a resident with a history of heart disease and hypertension. Although the nurse checked the resident's blood pressure, she did not check the heart rate as required by the physician's order, which specified to hold the medications if the systolic blood pressure was below 110 or the heart rate was below 60. The omission was identified by a surveyor before the medications were administered, and the nurse acknowledged forgetting to check the heart rate, confirming that both blood pressure and heart rate should be assessed prior to administration due to the medications' effects on these parameters. In another instance, a nurse prepared to administer Cyanocobalamin (Vitamin B12) to a resident with hypertension and hyperlipidemia. The physician's order specified a daily dose of 500 mcg, but the nurse was observed preparing a 1000 mcg tablet instead. The error was identified by the surveyor before administration, and the nurse confirmed that the incorrect dose was about to be given, stating that the physician's order was for 500 mcg and that giving 1000 mcg would be an error. Review of the facility's policies and procedures indicated that medications are to be administered in accordance with physician orders, and that medication labels and dosages must be verified against the medication administration record. The policies also require that vital signs be checked prior to administration when prescribed. The Director of Nursing confirmed that these procedures were in place and that failure to follow them could result in medication errors.
Failure to Check Heart Rate Before Administering Cardiac Medications
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to check a resident's heart rate prior to administering Hydrochlorothiazide and Verapamil, both of which were ordered with specific parameters to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. During a medication pass observation, the LVN checked the resident's blood pressure but did not check the heart rate before preparing and attempting to administer the medications. The surveyor intervened and questioned the LVN, who then acknowledged forgetting to check the heart rate and confirmed that the physician's order required it. The resident involved had diagnoses including atherosclerotic heart disease, hypertension, and a history of falls, with intact cognition and the capacity to make decisions. Facility policy and procedures reviewed by the Director of Nursing (DON) indicated that medications must be administered according to physician orders, including taking vital signs such as heart rate and blood pressure when required. The failure to follow these procedures and physician orders constituted a significant medication error as defined by the facility's policies.
Expired Insulin Pens Not Discarded per Policy
Penalty
Summary
Facility staff failed to follow established policies and procedures for medication storage and disposal when two insulin pens belonging to a resident were found in a medication cart past their 28-day expiration from the opened date. Observation and interviews confirmed that both an Insulin Glargine pen and an Insulin Lispro pen, each labeled with their respective opened dates, had not been discarded as required. The Insulin Glargine pen should have been discarded before its expiration, and the Insulin Lispro pen should have been discarded both due to expiration and because the order for it had been discontinued and replaced with another medication. The resident involved had a history of diabetes mellitus and hyperlipidemia, with severely impaired cognition and no capacity to make decisions, as documented in their medical records. Facility policy, as reviewed with the DON, clearly stated that insulin pens must be discarded within 28 days of first use or removal from refrigeration. Staff interviews confirmed awareness of this policy, yet the expired insulin pens remained accessible in the medication cart, contrary to facility procedures.
Improper Labeling and Storage of Nutritional Supplements in Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and storage of nutritional supplements and food products in medication carts, as required by facility policy. Specifically, an opened and undated carton of Ensure Plus was found in the bottom drawer of one medication cart, with no markings to indicate the date it was used or the resident for whom it was intended. The Minimum Data Set Nurse (MN) confirmed that the product should be discarded due to the lack of labeling, as it could be expired. Additionally, an unopened carton of Vital Cuisine Milkshake was found in another medication cart. The milkshake was labeled to be stored frozen but was found warm to the touch, in liquid form, and the carton was bulging with pressure felt when squeezed. The MN stated that the milkshake was expired due to improper storage and could cause illness if administered. The Director of Nursing (DON) reviewed the facility's policy, which requires proper food storage and discarding of leftovers not used within 48 hours, and confirmed that improper storage could lead to food spoilage.
Failure to Resolve Grievances and Update Care Plan
Penalty
Summary
The facility failed to ensure prompt resolution of grievances brought by a resident's family member, resulting in a violation of the resident's rights. The resident, who had diagnoses including cerebral infarction, cardiac pacemaker, atrial fibrillation, and dementia, was admitted to the facility with severely impaired cognition. The family member expressed concerns about inconsistency in care and specifically requested that the resident not be assigned to registry staff due to past negative experiences. Despite these requests, the facility continued to assign registry staff to the resident, and the grievance reports were not properly documented or resolved. The family member filed multiple grievances, including one reporting bruises on the resident's arms after being cared for by registry staff. The facility's follow-up included reporting the incident to authorities and providing staff training, but the resident's care plan was not updated to reflect the family's concerns. The facility's grievance policy requires that grievances be investigated, resolved, and documented, with findings communicated to the resident or their representative. However, the family member did not receive any written grievance resolutions, and the facility did not document specific interventions or resolutions for the grievances. Interviews with the family member and the Director of Nursing (DON) revealed that the facility acknowledged the grievances but stated that it was sometimes necessary to use registry staff. The DON admitted that no written grievance resolutions were provided to the family member, and the facility's grievance policy was not followed. The lack of documentation and communication regarding the grievances and the failure to update the resident's care plan contributed to the deficiency in addressing the resident's rights and preferences.
Failure to Implement Protective Measures for Resident's Skin Integrity
Penalty
Summary
The facility failed to implement a care plan for a resident who was at risk of skin damage due to self-pinching and scratching. The resident, who had a history of cerebral infarction, cardiac pacemaker, atrial fibrillation, and dementia, was supposed to wear Geri sleeves to protect her skin. Despite the care plan indicating the need for these protective sleeves, observations and interviews revealed that the resident was not wearing them, and they were not available in her room. Interviews with staff, including LVN1, CNA4, and CNA1, confirmed that the resident was seen pinching and scratching her arms, often due to hallucinations of seeing creatures on her skin. The MDS coordinator also confirmed that the care plan required the use of Geri sleeves, but during an observation, the resident was found without them. The Director of Nursing acknowledged the care plan requirement and the absence of the sleeves. The facility's policy on comprehensive care plans mandates that each resident's plan should include measurable objectives and interventions to meet their needs. However, the failure to provide the Geri sleeves as outlined in the care plan represents a deficiency in meeting the resident's medical and psychosocial needs, potentially compromising her quality of life and health.
Failure to Ensure Medications Administered by Licensed Personnel
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that medications were administered by licensed personnel only, as per the facility's policy and procedure titled Medication Pass Guidelines. This deficiency was identified for one resident who was admitted with diagnoses including peripheral vascular disease, paraplegia, and cardiomegaly. The resident, who was cognitively intact and capable of making healthcare decisions, reported that their assigned nurse, an LVN, did not administer blood pressure medications directly. Instead, the LVN delegated this task to CNAs or other nurses, which is against the facility's policy. The resident expressed concerns about the competence of the assigned LVN, stating that the LVN did not check their blood pressure before administering medications and did not provide direct care. The resident also reported feeling neglected and expressed a preference for a different medication nurse. Interviews with the Director of Nursing and the LVN confirmed that the LVN had been delegating medication administration to others due to a poor relationship with the resident. The facility's policy clearly states that only authorized personnel may prepare, administer, and record the administration of medication, which was not adhered to in this case.
Failure to Implement Person-Centered Care Plan for Dementia Resident
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident diagnosed with dementia, resulting in increased agitation and combative behavior. The resident, who had severely impaired cognition, expressed a preference not to be cared for by registry staff of a certain ethnicity, a request that was repeatedly communicated through the facility's grievance process by a family member. Despite this, the facility continued to assign registry staff to the resident, leading to episodes of agitation, refusal of care, and combative behavior, which resulted in bruising and discoloration on the resident's arms. The resident's care plans for cognitive loss, ADL functional/rehabilitation, aggressive behavior, and emotional and psychological deficits did not include specific interventions to address the resident's preference to avoid registry staff. The care plans also failed to communicate and endorse these interventions to facility staff. Additionally, the facility did not ensure the resident wore the correct identification bracelet at all times, as required by the facility's policy, which was reported by the family member. Interviews with staff and the resident revealed that the resident became agitated and combative when registry staff were involved in her care, particularly during an incident where the resident was prepared for an early morning appointment. The facility's failure to accommodate the resident's care preferences and ensure proper identification contributed to the resident's distress and physical harm, as evidenced by the bruising observed by the family member.
Failure to Follow Prescribed Diet Leads to Weight Gain
Penalty
Summary
The facility failed to adhere to the prescribed dietary orders for a resident, leading to an unintentional weight gain. The resident, who was on a very low-carbohydrate, double protein, 1200-calorie diet, did not receive meals in accordance with the correct order and prescribed portion sizes. Observations revealed that the resident was served meals that did not match the dietary requirements, such as receiving a breakfast tray with items not included in the diet order, like toast, a whole banana, and juice, while missing the required double portion of protein. The dietary supervisor confirmed that the meals served did not align with the ordered menu card, and the registered dietitian noted that the meals did not meet the prescribed diet. The resident's medical history included cerebral infarction, cardiac pacemaker, atrial fibrillation, and dementia, with severely impaired cognition. The resident's care plan indicated a significant weight gain over six months, which was not beneficial or planned. Despite the care plan's goals to maintain an acceptable weight and monitor food and fluid intake, the facility did not ensure the resident received the correct diet. The facility's policy and procedure for diet tray cards were not followed, as the tray card information did not match the diet prescribed by the physician, leading to the deficiency.
Failure to Ensure Personal Safety Alarm Placement for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a personal safety alarm (PSA) was placed on the bed of a resident who was assessed as a high risk for falls. The resident, who had a history of Alzheimer's disease, pelvis fracture, osteoporosis, and previous falls, was dependent on assistance for daily activities and had been identified as having severely impaired cognitive skills. The facility's policy required the use of a PSA to alert staff when the resident attempted to get out of bed unassisted, but during an observation, the PSA was not found on the resident's bed. The resident's care plan and physician orders specified the need for a PSA while in bed to remind the resident to call for assistance due to dementia and restlessness. Despite this, during an observation, the PSA was missing, and staff, including a CNA, PT, LVN, and RN, confirmed that the PSA was not in place and acknowledged its importance for the resident's safety. The absence of the PSA was noted during multiple interviews with staff, who recognized the potential risk of injury due to the resident's poor safety awareness and recent fall history. The facility's policy and procedure on personal safety alarms required licensed nurses to monitor the proper placement of PSAs every shift, and the administrator was responsible for ensuring compliance. However, the PSA was not in place during the observation, indicating a failure to adhere to the facility's policy. This deficiency had the potential to delay staff response when the resident attempted to get out of bed unassisted, increasing the risk of falls.
Failure to Respect Resident's Refusal of Care
Penalty
Summary
The facility failed to protect and promote the rights of a resident, identified as Resident 1, by not respecting her refusal of care during a diaper change. Despite Resident 1's agitation and refusal, LVN 1, CNA 2, and CNA 3 proceeded with the diaper change, which resulted in Resident 1 accidentally hitting her right hand against the bedrail, causing bruising. The incident occurred after Resident 1 had a bowel movement and resisted the care provided by the staff. Resident 1 had a history of cerebral infarction, depressive disorder, and anxiety disorder, and required varying levels of assistance with daily activities. The Minimum Data Set indicated that she needed substantial assistance with toileting. The resident's care plan included instructions to notify her family if she refused care, as her family could often calm her down. However, on the day of the incident, the staff did not inform the family despite being aware of this protocol. Interviews with the staff revealed that they were aware of the need to stop care and notify the family when Resident 1 refused care. LVN 1 admitted that she should have stopped the care and called the family, acknowledging that this could have prevented the injury. The facility's policy on refusal of care emphasized respecting a resident's wishes and notifying the resident's representative and physician without delay if care was refused.
Delayed Meal Service Affects Resident's Nutritional Intake
Penalty
Summary
The facility failed to serve a timely lunch tray to Resident 4, who was in the dining room, resulting in a delay of 45 minutes past the scheduled meal service time of 12:15 PM. This delay was observed during a concurrent observation and interview with the DSD, who noted that the kitchen had trouble locating Resident 4's tray. As a result, Resident 4 received her meal at 1:00 PM, after watching her table mate being fed for 40 minutes. The delay in serving the meal had the potential to affect the palatability, attractiveness, and temperature of the food, which could decrease food intake and impact Resident 4's nutritional health. Resident 4, who was admitted to the facility with diagnoses including autonomic neuropathy, vitamin D deficiency, and muscle wasting, required partial assistance with eating and substantial assistance with personal hygiene, dressing, and bathing. The facility's policy and procedure for meal service, dated 2018, indicated that meals should be delivered in a timely manner. However, during an interview with the DON, it was confirmed that the late delivery of the food tray could affect the food's temperature and palatability, potentially impacting the resident's intake and nutrition. The dietary service supervisor also stated that the process was to prep food early to ensure timely service, but the meal was not served within the expected timeframe.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to report an alleged violation involving potential abuse of a resident within the required two-hour timeframe to the California Department of Public Health. The incident involved Resident 1, who was admitted with multiple fractures and thrombocytopenia, making them susceptible to bruising and bleeding. On June 1, 2024, a CNA observed discoloration on Resident 1's left lower back, which was later confirmed by an LVN to be spreading and darkening. Despite these observations, the facility did not report the incident to the appropriate authorities until two days later. Interviews with facility staff revealed a lack of documentation and communication regarding the resident's condition. The ODLR for Resident 1 on May 28, 2024, was missing, and subsequent reports failed to document the progression of the bruising adequately. The LVN and RN involved did not follow the facility's policy to report suspected abuse immediately to the administrator or DON. The administrator admitted to not initiating an abuse investigation promptly due to the resident's medical history, which contributed to the delay in reporting. The facility's policy, titled Abuse and Neglect Clinical Protocol, mandates immediate reporting of suspected abuse or injuries of unknown origin within two hours if serious bodily injury is involved. However, the facility did not adhere to this protocol, resulting in a delay in addressing the potential abuse and ensuring the resident's safety. This deficiency placed Resident 1 and potentially other residents at risk of abuse and delayed necessary treatment.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on 4/22/2024. Three metal dumpsters were found uncovered and overflowing with garbage bags, along with additional trash bags, a broken sofa, a broken chair, and boxes left on the ground next to the dumpsters. This situation was confirmed during an observation with the Housekeeping Supervisor and Maintenance Supervisor, who acknowledged that the dumpsters should not be left open and overflowing, as it could attract animals and pests, potentially affecting the health of residents and staff. The Maintenance Supervisor informed the administrator about the issue for immediate cleanup. Interviews with the Dietary Supervisor, Director of Nurses, and Administrator further highlighted the health risks associated with the presence of insects and pests, which could bring bacteria and viruses into the facility. A review of the facility's policies and procedures on Pest Control and Sanitation and Infection Control indicated that the grounds should be kept free of trash, the dumpster area should be clean with lids closed, and food infested by insects or pests should be disposed of immediately. These policies were not adhered to, leading to the observed deficiency.
Failure to Ensure Advance Directives and POLST in Medical Records
Penalty
Summary
The facility failed to ensure that Advance Directives (AD) and Physician Orders for Life-Sustaining Treatment (POLST) were offered, obtained, and accessible in the medical records for four of five sampled residents. Specifically, Resident 187's AD acknowledgment form was not located in the paper chart, and the POLST was not completed. Additionally, Residents 30, 25, and 74 did not have AD acknowledgment forms in their medical records. This deficiency was identified through interviews and record reviews conducted by the Case Manager/Quality Assurance Nurse (CM) and the Director of Nursing (DON). Both the CM and DON confirmed that the AD acknowledgment forms and POLST should be kept in the residents' paper charts to ensure that staff are aware of the residents' wishes regarding treatment during emergencies. Resident 187 was admitted with diagnoses of sepsis and myocardial infarction and had moderately impaired cognition. Resident 30 had a diagnosis of cerebral infarction and atrial fibrillation and was noted to lack the capacity to make decisions. Resident 25, who was readmitted with cerebral infarction and psychosis, also lacked decision-making capacity and had severely impaired cognition. Resident 74, admitted with heart failure and hypertension, had intact cognition. The failure to include AD acknowledgment forms and complete POLSTs in the medical records of these residents could result in their medical treatment preferences not being honored during emergencies or when they are incapacitated.
Failure to Provide Required ROM and Mobility Treatments
Penalty
Summary
The facility failed to provide appropriate treatments and services to maintain or improve the range of motion (ROM) and mobility for three residents. Resident 68 did not receive the prescribed Restorative Nursing Aide (RNA) program treatments for passive range of motion (PROM) exercises on both lower extremities five times a week. Additionally, the facility did not apply both knee extension splints for the required duration and frequency, and failed to follow physician orders regarding the maximum time for splint application. Quarterly rehabilitation screens were also missed for Resident 68 in 2022 and 2023. Resident 25 did not receive RNA treatments for PROM to the left upper and lower extremities as ordered. The facility also failed to apply the left resting hand splint as prescribed and missed several quarterly rehabilitation screens in 2022 and 2023. During observations, it was noted that Resident 25 had limited mobility and required assistance with daily activities, highlighting the importance of the missed treatments. Resident 17, who had severe cognitive impairment and ROM limitations, did not receive the required quarterly rehabilitation screens in 2022 and 2023. The care plan for Resident 17 indicated a need for joint mobility assessments every three months, which were not completed. The failure to conduct these assessments could potentially lead to further decline in the resident's functional mobility and ROM.
Failure to Implement Fire Prevention Interventions
Penalty
Summary
The facility failed to ensure resident safety by not implementing fire prevention interventions, specifically by not keeping heating units free of potentially flammable items. Resident 35, who is cognitively intact and capable of performing daily activities independently, had multiple paper books on top of the heating unit in their room. Despite a visible sign indicating to keep the area clear, this hazard was not addressed. During an interview, an LVN confirmed that the heating unit should be clear to prevent fire hazards. Similarly, Resident 288, who requires moderate assistance with transfers and uses a wheelchair for mobility, had plastic containers stored on top of their heating unit. A CNA acknowledged that placing items on the heating unit is a fire issue. The Maintenance Supervisor also confirmed that the area on top of heating units should be clear to prevent fire and electrical hazards. The facility's policy on fire prevention emphasizes the importance of keeping heat-producing areas free of combustible materials, but this policy was not followed in these instances.
Failure to Document Controlled Drug Administration and E-Kit Usage
Penalty
Summary
The facility failed to ensure that the activities recorded in the Controlled Drug Records had corresponding administration documentations in residents' electronic medication administration records (eMAR) for two residents. Specifically, for one resident, there were 18 doses of morphine removed for administration, but no documented evidence of administration in the eMAR for six of those doses. Similarly, for another resident, there were 10 removal records of Norco, but no administration documentation in the eMAR for two of those doses. The Director of Nursing (DON) confirmed that the administration of PRN medications must be documented in the eMAR, in addition to the controlled drug records, but this was not done in these cases. Additionally, the facility did not have a policy for the accurate usage of the Emergency Medication Supplies (E-kit). During an observation, it was found that the E-kit logbook had missing entries for five out of eight usages. The Director of Staff Development (DSD) and the DON confirmed that the nursing staff need to fill out both E-Kit usage slips and the log book for accountability and accuracy of medication use. However, the facility could not present a specific policy for the use of the E-Kit, indicating a lack of proper procedures for accessing and documenting the use of emergency medications.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that one of the three medication carts was locked when left unattended in the hallway. Registered Nurse 2 (RN2) prepared medications and entered a resident's room without locking the medication cart, leaving it accessible to other residents, visitors, and staff. On top of the medication cart, there were seven over-the-counter medication bottles and one bubble pack, making these medications accessible to anyone in the hallway. The medications included Aspirin, Vitamin C, Calcium with Vitamin D3, Docusate sodium, multiple vitamins, Vitamin D3, Zinc, and Plavix. During an interview, RN2 acknowledged forgetting to lock the medication cart. The facility's policy and procedures for Medication Storage and Medication Administration, effective January 2021, require that medication carts remain locked when not in use or attended by authorized personnel. The failure to lock the medication cart and secure the medications on top of it was observed and confirmed by the surveyor, highlighting a breach in the facility's medication management protocols.
Failure to Ensure Proper Training and Competency of Kitchen Staff
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency and skills to carry out functions of the food and nutrition service. Specifically, staff did not demonstrate or verbalize the correct procedures for testing chlorine concentration in the low-temperature dish machine, following the manufacturer's guidelines for QT-40 test strips when checking Quaternary Ammonium Compounds (Quats) sanitizer concentration, and proper cooling procedures of food. These failures had the potential to result in cross-contamination, ineffective dish machine sanitation, unsanitized food preparation areas, and bacterial growth in food, which could lead to foodborne illness in 85 medically compromised residents who received food and ice from the kitchen. During an observation and interview, a diet aide incorrectly tested the chlorine concentration in the dish machine by not following the manufacturer's guidelines, which required immediate removal and blotting of the test strip. The dietary supervisor confirmed that the training provided did not align with the manufacturer's guidelines, which could compromise the effectiveness of the dish machine's sanitization process. Additionally, the diet aide did not follow the correct procedure for testing the Quat sanitizer concentration, as the solution's temperature was not checked, and the test strip was not used according to the manufacturer's instructions. Furthermore, a cook failed to follow proper cooling procedures for food, as evidenced by the incorrect cooling and temperature monitoring of an apple cinnamon dessert. The cook did not check the temperature at the required intervals and failed to record the temperature in the cool-down log. The dietary supervisor acknowledged that the cooling process was not followed correctly, which could lead to bacterial growth in the food. The facility's policies and procedures, as well as the Food Code 2017, were not adhered to, resulting in potential health risks for the residents.
Failure to Follow Menu Portion Sizes for Paprika Chicken
Penalty
Summary
The facility failed to follow the menu for 32 of 85 residents on a Regular texture diet by not adhering to the specified portion size for paprika chicken. During an observation of the lunch tray line, it was noted that the pieces of chicken were inconsistent in size, with some being small and others large, deviating from the prescribed 3-ounce portion size. Cook 1 and Cook 2 confirmed that their practice was to serve two small pieces of chicken, which often resulted in portions weighing more than the specified 3 ounces. This practice was contrary to the facility's menu spreadsheet, which indicated a 3-ounce portion size for all residents. The Dietary Supervisor acknowledged that the portions might have shrunk during cooking but emphasized the importance of following the menu spreadsheet to avoid exceeding residents' dietary restrictions and causing unintentional weight gain or loss. A review of the facility's diet spreadsheet and policies and procedures revealed that the menu should be followed as posted, with accurate portion control and the use of correct scoop sizes. The policies also highlighted the importance of standardized recipes for maintaining food production quality, quantity, consistency, and cost. Despite these guidelines, the facility's failure to adhere to the specified portion sizes for paprika chicken placed residents at risk of not meeting their nutritional needs and potentially delaying recovery from illness or injury.
Facility Fails to Maintain Sanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. Observations revealed that three storage racks in the walk-in refrigerator had rust-like discoloration, and the storage rack where bananas were stored had dust and dirt buildup. Additionally, the storage containers for ketchup, mixed jelly, creamer, and yellow cake mix had food and dirt residue, and the dry storeroom floors had dirt debris. The kitchen hood and vents near the tray line area also had grease and dirt buildup. These conditions were acknowledged by the Dietary Supervisor (DS), who admitted that the discolored racks, dirty storage containers, and unclean floors and vents could lead to cross-contamination and potential health risks for residents. The facility's policies and procedures were not followed, as these areas were supposed to be cleaned regularly to prevent such issues. The facility also failed to prevent cross-contamination. Two dented cans were found in the dry storage area and emergency supply room, and scoop and tong handles were not stored in one direction. Pots and pans were stacked wet, and staff did not check the chlorine solution concentration or Quaternary ammonium (Quat) concentration according to the test strips manufacturer's guidelines. These practices were confirmed by the DS, who stated that dented cans could harbor bacteria, and improper storage and testing of cleaning solutions could lead to ineffective sanitization and potential illness for residents. The facility's policies and procedures for handling and storing food and utensils were not adhered to, increasing the risk of cross-contamination. Furthermore, the facility failed to ensure that resident trays were not cracked and chipped, and proper food storage was not maintained. An apple cinnamon dessert was not properly cooled, and expired and unlabeled food was found in the resident's refrigerator. The resident's freezer also lacked a thermometer. Staff were observed wearing jewelry, long nails, and nail polish during meal preparation, which is against the facility's policy. These deficiencies were acknowledged by the DS, who admitted that cracked trays, improper cooling of food, and expired food could pose health risks to residents. The facility's policies and procedures for food handling and storage were not followed, leading to potential contamination and health hazards for the residents.
Failure to Obtain Informed Consent for Psychotropic Drugs
Penalty
Summary
The facility failed to obtain informed consent for psychotropic/psychotherapeutic drugs for a resident who was prescribed Sertraline and Divalproex. The resident, who had diagnoses including dementia, psychotic disorder, and depression, was capable of understanding and making healthcare decisions. Despite this, the informed consent form for these medications was incomplete, lacking the physician's name, signature, and the date the consent was obtained. This oversight was confirmed through interviews and record reviews with the Medical Data Set Nurse, a Registered Nurse, and the Director of Nursing, all of whom acknowledged the missing documentation and the absence of a policy on how to complete informed consent forms properly. The resident's medical records and physical chart did not contain any documentation indicating that informed consent for the use of psychotropic/psychotherapeutic drugs had been obtained by the physician. The facility's policy and procedure manual specified that the physician should obtain informed consent and that the licensed nurse should verify this before administering the drugs. However, this protocol was not followed, resulting in a violation of the resident's rights to be informed and to make decisions about their care and treatment. The Director of Nursing confirmed that the informed consent should have been signed by the physician as soon as possible, but this was not done, leading to the deficiency noted in the report.
Failure to Provide Reasonable Accommodations for Resident Needs and Preferences
Penalty
Summary
The facility failed to provide reasonable accommodations for the needs and preferences of two residents by not ensuring the overhead light cord was within their reach. Resident 22, who has diagnoses including atrial fibrillation, rheumatoid arthritis, and dry eye syndrome, was observed lying in bed with the overhead light cord hanging behind the bed, out of reach. This was confirmed by a CNA during an observation and interview. Resident 22's care plan indicated the need for an environment appropriate for the resident's cognition and needs, which was not met in this instance. Similarly, Resident 35, who has diagnoses including myocardial infarction, angina, and chronic kidney disease, expressed during an interview that she was unable to reach the overhead light cord to turn the light on or off. This was also confirmed by an LVN during an observation and interview. Resident 35's preference for having adequate lighting to read books, newspapers, and magazines was documented as very important in her care plan. The facility's policy on Quality of Life - Dignity emphasizes supporting and encouraging individual choices and preferences, which was not adhered to in these cases.
Failure to Provide Adequate Lighting for Resident
Penalty
Summary
The facility failed to provide adequate lighting suitable for tasks that a resident chooses to perform or that staff must perform to assist the resident. Resident 48, who was admitted with multiple fractures and is at high risk for falls due to balance issues and muscle weakness, expressed a preference for a well-lit environment. However, the resident's room was consistently dark, leading the resident to spend most of the time in the hallway where there was better lighting. This situation was confirmed through multiple interviews with the resident, a CNA, an LVN, and the DON, all of whom acknowledged the resident's preference for a brighter environment and the resident's avoidance of the dark room. The resident's care plan indicated a goal to decrease the risk of falls and injury by keeping the environment free of hazards and accommodating the resident's preferences. Despite this, the facility did not address the resident's need for adequate lighting in the room, resulting in the resident eating meals and spending most of the day in the hallway. The facility's policy on Quality of Life and Dignity emphasizes honoring resident choices in their physical environment, including lighting preferences, but this was not adhered to in the case of Resident 48.
Failure to Develop Individualized Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop individualized resident-centered care plans for two residents, Resident 17 and Resident 187. Resident 17's care plan lacked a measurable objective to ensure participation in activities. The care plan indicated a goal for the resident to participate in room/bedside activities a certain number of times per week, but this goal was not specific or resident-centered. During interviews, both the MDS Coordinator and the Director of Nursing acknowledged that the goal was not specific, attainable, or time-bound, which is necessary to determine if the goal has been met and to consider different interventions if it has not been met. Resident 187's care plan also lacked specificity and did not indicate the reason the resident was unable to attend group activities. The care plan goals stated that the resident would benefit and participate in room/bedside activities a certain number of times per week, but this goal was not specific. Interviews with the Case Manager/Quality Assurance Nurse and the Director of Nursing revealed that the care plan did not identify the problem areas or provide a clear, resident-centered goal. This lack of specificity and clarity in the care plan could affect the resident's psychosocial wellbeing and the achievement of the care plan goals.
Failure to Maintain Grooming and Personal Hygiene for Resident
Penalty
Summary
The facility failed to provide necessary care and services to Resident 46, who was dependent on staff for activities of daily living (ADL). Specifically, the facility did not maintain grooming and good personal hygiene by neglecting to shave the resident's long facial hairs above the lips and under the chin. This deficiency was observed during a concurrent observation and interview with a Licensed Vocational Nurse (LVN), who confirmed that the facial hairs should have been shaved during morning care. The resident's care plan indicated that she required extensive assistance and total dependence due to physical limitations and disabilities, with a goal to maintain comfort and dignity. Interviews with various staff members, including a Certified Nurse Assistant (CNA), a Registered Nurse (RN), and the Director of Nurses (DON), all confirmed that the resident's facial hairs should have been shaved as part of daily grooming to maintain physical appearance, dignity, and quality of life. The facility's policies and procedures on morning care and personal care needs also emphasized the importance of grooming and personal hygiene for residents who are unable to carry out ADLs. Despite these guidelines, the facility failed to adhere to them, resulting in the observed deficiency.
Failure to Provide Sufficient Hydration
Penalty
Summary
The facility failed to provide sufficient hydration to Resident 22, who was not provided and offered water at bedside as indicated in the resident's care plan. Resident 22, who has severe cognitive impairment and can independently use utensils to consume food and liquids, was observed without a water cup or pitcher at her bedside. Despite the care plan's directive to encourage fluid intake and frequently offer hydration, the resident was found pointing at her mouth and stating she needed water, indicating a lack of adherence to the care plan by the staff. Interviews with staff members revealed inconsistencies in the implementation of hydration protocols. A CNA mentioned that every resident receives a cup at the start of the shift, while an LVN stated that Resident 22 could have water at her bedside. The Registered Dietician confirmed that Resident 22 should be on a regular diet with a water pitcher available at bedside, allowing the resident to drink as much and as often as desired. The facility's policy on hydration emphasized the importance of providing sufficient fluid intake to maintain proper hydration and health, which was not observed in the care provided to Resident 22.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident while in bed. During an observation, the call light for Resident 39 was found stuck between the left side bedrail and the bed, hanging below the bottom of the mattress, making it unreachable. Resident 39, who had a history of falls and was at high risk for falls, was observed having difficulty putting on her sweater and stated she was cold and unable to reach the call light to call for assistance. The Social Service Director, Marketing Director/Interpreter, Licensed Vocational Nurse, and Registered Nurse all confirmed that the call light should be within reach for residents to call for assistance with ADLs and for safety. Resident 39's medical history included a displaced bicondylar fracture of the right tibia, osteoporosis, type 1 diabetes mellitus with chronic kidney disease, and a history of falls. The resident was usually able to make herself understood and understand others, and required varying levels of assistance with ADLs. The facility's policies and procedures indicated that call lights should be placed within the resident's reach to ensure their needs are met and for their safety. However, the facility failed to adhere to these policies, resulting in the call light being inaccessible to Resident 39.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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