La Palma Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 1130 La Palma Ave, Anaheim, California 92801
- CMS Provider Number
- 555329
- Inspections on file
- 22
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at La Palma Nursing Center during CMS and state inspections, most recent first.
A resident who lacked decision-making capacity had a POLST and physician order indicating Do Not Attempt Resuscitation (DNR). Facility policy required honoring such directives and using them to guide Basic Life Support and CPR decisions. When the resident became unresponsive and pulseless, a CNA initiated CPR and called for help. An RN and an LVN responded, confirmed the absence of a pulse, and continued CPR without first verifying the resident’s code status in the chart, despite later acknowledging that a DNR order was in place and that CPR should not have been initiated.
A resident in an LTC facility sustained multiple rib fractures after a fall, but the facility failed to investigate or document the incident properly. The facility did not request a physician's fracture progress report or conduct a root cause analysis as per policy. Additionally, after another fall, the facility did not perform required neurological evaluations or document the physician's recommendations, despite the resident being on blood thinners.
The facility failed to develop comprehensive care plans for the use of grab bars for several residents, as identified through observations and medical record reviews. This deficiency affected residents who relied on grab bars for mobility and repositioning, with care plans lacking necessary interventions and assessments. The absence of individualized care plans was acknowledged by the DON and staff.
The facility failed to ensure the safety of residents using bed rails, as assessments for 13 residents lacked documentation of the effectiveness of less restrictive measures before using grab bars. Observations and staff interviews confirmed incomplete assessments, putting residents at risk of entrapment and serious injuries.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as unsanitary cutting boards, wet and dirty utensils, and improperly maintained equipment like blenders and ice machines. These deficiencies were observed during a survey, with the Dietary Director and Maintenance Supervisor acknowledging the potential for cross-contamination and foodborne illnesses.
The facility failed to ensure complete entrapment assessments for residents using grab bars, with missing documentation for several zones. Observations showed residents using grab bars for mobility and transfers, but assessments often lacked documentation for Zones 5 to 7. The Maintenance Supervisor did not document or communicate results to nurses, leading to incomplete assessments, acknowledged by the DON and staff.
A resident with limited English proficiency, who spoke Gujarati, was not provided with effective communication tools in the facility. Staff communicated in English, which the resident did not understand, and relied on guessing or family translation. The facility's translation device was not used, and there was no communication board at the bedside, highlighting a deficiency in promoting dignity and respect.
A facility failed to obtain a physician's signature on the informed consent for a resident's psychotropic medication, trazadone, as required by their policy. The resident, who had the capacity to understand and make decisions, was prescribed trazadone for insomnia. Interviews with an LVN and the DON confirmed the absence of the necessary physician's signature, which is required to ensure the resident is informed about their care and treatment.
A resident was found with medications at her bedside without a proper assessment or physician's order for self-administration, contrary to facility policy. Despite being cognitively intact, her records lacked documentation of an assessment by the Interdisciplinary Team to determine if self-administration was clinically appropriate. Interviews with staff confirmed the oversight, and the resident indicated she had informed the facility about medication discrepancies.
A resident was found with their call light on the floor, out of reach, during a facility tour. The resident, who had intact cognition, was unable to communicate with staff due to this oversight. A CNA confirmed the call light should have been accessible, as per facility policy. The DON was informed and acknowledged the issue.
A facility failed to include a resident's advance directive in her medical record, despite its existence being noted on her POLST form. Staff interviews confirmed the absence of the document, which is crucial for guiding the resident's care and identifying the responsible party.
A facility failed to incorporate PASARR Level II recommendations into a resident's care plan, who was diagnosed with anxiety disorder and schizoaffective disorder. The oversight was confirmed by the DON and MDS Coordinator, who admitted to not having a system to alert them to review the determination results, leading to incorrect MDS coding and potential inadequate care.
The facility failed to provide adequate respiratory care for several residents, including incorrect oxygen administration for a resident, undated oxygen tubing for another, and improper storage of nebulizer tubing. Additionally, a resident's oxygen saturation levels were not documented, hindering assessment of their ability to tolerate room air. These deficiencies were confirmed by facility staff.
The facility failed to accurately post Daily Hours Per Patient Day (DHPPD) nurse staffing forms as per AFL 18-27 guidelines. Missing information included the facility's license number, total licensed bed capacity, and the DON's signature. The DON confirmed that the DHPPD was not signed daily, leading to potential inaccuracies in public staffing information.
The facility failed to document the administration of a controlled medication for a resident and did not follow proper procedures for the disposal of non-controlled medications. An LVN admitted to administering clonazepam without proper documentation, and the disposal of non-controlled medications was not signed off by two nurses as required.
The facility failed to ensure accurate monitoring and documentation for three residents using psychotropic medications. One resident's behavior manifestation for divalproex use was not specified, and orthostatic blood pressure readings were inaccurately recorded. Another resident's meal intake related to mirtazapine use showed discrepancies between MAR and CNA documentation. A third resident's orthostatic hypotension was not properly monitored, with identical blood pressure readings for different positions.
A medication error rate of 7.14% was identified in the facility, exceeding the acceptable threshold of 5%. An LVN failed to follow physician's orders by not checking a resident's heart rate before administering antihypertensive medications, metoprolol and diltiazem, which required specific parameters for safe administration. The DON acknowledged the error and confirmed the expectation for compliance with physician's orders.
A resident was administered metoprolol and diltiazem without checking their heart rate, contrary to physician's orders. The LVN admitted to forgetting this step, which was required to ensure the resident's safety due to the risk of an abnormally slow heart rate. The deficiency was acknowledged by the DON.
A facility failed to ensure proper storage, labeling, and disposal of medications, with medications for discharged or deceased residents not removed from supply, expired medications not discarded, and opened inhalation solutions not labeled. Bubble packs were found torn, and medications were left unattended, risking unauthorized access. These deficiencies were confirmed by staff during inspections.
The facility failed to implement its infection prevention and control program, with deficiencies in water management and laundry services. The Legionella Risk Assessment was not completed for the current year, and the facility lacked a water flow chart. In the laundry area, personal items were found on the clean linen folding table, violating infection control practices. The Administrator and MDS Coordinator acknowledged these issues.
The facility failed to maintain essential equipment safely, as a new glucometer was used without required calibration, and a medication refrigerator had significant ice buildup. An LVN confirmed the glucometer was used without quality checks, and an RN verified the refrigerator's condition, both posing potential risks to residents.
A facility failed to document a resident's name on a Grab Bar Use and Entrapment Risk Evaluation, posing a risk for inaccurate care. Interviews with LVN and DON confirmed the oversight, highlighting the importance of including resident names in documentation to ensure proper care.
Failure to Honor DNR Order and POLST During Cardio-Pulmonary Arrest
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented wishes to withhold life-sustaining treatment, including CPR, as specified in a POLST and physician order for Do Not Attempt Resuscitation (DNR). The facility’s policy on Basic Life Support and Cardiopulmonary Resuscitation, revised 10/2017, states that resident wishes expressed in an advance directive or POLST, including DNR orders, are to be honored and that a DNR order indicates the resident should not be resuscitated if respirations and/or cardiac function cease. The resident in question was admitted without capacity to make medical decisions and had a POLST form signed by the legally recognized decision maker indicating DNR, as well as a physician’s order for DNR documented on the Order Summary Report. Despite these orders, when the resident became unresponsive and pulseless, staff initiated and continued CPR. A CNA reported that while accompanying the resident in his room, the resident became unresponsive within approximately five minutes; the CNA checked for a pulse, found none, and immediately began CPR while calling for help. An RN responded to the emergency, assessed the resident, confirmed absence of a pulse, and provided CPR, later acknowledging awareness that the resident had a DNR order and stating she should have verified the code status by checking the Physician Order Summary Report and POLST form. An LVN also participated in providing CPR without verifying the resident’s code status and stated that CPR should not be initiated when a DNR order is in place. The Administrator and DON were informed of and acknowledged these findings.
Failure to Investigate and Document Resident's Fractures and Falls
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to prevent accident hazards, specifically in the case of a resident who sustained a subacute closed fracture of multiple ribs. The facility did not thoroughly investigate or document the resident's rib fractures, nor did they request the physician to complete a fracture progress report. Additionally, the facility did not conduct a root cause analysis by the interdisciplinary team (IDT) as per the facility's policy and procedures (P&P) when the fractures were identified after a fall incident. The facility's P&P required immediate notification and assessment by a licensed nurse following a fall, with an incident report and investigation to be reviewed by the Director of Nurses and the IDT. However, the facility did not follow these procedures for the resident's fall on 10/16/24, which resulted in multiple rib fractures. The resident's medical record did not show documentation of the fractures prior to the fall, and there was no evidence of an investigation into the cause of the fractures or a request for a physician's fracture progress report. Furthermore, after another fall incident on 10/25/24, the facility failed to conduct and document neurological evaluations and the physician's recommendations. The resident, who was on a blood thinner medication, was found lying on the floor with a bump to the head, but the facility did not complete the required change in condition evaluation or follow up with the physician. The Director of Nursing confirmed that the staff did not notify her or complete the necessary evaluations and documentation after the fall.
Failure to Develop Comprehensive Care Plans for Grab Bar Use
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for the use of grab bars for 13 out of 16 sampled residents. This deficiency was identified through observations, interviews, and medical record reviews, which revealed that the care plans did not reflect the individual care needs of the residents. The absence of these care plans meant that the residents were not provided with appropriate, consistent, and individualized care regarding the use of grab bars. For instance, Resident 32 was observed using bilateral grab bars for bed mobility, turning, and repositioning, as per a physician's order. However, the care plan did not include interventions for the use of grab bars, such as assessing for entrapment risks or considering less restrictive alternatives. Similarly, Resident 35's care plan lacked documentation for the use of grab bars, despite a physician's order and the resident's reliance on them for mobility and repositioning. The deficiency was further highlighted by the lack of care plans for other residents, such as Resident 40, who had no capacity to make decisions, and Resident 45, who used grab bars for transfers. The Director of Nursing (DON) and other staff members acknowledged the absence of individualized care plans for these residents, confirming the facility's failure to ensure comprehensive care planning for the use of grab bars.
Deficiency in Bed Rail Safety Assessments
Penalty
Summary
The facility failed to ensure the safety of residents using bed rails, as evidenced by the lack of complete and accurate assessments for 13 out of 16 residents reviewed. The facility's policy required an assessment of a resident's risk for entrapment before the installation of side rails or bed rails, but this was not consistently followed. The assessments did not document whether the least restrictive measures were effective or ineffective before resorting to the use of grab bars. This oversight put residents at risk of entrapment and serious injuries. Several residents, including those with cognitive impairments and those who could make decisions, were observed with elevated grab bars without proper documentation of the effectiveness of less restrictive measures. For instance, Resident 32, who was alert and responsive, had grab bars installed without evidence of prior assessment of alternative measures. Similarly, Resident 40, who lacked decision-making capacity, had grab bars installed without the completion of the least restrictive measures section in the assessment. Interviews with facility staff, including CNAs, LVNs, and the DON, confirmed the lack of documentation and assessment of the effectiveness of less restrictive measures. The DON acknowledged that proper assessments were not completed, and least restrictive approaches were not tried before the use of grab bars. The MDS Coordinator also verified that sections of the assessments were left incomplete, and the least restrictive measures were not reevaluated during quarterly reviews.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed during a survey. The cutting boards were found to be in poor condition, with deep grooves, discoloration, and fuzziness, making them difficult to clean and sanitize. This was acknowledged by the Dietary Director, who stated that new cutting boards had been ordered. Additionally, scoops used for food portioning were stored wet with visible water and dry, crusted food residue, which was verified by the Dietary Director. Further observations revealed that various kitchen utensils were not in good repair or cleanable condition. Stainless spatulas, a can opener, a peeler, a lemon squeezer, and a rolling pin were found to be chipped, deformed, dirty, and stained. The Dietary Assistant Director confirmed these findings and stated that these items should not be used to prevent food contamination. Additional utensils, such as a stainless slotted scooper, rubber spatulas, and a stainless strainer, were also found to be in poor condition, with melted handles and brownish stains. The facility also failed to ensure that equipment such as blenders, measuring containers, and drinking cups were air-dried before storage, as they were found wet with visible water. The kitchen hood was observed with a black, greasy residue, and the microwave used for reheating residents' food had dry, crusted food residue. The ice machine, used by residents and staff, was found with a light yellowish/pinkish stain, indicating a lack of proper cleaning and maintenance. These findings were verified by the Dietary Director and Maintenance Supervisor, who acknowledged the potential for cross-contamination and foodborne illnesses.
Incomplete Entrapment Assessments for Residents Using Grab Bars
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using grab bars, which could potentially lead to entrapment, serious injury, or death. The assessments were incomplete for 13 out of 16 sampled residents, with missing documentation for several entrapment zones. The facility's policy required assessments to be conducted prior to the installation of siderails or bedrails, but the assessments were not fully completed, leaving several zones unchecked. Observations and interviews revealed that residents were using grab bars for assistance with bed mobility, turning, repositioning, and transfers. However, the Grab Bar Use and Entrapment Risk Evaluations often lacked documentation for Zones 5 to 7, and in some cases, Zones 1 to 4 were also incomplete. The Maintenance Supervisor, who was responsible for measuring the entrapment zones, did not document or communicate the results to the licensed nurses, leading to incomplete assessments. The Director of Nursing (DON) and other staff members acknowledged the deficiencies in the entrapment assessments. The Maintenance Supervisor admitted to only recently starting to document the measurements and assessments, and there was a lack of communication between the maintenance and nursing staff regarding the entrapment zone measurements. This lack of documentation and communication contributed to the incomplete assessments, potentially putting residents at risk.
Failure to Provide Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide effective communication for a resident with limited English proficiency, specifically Resident 28, who spoke and understood only the Gujarati language. Despite having a care plan in place that included the use of translation tools and communication aids, these were not effectively utilized. Observations revealed that staff members, including CNAs, communicated with Resident 28 in English, which the resident did not understand. The staff often guessed the resident's needs based on routine rather than using available translation resources. There was no communication board at the resident's bedside, and the translation device available in the facility was not used or demonstrated to support the Gujarati language. Interviews with staff, including the DON and DSD, confirmed the lack of training on the translation device and the absence of a communication board for Resident 28. The DON acknowledged that the staff typically relied on the resident's family for translation, indicating a gap in the facility's ability to independently meet the communication needs of residents with language barriers. The Administrator and MDS Coordinator were informed of these findings, acknowledging the deficiency in providing necessary care that promotes dignity and respect for Resident 28.
Failure to Obtain Physician-Signed Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the informed consent for psychotropic medication was signed by the physician for one of the residents, identified as Resident 366. The facility's policy and procedure require that the attending physician, PA, or NP obtain informed consent from the resident or their responsible party before prescribing or increasing an order for psychotherapeutic medication. This policy also mandates that the facility verify informed consent has been obtained prior to administering such medication. However, a review of Resident 366's medical records revealed that the informed consent for the use of trazadone, prescribed for insomnia, lacked the physician's signature. Interviews conducted with LVN 4 and the DON confirmed the absence of the physician's signature on the informed consent form for Resident 366's trazadone medication. LVN 4 acknowledged that the physician's signature was necessary to indicate that the medication had been reviewed with the resident and approved. The DON also confirmed that the informed consent needed to be signed by the physician to allow the facility to administer the medication as ordered. This oversight posed a risk of the resident not being fully informed about their care and treatment regarding the use of psychotropic medication.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine if it was safe for Resident 316 to self-administer medications, as required by their policy. During an initial tour, Resident 316 was observed with several medications at her bedside, including Synthroid, Equate Gas Relief, Tylenol, and Neuriva Brain Health Plus. Despite being cognitively intact and having the capacity to understand and make decisions, there was no physician's order or care plan addressing her self-administration of medications. The facility's policy requires an assessment by the Interdisciplinary Team to determine if self-administration is clinically appropriate, but this was not documented in Resident 316's records. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed the presence of medications at Resident 316's bedside and the lack of a reassessment for her ability to self-administer medications. The resident herself stated that she informed the facility about the discrepancy in medication supply strength and that the licensed nurses were aware of her self-administration. However, her self-administration assessment indicated she preferred the licensed nurse to administer her medications. The Administrator and MDS Coordinator acknowledged these findings, highlighting a lapse in following the facility's policy for medication self-administration assessments.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to provide reasonable accommodation to meet the needs of a nonsampled resident, identified as Resident 60. During an initial tour of the facility, Resident 60 was observed lying in bed with the call light on the floor, out of reach. This observation was confirmed by CNA 4, who acknowledged that the call light should have been within the resident's reach. Resident 60's medical records indicated that their cognition was intact, suggesting they were capable of using the call light if it had been accessible. The facility's policy and procedure for call lights, dated January 2017, required staff to ensure call lights were within easy reach of residents when they were in bed or seated. The Director of Nursing was informed of these findings and acknowledged the deficiency.
Failure to Include Advance Directive in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive was included in her medical record, which could potentially lead to her healthcare decisions not being honored. The facility's policy and procedure on advance directives, revised in April 2017, requires that residents or their responsible parties provide a copy of the advance directive for inclusion in the clinical record. However, during a medical record review initiated on August 27, 2024, it was found that Resident 43, who was admitted earlier in the year, did not have a copy of her advance directive in her medical record. Interviews with facility staff confirmed the absence of the advance directive in the resident's medical record. The Health Information Director and LVN 9 both verified that although the resident's POLST form indicated the existence of an advance directive, no copy was found in the record. The Social Services Director also acknowledged the absence of the document, emphasizing its importance in guiding the resident's care and identifying the appointed responsible party. This oversight in documentation could potentially impact the resident's medical care and treatment decisions.
Failure to Implement PASARR Recommendations for Resident Care
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination into the care plan for a resident diagnosed with anxiety disorder and schizoaffective disorder. The PASARR Level II Evaluation, conducted by the Department of Health Care Services, recommended special services for the resident due to their medical and mental health conditions. However, a review of the resident's medical records and care plan revealed that these recommendations were not followed up or documented, indicating a lack of coordination in the resident's care planning process. Interviews with the Director of Nursing (DON) and the MDS Coordinator confirmed the oversight. The MDS Coordinator admitted to not having a system in place to alert her to review the Level II determination results, leading to an incorrect coding in the resident's annual MDS. The DON acknowledged the absence of documentation and the potential risk of the resident not receiving adequate care and services as recommended by the PASARR Level II determination.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide necessary respiratory care for several residents, leading to deficiencies in oxygen administration and equipment management. Resident 55 was observed receiving three liters per minute of oxygen via nasal cannula, contrary to the physician's order of one to two liters per minute. This adjustment was made by the night shift nurse without documentation of the resident's difficulty breathing or physician notification. LVN 3 confirmed these findings, indicating a lack of adherence to the prescribed oxygen therapy. Resident 15's oxygen tubing was not dated, and the humidifier was dated 8/11/24, despite the facility's policy of changing and dating the tubing and humidifier every Sunday. LVN 3 was unable to confirm when the oxygen tubing was last changed, highlighting a lapse in the facility's protocol for equipment maintenance. Additionally, Resident 34's nebulizer tubing was found touching the floor, and the oxygen tubing was not stored in a plastic bag when not in use, as verified by LVN 5 and the MDS Coordinator. Resident 59's medical records lacked documentation of oxygen saturation levels on room air, which was necessary to assess the resident's ability to tolerate room air without supplemental oxygen. The MAR showed check marks instead of actual oxygen saturation levels for several shifts, and both LVN 5 and the DON acknowledged this oversight. This deficiency in documentation prevented the facility from determining the resident's potential for weaning off oxygen, as required by the care plan.
Inaccurate Posting of Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Hours Per Patient Day (DHPPD) nurse staffing forms were accurately posted in accordance with the All Facility Letter (AFL) 18-27 guidelines. The review of the facility's documents titled Daily Staff from specific dates showed missing information such as the facility's license number, total licensed bed capacity, names of the administrator and the Director of Nursing (DON) or designee, designated census periods, actual nursing hours worked, actual DHPPD hours, and the DON or designee's signature to verify the accuracy of the information. The Payroll Director confirmed that the DON did not sign the DHPPD form daily but only twice a month, which was not in compliance with the AFL 18-27 requirements. Interviews with the Director of Staff Development (DSD), Payroll Director, and the DON confirmed the findings. The DSD acknowledged that the Daily Staff document was incomplete and only posted projected nursing hours without including actual nursing hours. The DON admitted that the facility's Daily Staff document did not accurately reflect the information as per AFL 18-27 guidelines and acknowledged that the DHPPD should be signed daily to ensure accurate staffing coordination based on the census. The failure to post accurate staffing information had the potential to result in inaccurate information being provided to the public.
Deficiencies in Medication Administration and Disposal
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the administration and documentation of controlled medications for a resident. During an inspection, it was found that a bubble pack of clonazepam, a controlled medication for anxiety, was not properly documented in the controlled drug record and Medication Administration Record (MAR) after administration. A Licensed Vocational Nurse (LVN) admitted to administering the medication but failed to document the removal and administration of the clonazepam on the required records. This oversight was confirmed by the Director of Nursing (DON) during a review. Additionally, the facility did not adhere to its policy for the disposal of non-controlled medications. The policy requires two licensed nurses to sign off on the disposal of such medications. However, a review of the Medication Disposition Record/Pass Log revealed that non-controlled medications were disposed of with only one nurse's signature. This discrepancy was verified by a Registered Nurse (RN) during an interview and document review.
Inaccurate Monitoring and Documentation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications, as evidenced by the lack of specific behavior manifestations and inaccurate monitoring of vital signs and meal intake. For one resident, the facility did not identify a specific behavior manifestation related to the use of divalproex, an antipsychotic medication. Additionally, the resident's orthostatic blood pressure was not accurately monitored, with identical readings recorded for both sitting and lying positions, contrary to physician orders. Furthermore, discrepancies were found between the meal intake documented by licensed nurses in the MAR and the documentation by CNAs in the POC Legend Report. Another resident's meal intake monitoring related to the use of mirtazapine, an antidepressant, also showed inconsistencies between the MAR and the POC Legend Report. The facility's failure to accurately document meal intake and behavior episodes related to poor appetite was evident, as the psychotherapeutic drug summary sheet did not match the actual meal intake records. Interviews with staff revealed conflicting accounts of the resident's meal consumption, further highlighting the lack of coordination in monitoring. For a third resident, the facility did not accurately monitor orthostatic hypotension as ordered by the physician. The blood pressure readings for both sitting and lying positions were identical, indicating a failure to properly assess the resident's condition. Interviews with the DON and LVN confirmed that the staff did not follow the correct procedure for monitoring orthostatic hypotension, as the blood pressure readings should have differed between positions.
Medication Administration Error Due to Non-compliance with Physician's Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the observed rate being 7.14%. This deficiency was identified during a medication administration observation involving a licensed vocational nurse (LVN 5) and Resident 16. LVN 5 did not adhere to the physician's orders for administering antihypertensive medications, specifically metoprolol and diltiazem. The orders required checking both the systolic blood pressure (SBP) and heart rate before administration, with instructions to hold the medication if the SBP was less than 110 mmHg or the heart rate was less than 60 beats per minute. However, LVN 5 only checked the resident's blood pressure and failed to measure the heart rate before administering the medications. Resident 16 had specific physician's orders for the administration of diltiazem and metoprolol due to hypertension, with parameters set to ensure safe administration. Despite these orders, LVN 5 proceeded to administer the medications without verifying the heart rate, which was a critical step in the process. The Director of Nursing (DON) acknowledged the findings and confirmed that the medications should be administered as per the physician's orders, emphasizing the expectation for licensed nurses to follow the specified parameters.
Failure to Monitor Heart Rate Before Administering Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of antihypertensive medications. During a medication administration observation, it was noted that a Licensed Vocational Nurse (LVN) did not check the resident's heart rate before administering metoprolol and diltiazem. According to the physician's orders, these medications should be withheld if the systolic blood pressure (SBP) is less than 110 mmHg or the heart rate is less than 60 beats per minute, and both the blood pressure and heart rate should be checked prior to administration. The resident involved had specific physician's orders requiring the monitoring of vital signs before medication administration due to the potential risk of an abnormally slow heart rate. The LVN admitted to forgetting to check the resident's heart rate before administering the medications. This oversight was acknowledged by the Director of Nursing (DON) after being informed of the findings. The failure to adhere to the physician's orders and facility policy and procedures (P&P) regarding medication administration led to this deficiency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, which was observed during an inspection of Medication Room A and Medication Cart A. Medications for residents who were discharged, transferred, or deceased were not removed from the current medication supply. Specifically, medications for Residents 22, 53, and 63 were found in the medication room despite their discharge or death. Additionally, expired medications were not removed from Medication Cart B, and opened inhalation solution medications for Residents 5, 15, and 40 were not labeled with an opened date. The facility also failed to maintain the integrity of medication packaging. Bubble packs containing medication tablets for Residents 2, 16, 37, and 45 were found with tears, compromising the tamper-evident packaging. Furthermore, orally administered medications were not stored separately from externally used medications, and medications were left unattended, posing a risk of unauthorized access. Resident 55's inhalation solution medication and Resident 37's insulin pen were left unattended on top of the medication cart and bedside table, respectively. These deficiencies were verified by the nursing staff during the inspection and interviews. The facility's policies and procedures for medication storage were not adhered to, as evidenced by the presence of outdated and improperly stored medications. The lack of proper medication management had the potential to negatively impact the residents' well-being and the effectiveness of the medications.
Infection Control Deficiencies in Water Management and Laundry Services
Penalty
Summary
The facility failed to implement its infection prevention and control program effectively, as evidenced by deficiencies in its water management and laundry services. The facility did not complete the Legionella Risk Assessment for the current year, which is crucial for identifying potential Legionella outbreaks. Additionally, the facility lacked a water flow chart to document how water circulates through the building and identify areas where water may stagnate. This oversight was confirmed during an interview with the Administrator, who acknowledged that the assessment and documentation were incomplete. In the laundry services area, the facility did not adhere to infection control practices. During an inspection, personal items belonging to the laundry staff, such as a water bottle, opened soda can, radio, purses, cookies, and a Styrofoam container, were found on the clean linen folding table. The Maintenance Supervisor confirmed that these items should not have been on the table, as it is designated as a clean area. The Administrator and MDS Coordinator were informed of these findings and acknowledged the breach in infection control practices.
Deficiencies in Equipment Maintenance and Calibration
Penalty
Summary
The facility failed to ensure that essential equipment was maintained in safe operating condition, specifically regarding the use of a new glucometer and the maintenance of a medication refrigerator. An inspection revealed that a new Assure Platinum glucometer, with serial number 1040-4324393, was used for residents' blood glucose monitoring without performing the required calibration or quality control checks. LVN 3 confirmed that the glucometer was brand new and acknowledged that no documentation was available to show that these checks were performed, despite the facility's protocol requiring such checks before using a new meter or test strips. Additionally, an inspection of the refrigerator used for medications in Medication Room A showed a significant ice buildup in the freezer compartment. This condition was verified by RN 1 and acknowledged by the DON. The ice buildup had the potential to affect the refrigerator's functionality and the potency of the medications stored inside, posing a risk to the residents who rely on these medications.
Failure to Document Resident's Name on Facility Document
Penalty
Summary
The facility failed to document the resident's name on a critical facility document for one of the sampled residents, identified as Resident 366. This oversight was discovered during a review of the Grab Bar Use and Entrapment Risk Evaluation dated 8/10/24, which lacked the resident's name. The absence of the resident's name on this document posed a risk for Resident 366 not receiving accurate and necessary care. The facility's policy and procedure (P&P) titled Facility Assessment emphasized the importance of personalized care and accurate resident assessments, yet this standard was not met in this instance. Interviews conducted with facility staff, including LVN 4 and the Director of Nursing (DON), confirmed the deficiency. LVN 4 acknowledged that the Grab Bar Use and Entrapment Risk Evaluation document was incomplete without the resident's name, which is essential for ensuring proper care and treatment. The DON also confirmed that facility documentation should include the resident's name and the date of completion, acknowledging the findings of the surveyors. This lapse in documentation accuracy was identified through a combination of interviews, medical record reviews, and facility policy reviews.
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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