Lake Balboa Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Van Nuys, California.
- Location
- 16955 Vanowen Street, Van Nuys, California 91406
- CMS Provider Number
- 056180
- Inspections on file
- 36
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Lake Balboa Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility’s RDs did not perform in-person, nutrition-focused physical assessments or direct interviews for two residents receiving hemodialysis, despite significant conditions such as ESRD, DM, and moderate protein-calorie malnutrition. The Dietary Supervisor obtained food preferences, and the RDs completed Nutrition Evaluation and RDN Reviews remotely or based solely on chart review and DS input, without speaking to the residents or their representatives or physically assessing chewing, eating ability, or skin integrity. One RD worked entirely remotely and stated she did not need face-to-face assessments, while the on-site RD acknowledged a high-risk dialysis resident should have been seen but was never assessed due to the resident’s dialysis schedule. These practices conflicted with facility policies, RD job descriptions, and the Academy of Nutrition and Dietetics’ Nutrition Care Process, which call for assessment data from interview, observation, and collaboration with the client.
The facility failed to follow its I&O policy and physician-ordered fluid restrictions for two dialysis residents with ESRD and other comorbidities. One resident with a 1,500 mL/day fluid restriction repeatedly received between 1,650 mL and 3,300 mL per day based on combined CNA and nurse documentation, despite clear orders and care plan breakdowns by shift. Another resident with a 1,000 mL/day restriction had multiple days where CNA documentation showed intake between 1,050 mL and 1,220 mL. The ADON acknowledged that CNAs provided fluids without proper coordination with licensed staff, that nurses did not adequately monitor or total 24-hour intake, and that the facility’s written I&O procedures for documenting and totaling fluids each shift were not effectively implemented.
Surveyors found multiple failures in food handling and storage, including an undated bag containing a cup of food brought in by a family member for a resident stored in a kitchen refrigerator, a container of strawberries with visible mold-like discoloration that had not been checked for spoilage, and an opened package of hamburger buns stored without an open date. The Dietary Supervisor acknowledged that family-prepared foods should be discarded after 24 hours, that staff had not checked the strawberries for spoilage, and that all opened food items should be labeled with an open date, as required by facility policies on foods brought by visitors, storing produce, and labeling and dating foods.
A resident with end stage renal disease, type 2 DM, and dependence on renal dialysis had a documented CCHO/renal diet and a care plan intervention to honor personal dietary choices, with the RDN noting a preference for soup at lunch and the meal card specifying soup as an added lunch item. During a lunch observation, the DON noted that the resident's tray did not include soup despite the meal ticket indicating it should, and the Dietary Supervisor later confirmed that kitchen staff are required to follow meal tickets and that the resident's preference was not honored, contrary to the facility's food preference policy.
A resident with severe cognitive impairment and multiple medical conditions had their detailed discharge summary and post-discharge plan, including full identifying and clinical information, mistakenly included in another resident’s discharge packet. An RN acting as supervisor relied on discharge paperwork pre-printed and placed in the chart, verified only the initial pages for the correct name and medication list, and failed to review all pages, resulting in the other resident receiving confidential PHI. The DON and RN acknowledged this as a HIPAA violation, contrary to facility policy requiring protection of all resident health information.
A physical therapist did not wear an isolation gown while providing range of motion exercises and repositioning a resident on enhanced barrier precautions for an MDRO infection and indwelling catheter. Despite clear signage and facility policy requiring gown and gloves for high-contact care, only gloves and a mask were used during the therapy session.
A resident with Parkinson's disease and dysphagia was assisted by a CNA who stood over him during feeding, contrary to the facility's policy requiring staff to sit at eye level to maintain dignity. The CNA stated it was easier for her to stand, despite the Director of Nursing's directive to assist residents in a sitting position.
A resident's privacy was compromised when an LVN left their electronic health record open and unattended during a medication pass. The resident, who was dependent on staff for care, had their medication list and photo visible on a computer screen. The LVN admitted this was a HIPAA violation, as the facility's policy requires that medication carts be locked and screens closed when not in use.
A facility failed to provide non-pharmacological interventions before administering opioid pain medication to a resident with atrial fibrillation and pneumonia. Despite physician orders to attempt non-pharmacological methods like repositioning and relaxation, the resident received Percocet on multiple occasions without these interventions, increasing the risk of adverse effects.
A resident with an indwelling catheter was observed with the catheter tubing touching the floor, contrary to the facility's infection control policy. The resident, who required substantial assistance due to mildly impaired cognition, was at risk of infection due to this oversight. Both an LVN and the DON acknowledged the risk of bacterial transmission from the tubing touching the floor.
The facility was found to have ten rooms that did not meet the required minimum square footage per resident during a recertification survey. Despite the deficiency, observations and interviews indicated that residents and staff did not experience issues with space for mobility or care. The facility had applied for a Room Variance Waiver, asserting that the space was adequate for residents' needs.
The facility failed to document essential pacemaker information for two residents with atrial fibrillation and cardiac pacemakers. The care plans lacked details such as the pacemaker type, insertion date, rate, and contact information, contrary to the facility's policy. Interviews with staff confirmed the oversight, and the Director of Nursing acknowledged the responsibility to obtain this information upon admission.
The facility failed to offer COVID-19 testing to visitors upon entry, contrary to its policy, and did not place a resident with E. coli bacteremia on contact isolation as ordered by a physician. The DON decided against isolation despite available private rooms and a physician's order, believing the infection was not severe enough. These actions led to deficiencies in infection control practices.
Failure to Perform Nutrition-Focused Physical Assessments for Dialysis Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Registered Dietitians (RDs) conducted nutrition-focused physical assessments, including direct interaction with residents or their representatives, for residents receiving hemodialysis. Resident 1 was admitted with ESRD, type 2 DM, moderate protein-calorie malnutrition, and dependence on hemodialysis. The care plan for Resident 1 identified risk for nutritional problems related to chronic kidney disease, ESRD, DM, and malnutrition, and included an intervention for the RD to evaluate and make diet change recommendations as needed. The facility’s process, as described by the Dietary Supervisor (DS), was that within the first three days of admission the DS interviews the resident for food preferences, and then the RD completes the second part of the evaluation and writes recommendations based on the DS’s information. Surveyors found that RD 1, who worked remotely, completed Nutrition Evaluation and RDN Reviews without conducting face-to-face assessments or speaking with residents or their families/representatives. RD 1 stated that she relied on the DS’s information and her own education and did not need to perform in-person assessments. For Resident 1, the Nutrition Evaluation and RDN Review were completed based on record review and DS input, without RD 1 physically assessing the resident or directly interviewing the resident or representative. The DON confirmed that RD 1 worked remotely and that RD 2 was expected to check and assess newly admitted residents, but also stated that, in the DON’s view, it was acceptable for RD 1 to assess residents remotely through thorough record review. For Resident 2, who was also on dialysis and considered high risk, RD 2 acknowledged that the resident should have been seen and evaluated in person but had not been assessed because the resident was off-site for dialysis on the day RD 2 was in the facility. RD 2 stated that RD 1 had assessed Resident 2 and documented the Nutrition Evaluation and RDN Review, again without an in-person assessment. RD 2 did not answer when asked about standards of practice for RDs or what a nutrition-focused physical assessment entails. The facility’s policies and job descriptions, as well as the Academy of Nutrition and Dietetics’ Nutrition Care Process documents reviewed by surveyors, emphasized assessing nutritional status through interview, observation, and physical assessment, and collaborating with the client in developing goals and monitoring outcomes, which contrasted with the facility’s practice of remote, record-based RD assessments for these residents on hemodialysis.
Failure to Monitor and Enforce Fluid Restrictions for Dialysis Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its intake and output (I&O) policy and physician-ordered fluid restrictions for residents on dialysis. For one resident with end stage renal disease, type 2 diabetes mellitus, and dependence on renal dialysis, the physician’s order and care plan specified a 1,500 mL daily fluid restriction divided among nursing and dietary shifts. The Assistant Director of Nursing (ADON) explained that licensed nurses were to document fluids they provided on an I&O record, CNAs were to document fluids they provided in the electronic health record, and that the combined total for each 24-hour period should not exceed the ordered restriction. However, review of CNA fluid intake documentation and the licensed nurses’ I&O records from multiple dates showed that the resident’s total daily fluid intake consistently exceeded the 1,500 mL restriction, ranging from 1,650 mL to 3,300 mL per day. The ADON stated that only fluids provided by licensed nurses and from the kitchen should be offered to residents on fluid restrictions, and that CNAs should inform licensed nurses before offering fluids to such residents for proper monitoring. The ADON acknowledged that the facility failed to monitor this resident’s intake according to the physician’s order and that licensed nurses should have communicated with each other, including during huddles, to remind CNAs which residents were on fluid restrictions. This failure resulted in repeated instances where the resident received more fluid than prescribed over an 11-day period. A second resident, also with end stage renal disease, dependence on renal dialysis, and hypertension, had a physician’s order, care plan, and dietary evaluation specifying a 1,000 mL fluid restriction divided among breakfast, lunch, and dinner, with PO intake to be monitored. Review of CNA task documentation over a one-month period showed that this resident’s daily fluid intake exceeded the 1,000 mL restriction on multiple dates, with recorded intakes between 1,050 mL and 1,220 mL. During interview and record review, the ADON confirmed that the resident received more fluids than ordered on those dates and stated that licensed nurses should have monitored the resident’s fluid intake to ensure it did not exceed 1,000 mL. The facility’s written I&O policy required nursing assistants to document all fluids consumed on a daily I&O sheet, licensed staff to document fluids given with medications, and the 3–11 shift to total 24-hour intake each day, but the documented intakes show that these monitoring and documentation processes did not prevent the residents from exceeding their ordered fluid restrictions.
Failure to Properly Label, Date, and Discard Resident and Kitchen Food Items
Penalty
Summary
Surveyors identified deficiencies in food handling and storage practices in the facility kitchen during an observation with the Dietary Supervisor (DS). In one refrigerator, an undated clear plastic bag containing a cup of food brought in by a family member was stored on the bottom shelf and labeled only with a resident’s room number, without a date indicating when it was brought into the facility. The DS stated that food prepared and cooked by family members for residents was stored in this refrigerator and should be discarded after 24 hours for resident safety. Review of the facility’s policy titled “Foods brought by family or visitor” indicated that perishable prepared foods must be checked by designated dietary staff, discarded after 24 hours of storage, stored in the facility kitchen, and labeled with the resident’s name, location, and date. In the same kitchen, surveyors observed a clear plastic container of strawberries dated 2/27/2026 in Refrigerator 2 with visible black/green discoloration consistent with a mold-like substance on several strawberries. The DS acknowledged that the strawberries had not been checked for spoilage or mold and stated that staff should ensure food items are fresh and safe to use and discard them if not. In another refrigerator (Refrigerator 3), an opened package of hamburger buns was stored without an open date label. The DS confirmed the buns did not have an open date and stated that food items should have an open date label to follow guidelines on when to use the food item by. Review of facility policies on “Storing Produce” and “Labeling and dating of foods” showed requirements to check produce for spoiled items and discard them upon delivery, and to mark commercially processed, ready-to-eat cold foods stored more than 24 hours with a use-by date, which were not followed in these instances.
Failure to Honor Resident Food Preference for Soup at Lunch
Penalty
Summary
The facility failed to provide meals that accommodated a resident's documented food preferences. A resident with end stage renal disease, type 2 DM, and dependence on renal dialysis was admitted on 2/27/2026 and had a care plan for nutrition related to diabetes and chronic kidney disease with hemodialysis, which included an intervention to honor the resident's rights to make personal dietary choices. The resident's orders specified a CCHO/renal diet with regular/thin liquids. A Nutrition Evaluation and RDN Review completed on 2/28/2026 documented that the resident liked soup for lunch, and the resident's meal card indicated added food for lunch: soup. On 3/11/2026, during observation of the resident's lunch tray with the DON, it was noted that the resident did not receive soup, despite the meal card indicating that soup should be served. The DON confirmed that the resident should have had soup based on the meal card. In a subsequent interview, the Dietary Supervisor stated that kitchen staff are supposed to follow what is on residents' meal tickets at all times to honor residents' preferences and choices, and acknowledged that the facility failed to honor this resident's food preference by not serving soup at lunch. The facility's Food Preferences policy, last reviewed 2/17/2026, stated that residents' food preferences will be adhered to within reason and obtained through an initial resident screen within seven days of admission by the FNS Director.
Unauthorized Disclosure of Resident PHI in Discharge Paperwork
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s confidential personal and medical information when discharge documents for one resident were mistakenly given to another resident. The affected resident had been admitted and later readmitted with diagnoses including sepsis, Non-Hodgkin lymphoma, and hypotension. An admitting evaluation documented fluctuating capacity to understand and make decisions, and an MDS assessment showed severely impaired cognition. The resident’s Discharge Summary and Post-Discharge Plan of Care contained extensive protected health information, including full name, date of birth, admission and discharge dates, diagnoses, cognitive and physical status, nutritional status, height, weight, home address and phone number, physician and home health agency contact information, and medical equipment orders. The incident came to light when the husband of another resident who was being discharged contacted the facility’s Patient Concierge to report that the first resident’s discharge papers had been included with his spouse’s discharge paperwork. The Patient Concierge reported this to the medical records department. Review of a facility letter to the affected resident confirmed that the information disclosed included the resident’s full name, date of birth, admission date, address, discharge date, diagnosis, phone number, reason for admission, physician order for home health, height, weight, and reason for discharge. This disclosure occurred despite a facility policy stating that all resident health information is confidential, protected by HIPAA, and must not be disclosed in any form without legal authorization. Interviews with staff clarified how the error occurred. The Medical Records Assistant stated that nurses, not medical records, print discharge paperwork. The Infection Prevention Nurse, who was acting as the RN supervisor on the day in question, reported that night shift typically prepares and prints discharge paperwork and places it in residents’ physical charts. While discharging the second resident, the Infection Prevention Nurse pulled the discharge papers from that resident’s chart, checked only the first few pages to verify that the face sheet and medication list matched the correct name, and did not review all pages. As a result, the first resident’s Discharge Summary and Post-Discharge Plan of Care were inadvertently included in the second resident’s discharge packet. The Infection Prevention Nurse and the DON both acknowledged that all documents should have been checked to ensure they belonged to the correct resident and that providing these documents to another resident constituted a HIPAA violation and a breach of confidentiality.
Failure to Use Required PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a physical therapist (PT) failed to follow infection control practices by not wearing an isolation gown while providing in-bed physical therapy services to a resident who was on enhanced barrier precautions (EBP) due to an indwelling catheter and a multidrug-resistant organism (MDRO) infection. The resident had a history of right femur fracture, urinary tract infection, and extended spectrum beta-lactamase (ESBL) producing bacteria, and was dependent on staff for multiple activities of daily living. Facility records and signage indicated that gown and gloves were required for high-contact care activities under EBP. During direct observation, the PT was seen wearing only gloves and a surgical mask while performing range of motion exercises and repositioning the resident, despite EBP signage posted at the room entrance. The infection preventionist and the director of nursing both confirmed that an isolation gown should have been worn for such high-contact activities. The facility's infection control policy also specified the use of gown and gloves for high-contact care under EBP to prevent the spread of MDROs.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance a resident's dignity and respect, as observed during a meal assistance session with a resident diagnosed with Parkinson's disease, dysphagia, and depression. The resident, who required verbal cues to feed himself, was assisted by a Certified Nursing Assistant (CNA 2) who stood over him while feeding. This practice was contrary to the facility's policy, which requires staff to sit at eye level with residents during feeding to promote dignity and allow for better observation of any swallowing difficulties. During the observation, the CNA admitted to standing over residents because it was easier for her, despite the facility's policy and the Director of Nursing's statement that staff should assist residents in a sitting position to maintain their dignity. The facility's policies on feeding dependent residents and maintaining dignity and respect were reviewed, both emphasizing the importance of sitting at eye level with residents to ensure respectful and dignified care.
Violation of Resident Privacy Due to Unattended EHR
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records when a Licensed Vocational Nurse (LVN 1) left the electronic health record (EHR) of a resident open and unattended. This incident involved Resident 94, who was admitted to the facility with acute pulmonary edema and heart failure. The resident's Minimum Data Set (MDS) indicated that they had limited ability to understand others and were totally dependent on staff for personal care tasks. During a medication pass, LVN 1 left the computer screen displaying the resident's medication list and photo open while stepping away from the medication cart to enter the resident's room. LVN 1 acknowledged that leaving the electronic chart accessible was a violation of the Health Insurance Portability and Accountability Act (HIPAA), which mandates the protection of residents' health information. The facility's policy requires that medication carts be kept closed and locked when not in sight and that resident information be kept private by closing the computer screen when not in use. This incident highlights a breach in the facility's adherence to HIPAA regulations and its own policies regarding the safeguarding of electronic protected health information (ePHI).
Failure to Provide Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions to a resident before administering as-needed opioid pain medication. The resident, who was admitted with diagnoses including atrial fibrillation and pneumonia, had intact cognition and required substantial assistance with daily activities. The physician's orders included administering Percocet for severe pain and providing non-pharmacological interventions such as repositioning and relaxation every shift. However, the Medication Administration Record showed that on three occasions, Percocet was administered without prior non-pharmacological interventions. During an interview, the Director of Nursing confirmed that non-pharmacological interventions should be attempted first to address potential external factors causing pain. The failure to do so increased the risk of adverse side effects from opioid use, such as dizziness and respiratory depression. The resident's care plan aimed to prevent interruptions in normal activities due to pain, and the facility's policy emphasized the inclusion of both pharmacological and non-pharmacological interventions in the care plan.
Infection Control Deficiency: Catheter Tubing Touching Floor
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for a resident with an indwelling catheter. The deficiency was observed when the catheter tubing of a resident, who was admitted with multiple diagnoses including a fracture of the neck of the femur, hypertension, and acute kidney failure, was found touching the floor. This observation was made during a review of the resident's care, which indicated that the catheter tubing should be positioned below the bladder level and away from the entrance room door. The resident's Minimum Data Set (MDS) indicated mildly impaired cognition and a need for substantial assistance with personal hygiene. During an interview, a Licensed Vocational Nurse (LVN) confirmed that the catheter tubing was indeed touching the floor, acknowledging the risk of infection. The Director of Nursing (DON) also stated that the tubing should not touch the floor due to the potential for bacterial transmission, which could lead to infection. The facility's policy on indwelling urinary catheter care, last reviewed in February 2025, mandates daily catheter care to promote hygiene and reduce infection risk. Despite these guidelines, the failure to maintain the catheter tubing off the floor was identified as a deficiency in the facility's infection control practices.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in ten of its 26 rooms, as observed during a recertification survey. Specifically, the rooms in question did not meet the regulatory requirement of at least 80 square feet per resident in multiple-resident rooms and 100 square feet in single-resident rooms. The rooms identified were 101, 102, 105, 107, 110, 112, 115, 117, 119, and 121, with square footage per resident ranging from 76 to 79.5 square feet, which is below the mandated minimum. Despite this deficiency, observations and interviews with residents and staff indicated that the space was sufficient for residents to move freely and for staff to provide care without restrictions. The facility had submitted an application for a Room Variance Waiver, which was dated 3/28/2025, to address the space deficiency. The waiver request indicated that the rooms, although smaller than required, did not interfere with the free movement of wheelchairs or other mobility devices and did not adversely affect the residents' health, safety, or well-being. Interviews with residents and staff confirmed that the rooms provided adequate space for care and privacy, and no concerns were raised regarding the lack of space. The facility's policy, last reviewed in February 2025, reiterated the requirement for room sizes, highlighting the discrepancy between policy and practice.
Failure to Document Pacemaker Information for Residents
Penalty
Summary
The facility failed to provide resident-centered care by not implementing its policy on pacemaker documentation for two residents. Resident 2 was admitted with diagnoses including atrial fibrillation and a cardiac pacemaker. The care plan for Resident 2, initiated shortly after admission, lacked essential pacemaker information such as the type, date of insertion, rate, pacemaker check lab, and contact number. Interviews with the MDS Nurse and Assistant Director of Nursing (ADON) confirmed the absence of this critical information, which should have been obtained upon admission. Similarly, Resident 5 was admitted with atrial fibrillation and a cardiac pacemaker. The physician's order for Resident 5 indicated missing details like the pacemaker's model and serial number. The care plan for Resident 5 also lacked information on the pacemaker's rate, check lab, and contact number. The MDS Nurse and ADON acknowledged the missing documentation and the ADON's unsuccessful attempt to obtain the information from the resident's cardiologist. The Director of Nursing (DON) stated that it is the facility's responsibility to gather pacemaker information upon admission. The facility's policy, reviewed shortly before the incidents, required periodic checks of residents with pacemakers and documentation of specific details in the care plan. The failure to adhere to this policy resulted in incomplete medical care information for the residents, potentially affecting their care and safety.
Failure to Implement Infection Control Policies
Penalty
Summary
The facility failed to implement its infection control policy by not offering COVID-19 testing to visitors upon entry, as required by their own policy. Interviews with family members, staff, and the Infection Preventionist (IP) revealed that visitors were not offered COVID-19 tests unless they exhibited symptoms, contrary to the facility's policy. The Director of Nursing (DON) stated that testing was not offered because the facility was not experiencing a COVID-19 outbreak and lacked resources to test every visitor. However, the facility's policy indicated that all visitors should be offered self-testing with a COVID-19 antigen test upon entry, regardless of symptoms or outbreak status. Additionally, the facility failed to place a resident on contact isolation as ordered by a physician. Resident 4, who was readmitted with a diagnosis of E. coli bacteremia, was not placed in a private isolation room despite having a physician's order for contact isolation. The IP and DON acknowledged that a private room was available, but the resident was instead placed in a shared room. The DON decided against isolation, believing the infection was not severe enough to warrant it, despite the physician's order. The facility's policy on infection prevention and control requires implementing contact precautions for known infections spread by direct or indirect contact. The failure to adhere to these policies and physician orders resulted in deficiencies in the facility's infection control practices, potentially putting residents, staff, and visitors at risk of spreading infections.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
