Leisure Glen Post Acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, California.
- Location
- 330 Mission Road, Glendale, California 91205
- CMS Provider Number
- 055845
- Inspections on file
- 28
- Latest survey
- June 27, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Leisure Glen Post Acute Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident did not receive safe and appropriate respiratory care when it was needed, as required by their condition. The facility did not ensure that necessary respiratory support was provided.
A visitor was observed taking cups, juice, water, and spoons from a medication cart without staff intervention, despite facility policy prohibiting such actions to prevent contamination. An LVN did not instruct the visitor to stop, and the incident involved a resident with acute respiratory failure and diabetes. The infection prevention nurse confirmed that this practice is not allowed under the facility's infection control policy.
A resident with dementia and other health conditions was not provided with a functional wall clock in their room, resulting in frustration and disorientation. Staff acknowledged the importance of accurate timekeeping for resident orientation and comfort, and the facility's policy supported this requirement.
A resident's representative reported missing clothing items to the Social Service Assistant, but no grievance report was initiated and no follow-up occurred, despite facility policy requiring prompt action. The resident, who had dementia and required significant assistance, was discharged home without resolution or communication regarding the missing items, resulting in a violation of the resident's right to have grievances addressed.
Two residents with dementia were not properly evaluated for elopement risk, as their MDS and Quarterly Risk Assessments contained inaccuracies regarding their mobility and omitted required elopement risk evaluations. Staff interviews revealed misinterpretation of assessment questions and failure to follow facility policy, resulting in incomplete and inconsistent documentation.
Two residents with dementia did not have their care plans updated to reflect specific behaviors or interventions, despite changes in their condition and observed behaviors such as increased mobility and entering other residents' rooms. Staff interviews and record reviews confirmed that the care plans were not individualized as required by facility policy.
A resident with a history of pressure injury and multiple risk factors was found with their Low Air Loss mattress set at 350 lbs, despite the correct setting being 120-180 lbs as indicated by both physician orders and manufacturer guidelines. Staff interviews revealed a lack of awareness and responsibility for ensuring the correct mattress setting, resulting in noncompliance with prescribed pressure ulcer prevention measures.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards.
The facility did not post required daily nurse staffing information, including the number of RNs, LPNs/LVNs, and CNAs per shift, in a visible location as required by policy. Instead, the information was placed behind other postings, making it inaccessible to residents and visitors. Staff interviews confirmed this practice, and the DON acknowledged the failure to provide clear staffing data as outlined in facility procedures.
The facility failed to conduct annual competency evaluations for CNAs, as required by their policy. Interviews and record reviews revealed that three CNAs had not been evaluated annually, and there was no system to track performance evaluations. The DSD, new to the position, lacked a system to log and track the ACCC, and an in-person lesson conducted by the IPN did not cover all required skills.
The facility failed to properly label and store food items, with multiple open items in the refrigerator lacking use-by dates. Additionally, improper hygiene practices were observed, as a staff member did not change soiled gloves before handling clean plates and utensils. These actions violate the facility's policies on food safety and handling.
A resident with cognitive impairments was assisted during a meal by a CNA who stood over them, contrary to the facility's policy requiring staff to be seated to promote dignity. The DON confirmed the policy and the CNA acknowledged the inappropriateness of standing.
A resident with a history of falls and impaired cognitive skills was found without a call light within reach while sitting in a wheelchair with a meal tray. The facility's policy requires call lights to be accessible, but this was not followed, as confirmed by a CNA.
A resident was not informed about the location of the meal menu, impacting their ability to make food choices. Despite having a care plan for nutritional risk, the resident was unaware of alternative meal options and experienced delays in receiving requested meals. Staff provided inconsistent information about menu locations, and the resident's limited mobility and poor vision further hindered access.
A facility failed to ensure a copy of an Advance Health Care Directive (AHCD) was available in a resident's medical record. The resident, with fluctuating decision-making capacity and moderate cognitive impairment, had a POLST indicating an AHCD, but it was not filed in their chart. Interviews with staff revealed that the resident's family held the original AHCD, and there was no follow-up to obtain a copy, contrary to facility policy.
A resident with moderate cognitive impairment and language barriers did not have a care plan addressing communication needs, leading to potential miscommunication with staff. Despite the resident's inability to understand or speak the facility's formal language, no measures were documented to facilitate communication, as confirmed by staff interviews and record reviews.
A resident with moderate cognitive impairment and limited English proficiency was not provided with a communication board, as required by the facility's policy. Despite the resident's ability to verbalize needs in a foreign language, staff confirmed the absence of a communication board, which was necessary for effective communication and care delivery.
A resident with severe cognitive impairment and incontinence was left in a wet brief for nearly an hour, despite calling for help. Staff failed to respond promptly, leading to a delay in care. The facility's policy requires immediate assistance to prevent skin damage, which was not followed.
A resident with severe cognitive impairment and respiratory issues was found with an empty oxygen tank, indicating a failure in providing continuous oxygen therapy. The LVN was unsure of the last check or setup of the tank, and there was no documentation of the assessment or setup as required by the facility's policy. The DON confirmed the lack of adherence to the policy, which mandates documentation and periodic checks by licensed staff.
A resident with a Permacath for hemodialysis was found with a dressing that was peeling off, contrary to the facility's infection control policy. The dressing should have been changed by staff when its integrity was compromised, as confirmed by the DON and a nurse. This failure put the resident at risk for infection and dislodgement of the Permacath.
A resident with hemiplegia and moderately impaired cognition reported feeling sexually and verbally abused by the Administrator due to inappropriate comments made in a common area. Despite law enforcement involvement, the Social Services Director did not document follow-up attempts, and the Director of Nursing confirmed no investigation was conducted, violating the facility's policy on abuse reporting and investigation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care in accordance with their needs. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Enforce Infection Control Policy for Visitor Access to Medication Cart
Penalty
Summary
During a medication pass observation, a visitor was seen taking multiple cups from the middle of a cup stack on top of the medication cart and pouring juice and water in the presence of an LVN. The LVN did not intervene or instruct the visitor that obtaining cups, juice, and water from the medication cart was not permitted. Shortly after, the same visitor was observed exiting a resident's room and returning to the medication cart to grab spoons, again without any staff intervention. The resident involved had been admitted with acute respiratory failure with hypoxia and type 2 diabetes mellitus. According to the facility's infection prevention policy, visitors and residents are not allowed to access items from the medication cart to prevent contamination, as their hand hygiene status is unknown. The infection prevention nurse confirmed that this practice is not allowed due to the risk of contamination, and the facility's policy requires education and instruction for residents, visitors, and volunteers on hand hygiene and infection control practices.
Failure to Provide Functional Wall Clock for Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident by not ensuring the presence of a functional wall clock in the resident's room. The resident, who had diagnoses including dementia, osteoarthritis, and muscle wasting, was observed to be frustrated and disoriented due to the incorrect time displayed on the wall clock. The resident expressed frustration at having to ask staff for the correct time, and staff confirmed that the clock was not showing the accurate time. Interviews with facility staff, including a CNA, LVN, and the Director of Nursing, confirmed the importance of having a functional clock for resident orientation and comfort. The facility's own policy emphasized the need for a homelike environment, which includes providing accurate and functional clocks in resident rooms. The lack of a working clock directly contributed to the resident's confusion and frustration, as observed and reported by both the resident and staff.
Failure to Promptly Address Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to promptly address a grievance reported by the representative of a resident with dementia, atherosclerotic heart disease, and chronic kidney disease. The resident, who required varying levels of assistance with daily activities and did not have the capacity to make decisions, was discharged home, at which point her representative reported missing clothing items to the Social Service Assistant (SSA). Despite being informed of the missing items, the SSA did not initiate a grievance report or follow up with the representative, and no entry was made in the facility's grievance log. The SSA acknowledged that a grievance report should have been initiated and that failing to do so was a violation of the resident's rights. Further interviews with the Director of Nursing (DON) and the Administrator confirmed that they were not informed of the grievance and that the facility's policy required prompt initiation and resolution of grievances. The facility's policies also stipulated that all grievances should be responded to in writing, with actions and rationale documented. The lack of prompt response and failure to follow established grievance procedures resulted in a delay in investigating the missing clothing and violated the resident's right to have grievances addressed without discrimination or reprisal.
Failure to Accurately Complete MDS and Elopement Risk Assessments for Residents with Dementia
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) and Quarterly Risk Assessments were completed accurately for two residents diagnosed with dementia. Both residents were not properly evaluated for elopement risk, despite documentation indicating they were independently mobile within the facility. The assessments either omitted the elopement risk evaluation or incorrectly stated that the residents were not independently mobile, which was inconsistent with other records and staff observations. For one resident, multiple assessments and interviews revealed discrepancies in documentation regarding mobility and elopement risk. The resident was noted to walk frequently without limitation, yet the elopement risk evaluation was not completed, and the assessment incorrectly indicated the resident was not independently mobile. Staff interviews confirmed that the resident was seen walking throughout the facility, but the MDS nurse misinterpreted the assessment questions and did not consider dementia as a risk factor for elopement. The nurse admitted to using personal judgment rather than following assessment protocols, and the oversight was not caught during supervisory review. A second resident with similar diagnoses also had inconsistent documentation regarding mobility and elopement risk. The resident was described as walking occasionally with no limitation, but the risk assessment was not completed, and the evaluation again incorrectly indicated the resident was not independently mobile. Staff interviews confirmed the elopement risk evaluation was not completed due to a misunderstanding of the assessment criteria. Facility policy required accurate and complete risk assessments on admission and quarterly, but these were not followed, resulting in inaccurate documentation for both residents.
Failure to Revise Dementia Care Plans with Resident-Specific Behaviors
Penalty
Summary
The facility failed to ensure that care plans were revised to include resident-specific behaviors for two residents diagnosed with dementia. For one resident, records showed diagnoses of metabolic encephalopathy, unspecified dementia, and Alzheimer's disease, with documentation indicating the resident lacked decision-making capacity. Despite increased mobility and behaviors such as entering other residents' rooms, the dementia care plan did not specify behaviors to monitor or interventions tailored to the resident. Interviews with nursing staff confirmed that the care plan lacked resident-specific details and that updates should have been made to address observed behaviors. Similarly, another resident with unspecified dementia, muscle wasting, and cognitive communication deficits also had a care plan that did not identify specific behaviors to monitor. Staff interviews and record reviews confirmed the absence of individualized behavioral interventions in the care plan. The facility's policy required comprehensive, person-centered care plans to be updated as residents' conditions changed, but this was not followed for these residents, resulting in care plans that were not tailored to their current needs and behaviors.
Failure to Set Pressure Mattress According to Resident Weight
Penalty
Summary
The facility failed to set the Alternating Pressure Mattress (APM) according to the resident's weight as specified in both the manufacturer's guidelines and the physician's orders. A review of the resident's records showed that the physician had ordered a Low Air Loss mattress for skin management, with instructions to monitor its function and settings every shift. During observation, the mattress was found set at 350 lbs, while a sticker on the bed indicated the correct setting should be between 120-180 lbs based on the resident's weight. Staff interviews revealed that the Licensed Vocational Nurse was unaware of the correct setting and deferred responsibility to the Treatment Nurse, who also confirmed the setting was incorrect and could not explain why it had been set improperly. The resident involved had a history of significant medical issues, including a previous unstageable pressure injury to the sacrococcyx, muscle wasting, and type 2 diabetes, and was assessed as being at continued risk for skin breakdown. The resident was also noted to have severely impaired cognition and required assistance with daily activities. Despite these risk factors and clear preventive measures outlined in the care plan, the mattress was not set appropriately, as required by both the physician's order and the manufacturer's instructions.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest possible level of well-being for each resident, as required by regulatory standards.
Failure to Prominently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, specifically the number of Registered Nurses (RNs), Licensed Vocational Nurses (LVNs)/Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Nursing Assistants (NAs) per shift, in a prominent and visible location as required by facility policy. Observations on two separate days revealed that only the Census and Direct Care Service Hours per Patient Day (DHPPD) were posted near the facility entrance and nursing stations, with no visible information about the actual number of nursing staff on duty for each shift. During one observation, it was discovered that the required staffing information was placed behind the DHPPD posting, making it not visible to residents and visitors. Interviews with the staff member responsible for posting the information confirmed that the staffing data had consistently been placed behind the DHPPD, contrary to the policy that requires clear and visible posting. The Director of Nursing (DON) acknowledged that the facility did not post the complete nursing staffing information for each shift, which could result in residents and visitors not knowing the actual number of nursing staff providing care. Review of the facility's policy confirmed the requirement to post nurse staffing data for each shift in a prominent and accessible location within two hours of the beginning of each shift.
Failure to Conduct Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to complete annual performance reviews for Certified Nurse Assistants (CNAs) by not conducting the Annual Core Clinical Competencies (ACCC) assessments. This deficiency was identified through interviews and record reviews, revealing that three out of five CNAs had not been evaluated for their competencies annually. The facility lacked a system to track the CNAs' performance evaluations, which could potentially result in residents not receiving quality care from CNAs with insufficient skills and competencies. The facility's tracking log did not indicate which CNAs required training, and there was no system in place to ensure that the ACCC was completed or up to date. Interviews with the Registered Nurse (RN) and the Director of Staff Development (DSD) confirmed that CNAs were supposed to have yearly clinical skills competency checks. However, the DSD, who had been in the position for eleven weeks, admitted to not having a system to log and track the CNAs' ACCC. Additionally, the Infection Control Nurse (IPN) conducted an in-person lesson in July and August 2023, which was considered an annual ACCC, but not all skills listed in the facility's CNA Core Clinical Competencies were included. The facility's policy and procedure required competency evaluations upon hire, annually, and as deemed necessary, but these were not consistently conducted.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety by not labeling, dating, and storing food properly in the refrigerator and freezer. During an observation, multiple open food items in the walk-in refrigerator were found without a use-by date, including chicken broth, lemon juice, sweet sour sauce, yogurt, feta cheese, half watermelon, fruit cocktail, bacon, fish, milk, apple sauce, and Ready Care shakes. The Dietary Service Supervisor acknowledged the absence of use-by date labels and stated that the facility relies on the manufacturer's expiration date. Additionally, frozen food boxes were observed on the floor of the freezer, which is against proper storage practices. Dry items, including canned goods, were also found without use-by dates. The facility also failed to maintain proper hygiene practices during food handling. An observation revealed that a staff member did not change visibly soiled gloves before plating residents' food. The staff member used the same gloves to handle clean plates and other utensils after handling food items like breaded fish filet and lasagna, which resulted in cross-contamination. The facility's policy requires gloves to be changed when soiled, but the staff member admitted to not changing gloves. The Infection Preventionist confirmed that items like apple sauce and juice on the medication cart must be changed daily and labeled with a use-by date to ensure safety.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide care that maintained or enhanced a resident's dignity and respect, as observed during a meal assistance for a resident with severely impaired cognitive skills. The resident, who was admitted with diagnoses including hyperlipidemia and type II diabetes mellitus, required partial assistance with daily activities. During a meal observation, a Certified Nursing Assistant (CNA) was seen standing over the resident while assisting with feeding, creating a two-foot height difference between them. This was contrary to the facility's policy, which requires staff to be at eye level and seated to promote resident dignity during meals. Interviews conducted with the CNA and the Director of Nursing (DON) confirmed that the CNA did not sit while assisting the resident, acknowledging that standing was inappropriate. The DON reiterated the facility's policy that staff should be seated to ensure a dignified dining experience for residents. The facility's policy on dignity, revised in February 2024, emphasizes treating residents with respect and providing a dignified dining experience at all times.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the residents, identified as Resident 11. This deficiency was observed during a survey when Resident 11 was found sitting in a wheelchair with a lunch tray in front of her, and no staff present to assist. The call light, which is crucial for requesting assistance, was not within reach of the resident. This oversight was confirmed by CNA 4, who acknowledged the importance of having the call light accessible, especially in emergencies such as choking while eating. Resident 11's medical history includes repeated falls and abnormalities in gait and mobility, and she is considered high risk for falls. Her care plan emphasizes the need to reinforce the use of the call light for assistance. Additionally, the resident's Minimum Data Set (MDS) assessment indicates severely impaired cognitive skills and a requirement for extensive assistance with daily activities. The facility's policy, revised in 2010, mandates that the call light should be within easy reach for residents confined to a bed or chair, which was not adhered to in this instance.
Failure to Inform Resident of Meal Menu Location
Penalty
Summary
The facility failed to ensure that Resident 46 was informed about the location of the facility's monthly and alternative meal menus, which is a violation of the resident's right to self-determination and choice in food preferences. Resident 46, who was admitted with a right femur fracture and mobility issues, was not aware of where to find the menu and expressed that alternative meal requests took one to two hours to fulfill. The resident had a care plan indicating nutritional risk and required dietary services to assess food preferences and offer alternatives, yet was not informed about the availability of an alternative menu. Interviews with staff revealed inconsistencies in the location of the menu, with some stating it was kept in residents' rooms, while others indicated it was posted in the hallway or in front of the kitchen. Observations confirmed the absence of a menu in Resident 46's room, and the resident, who had poor vision and limited mobility, was unable to access the menu independently. The family member of Resident 46 also confirmed a lack of communication regarding the menu's location and the availability of alternative meal options. The facility's policy required accommodating resident preferences and offering food substitutes, but this was not effectively communicated or implemented for Resident 46.
Failure to Maintain Advance Health Care Directive in Resident's Record
Penalty
Summary
The facility failed to ensure that a copy of an Advance Health Care Directives form (AHCD) was readily available in the medical record of one of the sampled residents, Resident 162. This deficiency was identified during a review of the resident's records and interviews with facility staff. Resident 162, who was admitted with diagnoses including hyperlipidemia and major depression, had fluctuating capacity to understand and make decisions, as noted in their History and Physical Examination. The Minimum Data Set indicated that the resident's cognitive skills were moderately impaired, requiring assistance with daily activities. Despite having a Physician Orders for Life-Sustaining Treatment form indicating the existence of an AHCD, the document was not found in the resident's medical chart. Interviews with facility staff, including an LVN, the Director of Nursing (DON), and the Social Service Director (SSD), revealed that the AHCD was not filed in the resident's medical record. The LVN acknowledged the importance of having the AHCD in the chart to understand the resident's wishes. The DON confirmed that staff should obtain and file a copy of the AHCD if it exists. The SSD stated that the resident's family had the original AHCD and was supposed to provide a copy to the facility, but there was no documentation of follow-up to obtain it. The facility's policy required the SSD or admission staff to place a copy of the AHCD in the resident's medical record upon admission, which was not done in this case.
Failure to Address Communication Needs in Resident Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing the communication needs of Resident 35, who was unable to understand and speak the formal language used in the facility. This deficiency was identified through observation, interviews, and record reviews. Resident 35, who has diagnoses including encephalopathy, diabetes mellitus, and muscle weakness, was noted to have moderate cognitive impairment and required supervision for activities such as eating. Despite these needs, the resident's care plan lacked documentation to address communication barriers, as the resident was only able to verbalize needs in a foreign language. During interactions with staff, it was observed that Resident 35 communicated in a non-English language, which staff members, including a CNA and an LVN, could not understand. The LVN confirmed the absence of a care plan for communication needs, acknowledging its importance for facilitating effective communication between staff and the resident. The Director of Nursing also recognized the necessity of a care plan to address these needs, especially during care delivery. The facility's policy on comprehensive, person-centered care plans emphasizes incorporating identified problem areas to prevent or reduce functional decline, yet this was not adhered to in Resident 35's case.
Failure to Provide Communication Tool for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication tool for a resident who did not understand the formal language used in the facility. This deficiency was identified during an observation and interview with a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), who both confirmed that the resident did not have a communication board. The resident, who was admitted with diagnoses including encephalopathy, diabetes mellitus, and muscle weakness, was noted to have moderate cognitive impairment and required supervision for activities such as eating. Despite the resident's ability to verbalize needs in a foreign language, the facility did not provide a communication board, which was necessary for effective communication between the resident and staff. The facility's policy and procedure on communication with persons with limited English proficiency indicated that language assistance should be provided through interpreters and a communication board. However, the communication board was not made available in the resident's room, contrary to the facility's policy. Interviews with the Director of Nursing (DON) and other staff confirmed that the resident only understood and communicated in a foreign language, and a communication board was essential for immediate communication needs, especially during care. The lack of a communication board had the potential to lead to miscommunication and delay in care delivery for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely care and services for a resident with urine and bowel incontinence, as outlined in the resident's care plan and the facility's policy. The resident, who was admitted with conditions including muscle wasting, diabetes, osteoporosis, and urinary tract infection, was observed to have severe cognitive impairment and was dependent on assistance for personal hygiene. The care plan specified that the resident should be kept clean and dry to prevent skin breakdown and urinary tract infections, with incontinence care provided promptly after each episode. On the day of the incident, the resident was observed tapping on the bed siderail and calling for help after urinating in her brief. Despite this, multiple staff members walked past the room without assisting. It was not until nearly an hour later that a Certified Nurse Assistant (CNA) attended to the resident, who stated she was busy with another task. The CNA acknowledged that she should have sought help from other staff members to assist the resident sooner. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD), confirmed that the resident should have received immediate assistance to prevent skin damage from prolonged exposure to a wet brief. The facility's policy emphasized the importance of prompt incontinence care to prevent pressure injuries, highlighting a failure in staff communication and response to the resident's needs.
Failure to Ensure Continuous Oxygen Therapy for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy. The resident, who has severe cognitive impairment and a history of respiratory issues, was observed with an empty oxygen tank, indicating a lack of oxygen supply. The Licensed Vocational Nurse (LVN) acknowledged that the oxygen tank was empty and was unsure when it was last checked or who connected it. There was no documented evidence of the oxygen tank being assessed or the resident being set up to use it. The Director of Nursing (DON) confirmed that the facility's policy and procedure for oxygen administration required documentation of the setup and periodic checks of the oxygen tank level by licensed nursing staff. The policy also outlined specific documentation requirements, including the date and time of the procedure, the name and title of the individual performing it, and assessment data. The lack of documentation and assessment led to the resident being connected to an empty oxygen tank, which could have resulted in an episode of shortness of breath.
Failure to Maintain Permacath Dressing Integrity
Penalty
Summary
The facility failed to implement its infection prevention and control policy for a resident with a Permacath used for hemodialysis. The resident, who was admitted with diagnoses including dependence on renal dialysis and type 2 diabetes mellitus, was observed with a transparent gauze dressing on the Permacath that was peeling off at three corners, and the gauze dressing had come loose. This observation was made during a visit, and it was confirmed by a Licensed Vocational Nurse, who acknowledged that the dressing should be changed by dialysis staff during each treatment to minimize infection risk. The Director of Nursing confirmed the importance of maintaining the dressing in a clean, dry, and intact manner to prevent infection. The facility's policy indicated that licensed nurses should change the dressing if its integrity is compromised. However, the dressing was not changed despite being loose, which was against the facility's policy and the physician's orders. This oversight placed the resident at risk for infection and potential dislodgement of the Permacath.
Failure to Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Department and other officials within the mandated timeframe of two hours. This deficiency involved a resident who had been admitted with diagnoses including hemiplegia and hemiparesis following a stroke. The resident, who had moderately impaired cognition, reported feeling sexually and verbally abused by the Administrator due to a lack of privacy and inappropriate comments made in a common area regarding the use of a suppository applicator. The incident was initially brought to the facility's attention when two local law enforcement officers visited to speak with the resident about the concerns raised. Despite the involvement of law enforcement, the Social Services Director (SSD) did not document any follow-up attempts to speak with the resident, and the Director of Nursing (DON) confirmed that there was no documented evidence of an investigation or follow-up. The facility's policy required all reports of abuse to be thoroughly investigated and documented, but this was not adhered to in this case. The failure to report and investigate the allegation in a timely manner could potentially lead to underreporting and inadequate addressing of abuse allegations, compromising the resident's psychosocial well-being.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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